4
6. Implement a nursing care plan to address common issues related to growth and development in toddlerhood.
7. Encourage growth and learning through play.
8. Develop a teaching plan for safety promotion in the toddler period.
9. Demonstrate an understanding of toddler needs related to sleep and rest, as well as dental health.
10. Develop a nutritional plan for the toddler based on average nutritional requirements.
11. Provide appropriate anticipatory guidance for common developmental issues that arise in the toddler period.
12. Demonstrate an understanding of appropriate methods of discipline for use during the toddler years.
13. Identify the role of the parent in the toddler’s life and determine ways to support, encourage, and educate the parents about toddler growth, development, and concerns during this period.
Jose Gonzales is a 2-year-old boy brought to the clinic by his mother and father for his 2-year-old check-up. During your assessment, you find that his weight is 30 pounds, height 33 inches, and head cir cumference 19.5 inches. As the nurse caring for him, assess Jose’s growth and development, and then provide appropriate anticipatory guidance to the parents.
The toddler period encompasses the second 2 years of life, from age 1 year to age 3 years. This period is a time of significant advancement in growth and development for the child. It can also be quite a challenging time for parents. The theme during the toddler years is one of holding on and letting go. Having learned that parents are predictable and reliable, the toddler is now learning that his or her behavior has a predictable, reliable effect on others. The challenge is to encourage independence and autonomy while keeping the curious toddler safe.
Take Note!
As more grandparents are assuming the primary caregiver role for their grandchildren, nurses should be alert to the possibility of increased stress that is placed upon the older caregiver, particularly during the active and sometimes trying years of toddlerhood (Leder, Grinstead, & Torres, 2007).
GROWTH AND DEVELOPMENT OVERVIEW
Infancy is a time of intense growth and development. Both physical growth and acquisition of new motor skills slow somewhat during the toddler years. Refinement of motor skills, continued cognitive growth, and acquisition of appropriate language skills are of prime importance during toddlerhood. The nurse uses the knowledge of normal toddler development as a roadmap for behavioral assessment of the 1- to 3-year-old child.
Physical Growth
The toddler’s height and weight continue to increase steadily, though the increase occurs at a slower velocity compared to infancy.
Toddler gains in height and weight tend to occur in spurts, rather than in a linear fashion (Fig. 4.1). The average toddler weight gain is 3 to 5 pounds per year. Length/height increases by an average of 3 inches per year. Toddlers generally reach about half of their adult height by 2 years of age. Head circumference increases about 1 inch from when the child is between 1 and 2 years of age, then increases an average of a half-inch per year until age 5. The anterior fontanel should be closed by the time the child is 18 months old.
Head size becomes more proportional to the rest of the body near the age of 3 years (Hagan, Shaw, & Duncan, 2008).
Organ System Maturation
Though not as pronounced as the changes occurring during infancy, the toddler’s organ systems continue to grow and mature in their functioning. Significant functional changes occur within the neurologic, gastrointestinal, and genitourinary systems. The respiratory and cardiovascular systems undergo changes as well.
FIGURE 4.1 The typical toddler appearance is that of a rounded abdomen, a slight swayback, and a wide-based stance.
Neurologic System
Brain growth continues through toddlerhood, and the brain reaches about 80% of its adult size by 3 years of age (Zero to Three,
2011). Myelinization of the brain and spinal cord continues to progress and is complete around 24 months of age. Myelinization results in improved coordination and equilibrium as well as the ability to exercise sphincter control, which is important for bowel and bladder mastery. Integration of the primitive reflexes occurs in infancy, allowing for the emergence of the protective reflexes near the end of infancy or early in toddlerhood. The forward or downward parachute reflex is particularly helpful when the child starts to toddle. Rapid increase in language skills is evidence of continued progression of cognitive development.
Respiratory System
The respiratory structures continue to grow and mature throughout toddlerhood. The alveoli continue to increase in number, not reaching the adult number until about 7 years of age. The trachea and lower airways continue to grow but remain small compared with the adult. The tongue is relatively large in comparison to the size of the mouth. Tonsils and adenoids are large and the Eustachian tubes are relatively short and straight.
Cardiovascular System
The heart rate decreases and blood pressure increases in toddlerhood. Blood vessels are close to the skin surface and so are compressed easily when palpated.
Gastrointestinal System
The stomach continues to increase in size, allowing the toddler to consume three regular meals per day. Pepsin production matures by 2 years of age. The small intestine continues to grow in length, though it does not reach the maximum length of 2 to 3 meters until adulthood. Stool passage decreases in frequency to one or more per day. The color of the stool may change (yellow, orange, brown, or green) depending on the toddler’s diet. Since the toddler’s intestines remain somewhat immature, the toddler often passes whole pieces of difficult-to-digest food such as corn kernels. Bowel control is generally achieved by the end of the toddler period.
Genitourinary System
Bladder and kidney function reach adult levels by 16 to 24 months of age. The bladder capacity increases, allowing the toddler to retain urine for increased periods of times. Urine output should be about 1 mL/kg/hour. The urethra remains short in both the male and female toddler, making them more susceptible to urinary tract infections compared to adults.
Musculoskeletal System
During toddlerhood, the bones increase in length and the muscles mature and become stronger. The abdominal musculature is weak in early toddlerhood, resulting in a pot-bellied appearance. The toddler appears to have a swayback along with the potbelly. Around 3 years of age, the musculature strengthens and the abdomen is flatter in appearance.
Psychosocial Development
Erikson defines the toddler period as a time of autonomy versus shame and doubt. It is a time of exerting independence. Since the toddler developed a sense of trust in infancy, he or she is ready to give up dependence and to assert his or her sense of control and autonomy (Erikson, 1963). The toddler is struggling for self-mastery, to learn to do for himself or herself what others have been doing for him or her. Toddlers often experience ambivalence about the move from dependence to autonomy, and this results in emotional lability. The toddler may quickly change from happy and pleasant to crying and screaming. Exertion of independence also results in the toddler’s favorite response, “no.” The toddler will often answer “no” even when he or she really means “yes.”
This negativism—always saying “no”—is a normal part of healthy development and is occurring as a result of the toddler’s attempt to assert his or her independence. Table 4.1 gives further information related to developing a sense of autonomy.
Cognitive Development
According to Jean Piaget (1969), toddlers move through the last two substages of the first stage of cognitive development, the sensorimotor stage, between 12 and 24 months of age. Young toddlers engage in tertiary circular reactions and progress to mental combinations. Rather than just repeating a behavior, the toddler is able to experiment with a behavior to see what happens. By 2 years of age, toddlers are capable of using symbols to allow for imitation. With increasing cognitive abilities, toddlers may now engage in delayed imitation. For example, they may imitate a household task that they observed a parent doing several days ago.
Piaget identified the second stage of cognitive development as the preoperational stage. It occurs in children between ages 2 and 7 years. During this stage toddlers begin to become more sophisticated with symbolic thought. The thinking of the older toddler is far more advanced than that of the infant or young toddler, who views the world as a series of objects. During the preoperational stage, objects begin to have characteristics that make them unique from one another. Objects are considered large or small, a particular color or shape, or a unique texture. This moves beyond the connection of sensory information and physical action. Words and images allow the toddler to begin this process of developing symbolic thought by providing a label for the objects’ characteristics (Piaget, 1969).
Toddlers also use symbols in dramatic play. First they imitate life with appropriate toy objects, and then they are able to substitute objects in their play. A bowl may be used to pretend to eat from, but then later it can be used upside down on the head as a hat (Fig.
4.2). Human feelings and characteristics may also be attributed to objects (animism) (Papalia & Feldman, 2011). See Table 4.1 for further explanation of cognitive development in toddlerhood.
Take Note!
Mothers who are depressed may not be as sensitive to their children as other mothers. For this reason, maternal depression is a risk factor for poor cognitive development. Be alert to the mental status of a toddler’s mother so that appropriate referrals can be made if needed (Wacha-rasin, Barnard, & Speiker, 2003).
Motor Skill Development
Toddlers continue to gain new motor skills as well as refine others. Walking progresses to running, climbing, and jumping. Pushing or pulling a toy, throwing a ball, and pedaling a tricycle are accomplished in tod-dlerhood. Fine motor skills progress from holding and pinching to the ability to manage utensils, hold a crayon, string a bead, and use a computer. Development of eye-hand coordination is necessary for the refinement of fine motor skills. These increased abilities of mobility and manipulation help the curious toddler explore and learn more about his or her environment (Fig. 4.3). As the toddler masters a new task, he or she has confidence to conquer the next challenge. Thus, mastery in motor skill development contributes to the toddler’s growing sense of self-esteem. The toddler who is eager to face challenges will likely develop more quickly than one who is reluctant. The senses of sight, hearing, and touch are useful in helping to coordinate gross and fine motor movement.
Gross Motor Skills
As gross motor skills are mastered and then used repeatedly, the large muscle groups in the toddler are strengthened. The “toddler gait” is characteristic of new walkers. The toddler does not walk smoothly and maturely. Instead, the legs are planted widely apart, toes are pointed forward, and the toddler seems to sway from side to side while moving forward (Fig. 4.4). Often the toddler seems to speed along, pitching forward, appearing ready to topple over at any moment. The toddler may fall often, but will use outstretched arms to catch himself or herself (parachute reflex). After about 6 months of practice walking, the toddler’s gait is smoother and the feet are closer together. By 3 years of age, the toddler walks in a heel-to-toe fashion similar to that of adults. Toddlers often use physical actions such as running, jumping, and hitting to express their emotions because they are only just learning to express their thoughts and feelings verbally. Table 4.2 lists motor skill expectations in relation to age.
FIGURE 4.2 The toddler will (A) pretend with items in the way they are intended to be used as well as (B) find other creative uses for them.
FIGURE 4.3 The toddler’s curiosity about the world increases, as does her ability to explore it.
Fine Motor Skills
Fine motor skills in the toddler period are improved and perfected. Holding utensils requires some control and agility, but even more is needed for buttoning and zipping. Adequate vision is necessary for the refinement of fine motor skills because eye-hand coordination is crucial for directing the fingers, hand, and wrist to accomplish small muscle tasks such as fitting a puzzle piece or stringing a bead.
See Table 4.2 for age expectations for various motor skills.
FIGURE 4.4 The young toddler (early walker) walks with a wide-based stance, feet pointing forward and arms akimbo.
Sensory Development
Toddlers use all of their senses to explore the world around them. Toddlers examine new items by feeling them, looking at them, shaking them to hear what sound they make, smelling them, and placing them in their mouths. Toddler vision continues to progress and should be 20/50 to 20/40 in both eyes. Depth perception also continues to mature. Hearing should be at the adult level, as infants are ordinarily born with hearing intact. The sense of smell continues to mature, and toddlers may comment if they do not care for the scent of something. Though taste discrimination is not completely developed, toddlers may exhibit preferences for certain flavors of foods.
The toddler is more likely to try a new food if its appearance or smell is familiar. Lack of complete taste discrimination places the toddler at risk of accidental ingestion.
Communication and Language Development
Language development occurs rapidly during the toddler years. The acquisition of language is a dynamic and complex process. The child’s age and social interactions and the types of language to which he or she has been exposed influence language development.
Receptive language development (the ability to understand what is being said or asked) is typically far more advanced than expressive language development (the ability to communicate one’s desires and feelings) (Feigelman, 2007b; Goldson & Reynolds, 2011). In other words, the toddler understands language and is able to follow commands far sooner than he or she can actually use the words himself or herself. Language is a very important part of the toddler’s ability to organize his or her world and actually make sense of it. Thoughtfully planned use of language can provide behavior guidance and contribute to the avoidance of power struggles.
In regard to expressive language development, the young toddler begins to use short sentences and will progress to a vocabulary of 50 words by 2 years of age (Feigelman, 2007b; Goldson & Reynolds, 2011). Echolalia (repetition of words and phrases without understanding) normally occurs in toddlers younger than 30 months of age. “Why” and “what” questions dominate the older toddler’s language. Telegraphic speech is common in the 3-year-old. Telegraphic speech refers to speech that contains only the essential words to get the point across, much like a telegram. Rather than “I want a cookie and milk,” the toddler might say, “Want cookie milk.” In telegraphic speech the nouns and verbs are present and are verbalized in the appropriate order (Feigelman, 2007b). Table 4.3 gives an overview of receptive and expressive language development in the toddler.
Take Note!
Stuttering usually has its onset between 2 and 4 years of age. It occurs more often in boys than in girls. About 75% of all cases of stuttering resolve within 1 to 2 years after they start (Prasse & Kikano, 2008).
Early identification and referral of children with potential speech delays is critical. If a delay is identified, early intervention may increase the child’s potential to acquire age-appropriate receptive and expressive language skills.
Take Note!
Children with preexisting conditions such as genetic syndromes that are known to have an effect on language development should be referred to a speech-language pathologist as soon as the condition is recognized rather than waiting until the child exhibits a delay.
Of special concern in the toddler years is the development of speech and language in potentially bilingual children. At the age of 1 to 2 years, the potentially bilingual child may blend two languages—that is, parts of the word in both languages are blended into one word. At age 2 to 3 years, the potentially bilingual toddler may mix languages within a sentence. Thus, the assessment of adequate language development is more complicated in bilingual children. There are websites that may be helpful to parents of potentially bilingual children, where they can find support and resources. A list of websites is included on at http://thePoint.lww.com/Kyle2e.
Take Note!
Bilingual children often mix languages, and thus speech delay may be more difficult to assess in this population. The bilingual child should have command of 20 words (between both languages) by 20 months of age and should be making word combinations. If this is not the case, further investigation may be warranted (Abell & Ey,
2007).