Pediatric Primary Care (23 page)

4.  Avoid naps late in day that may interfere with nighttime sleeping.

C.  Safety.

1.  Mattress should be in lowest position to prevent climbing out of crib.

2.  No bottles in bed.

3.  All cords, small objects, plastic bags, latex balloons removed.

V.  GROWTH AND DEVELOPMENT

A.  Physical.

1.  Most toddlers will have tripled birth weight.

2.  Overall growth slows; typically will gain 3-3.5 kg (6-8 lbs) in next year and gain about 12 cm (5 in.) in length.

3.  Head circumference averages about 47 cm (18 in.); brain weight doubles its birth weight in first year.

B.  Motor.

1.  Fine.

a.  Pincer grasp well developed.

b.  Puts block in cup.

c.  Can hold crayon/pencil and make marks on paper.

2.  Gross.

a.  Stands alone for a few seconds. May take some free steps.

b.  Cruising around furniture.

C.  Cognitive.

1.  Continues in Piaget's sensorimotor stage; actions more intentional.

2.  Increasing mobility fosters exploration of environment.

3.  Toddler observes other's actions, listens, touches/mouths objects.

4.  Play more spontaneous and self-initiated.

D.  Language.

1.  Uses 1-2 words.

2.  “Dada” and “mama” specific.

3.  Imitates sounds.

4.  Begins to respond to simple commands.

5.  Understands “no,” “hot.”

6.  When an object is named, will look for it.

VI.  SOCIAL DEVELOPMENT

A.  Relationships.

1.  Anxious around strangers.

2.  Emotions emerge such as anger, affection.

B.  Environment: conditions that foster trust and development of positive psychosocial feelings.

1.  Waves “byea-bye.”

2.  Plays games such as “pat-a-cake.”

3.  Indicates wants.

4.  Imitates activity of others.

VII.  IMMUNIZATIONS (SEE
APPENDIX A
)

A.  HepB #3 if necessary.

B.  Hib #4 between 12 and 18 months.

C.  IPV #3 if necessary.

D.  MMR between 12 and 15 months.

E.  Varicella at 12 months or after.

F.  PCV 12-15 months.

G.  Influenza annually.

VIII.  SAFETY

A.  Toddler care activities.

1.  Always check bathwater temperature; make sure hot water thermostat < 120°F (48.9°C).

2.  Never leave toddler alone in tub, changing table, highchair.

3.  Use sunscreen, avoid prolonged sun exposure.

B.  Environment.

1.  Switch to toddler car seat. Never leave toddler alone in car.

2.  Never leave toddler alone outside.

3.  Reexamine “baby proofing” from toddler walking perspective: outlet covers, door/drawer latches, safety gates. Remove cords, wires, string, small objects, plastic bags from toddler's environment.

4.  Climbing follows walking; anticipate dangers on counters, tables, stairs.

5.  Keep sharp objects out of reach.

6.  Maintain smoke-free environment; use smoke alarms.

7.  Do not leave alone in room with pets or young children. Feed pets in area away from toddler. Do not allow infant near pet when eating. Keep litter boxes away from toddler's environment.

8.  Avoid tablecloths or remove heavy or hot objects from tables with tablecloths.

9.  Keep toilet lid down, remove buckets with water.

10.  Protective enclosures around swimming pools, hot tubs, other water sites (ponds, fountains).

11.  Provide poison control number (to be placed by telephone). Syrup of ipecac no longer recommended.

12.  Keep houseplants out of reach; remove any poisonous plants.

IX.  ANTICIPATORY GUIDANCE

A.  Parent-toddler interaction.

1.  Continue to talk, sing, tell stories to toddler.

2.  Parent should make it a habit to describe what she/he is doing with toddler (e.g., “this is how we put on socks”).

3.  Play games such as naming things, body parts, people.

4.  Encourage reading activities with picture books, infant board books.

5.  Limit TV to 1 hour or preferably less per day.

6.  Toddlers explore; this includes genital area.

B.  Discipline.

1.  Consistency reinforces trust.

2.  Discuss appropriate discipline measures aimed primarily at protecting infant from injury; cognitively, infant cannot appreciate danger or intent.

3.  Positive reinforcement to support appropriate behavior; distraction continues to be effective.

4.  Limit use of word “no.”

5.  Spanking never appropriate.

6.  Occasionally gentle physical restraint (holding toddler) may be necessary to prevent injury.

7.  Decide on a few important rules and be consistent about enforcing them.

C.  Oral hygiene.

1.  No bottles in bed.

2.  Assess for bottle mouth caries.

3.  Use soft toothbrush, small pea size amount of fluoridated toothpaste. Assess fluoride source, supplement as necessary (see
Appendix B
).

4.  Make appointment for first dental visit.

D.  Illness prevention.

1.  Review illness symptoms and interventions.

2.  Reinforce importance of immunizations.

3.  Reinforce importance of handwashing.

4.  Use cool mist vaporizer for upper respiratory illness.

E.  When to call healthcare provider:

1.  Breathing difficulties.

2.  Seizures.

3.  Irritability.

4.  No urine output in 12 hours.

5.  Rash.6. Concerns.

BIBLIOGRAPHY

Burns CE, et al.
Pediatric Primary Care: A Handbook for Nurse Practitioners.
4th ed. Philadelphia, PA: W.B. Saunders; 2009.

Centers for Disease Control and Prevention.
2011 Recommendations and Guidelines: Childhood & Adolescent Immunization Schedules.
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm
. Accessed June 2, 2011.

Dixon SD, Stein MT.
Encounters with Children: Pediatric Behavior and Development. 4th ed. St. Louis, MO: Mosby; 2006.

Hagan JF, Shaw JS, Duncan P, eds.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Porter RS, Kaplan JL.
The Merck Manual Online:
http://www.merck.com/mmpe/index.html
. Accessed June 2, 2011.

Mindell JA, Owens JA.
A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Ontario Society of Nutrition Professionals in Public Health.
Pediatric Nutrition Guidelines for Primary Care Providers.
Ontario, CA; 2008:
http://www.osnpph.on.ca/pdfs/ImprovingOddsJune-08.pdf
. Accessed June 3, 2011.

Recommendations for using fluoride to prevent and control dental caries in the United States.
Morb Mortal
Weekly Rep.
2001;50:RR-14.

Samour PQ, King K.
Handbook of Pediatric Nutrition.
3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2005.

CHAPTER 13

Fifteen- to Eighteen-Month
Visit

Susan G. Rains

The toddler is no longer an infant. The world is forever changed by the new ability to
move
, explore, and
control
the environment.