Pediatric Primary Care (25 page)

Note:
Early signs of autism spectrum disorder (ASD), including atypical development in socialization and communication, are now detected by pediatric providers in children as young as 18 months. Consistently, those signs include decreases in frequency of gaze to the examiner's face, social smiles, and vocalizations to others.

C.  Developmental milestones.

1.  By 15 months: says 3-6 words; can point to a body part; understands simple commands; walks well; stoops; climbs stairs; stacks two blocks; feeds self with fingers; drinks from a cup; listens to a story; tells what he wants by pulling, pointing, or grunting.

2.  By 18 months: Walks backwards; throws ball; says 15-20 words; imitates words; uses two-word phrases; pulls a toy along the ground; stacks three blocks; uses a spoon and cup; listens to a story, looking at pictures and naming objects; shows affection; kisses; follows simple directions; points to some body parts; scribbles.

D.  Developmental delay–possible referral if not present by 18 months:

1.  Walks upstairs with assistance.

2.  Self-feeds with spoon at times.

3.  Mimics actions of others.

4.  Uses at least 6 words.

V.  SOCIAL

A.  Growth, development, and socialization of the child are demonstrated in play activities. The toddler progresses from the sensorimotor play of infancy to parallel play, incorporating imitation, fine and gross motor skills, and new language.

B.  Appropriate toys for the toddler are: swing sets, sandboxes, play kitchens, play tools, musical and “talking” toys (especially interactive ones), riding toys (especially without pedals), push toys, balls, containers, telephones, mirrors, dolls and puppets, large crayons, and books. (Contact Reach Out and Read for information in setting up a literacy promotion program in clinics and offices:
http://www.reachoutandread.org
.)

C.  The toddler's new mobility and drive for autonomy make discipline a new challenge for the parent and caregiver. Appropriate discipline guidelines for the toddler include offering choices when available, including following a “no” with a “yes;” keep “catching the child being good;” and rewarding positive behaviors with verbal praise and physical affection. Time-out is not appropriate until 2.5-3 years.

D.  Parents should be encouraged to help the child learn to express emotions such as joy, fear, anger, sadness, and frustration.

E.  Dealing with temper tantrums.

1.  Tantrums are a frequent occurrence in toddlers as the young child begins to establish independence and easily becomes frustrated in doing so. He also often does not have his every need met immediately (hunger and fatigue) and is even told “no” on occasion!

2.  Parents should: Attend to hunger and sleep needs if possible to help allay underlying causes; stay calm, firm, and consistent; help allay frustrations by helping the child do/learn whatever it is that is frustrating them; distract the child by offering an alternate activity; quietly walk away.

3.  Time out can be used with a toddler. One minute per year of age is recommended for time out. This may be too long for a toddler, however, and the adult may need to help them physically (and calmly) stay in time out, again, keeping all conversation to a minimum, to avoid reinforcing negative behavior by giving it attention. Many children quickly learn that they are able to acquire a parent's one-on-one attention with negative behavior, and often do not care if it is negative attention.

4.  Do praise and give reinforcement for positive behaviors such as tantrums ceasing. Give choices if possible.

5.  Spanking has no place in the discipline (which means teaching) of children. When spanking and hitting are used by parents, children often learn to use physical force to express anger and deal with conflict.

6.  Signs of abnormal behaviors may include: Self-injurious behavior during a tantrum, consistent aggressive behavior toward others or destructive behavior toward objects > 50% of the time during a tantrum, high frequency of tantrums (> 5/day or > 10-20/month), tantrums > 25 minutes.

VI.  SAFETY

A.  Toddlers are at increased risk for injury due to increased locomotion and primitive cognition. Leading causes of death and injury and prevention strategies are listed.

B.  Motor vehicles.

1.  Use federally approved car seat in backseat of vehicle. May face forward if older than 1 year and > 20 lbs. Child safety seat inspection: 1-866-SEAT-CHECK;
seatcheck.org
.

2.  Use bike helmet.

3.  Teach children pedestrian/vehicle safety.

4.  Never allow toddlers to play alone outside.

C.  Poisoning.

1.  Use childproof caps on medications; keep medications and household poisons (including plants) out of reach or better locked.

2.  Have poison control number readily available for all caregivers. 1-800222-1222. Never tell children medication is candy.

3.  Screen for lead risk.

D.  Burns.

1.  Use caution in kitchen with young children present.

2.  Turn handles of cooking utensils away from outer edge of stove.

3.  Adjust hot water to 120°F.

4.  Keep matches/candles out of reach.

5.  Use sunscreen when children are exposed to sunlight.

6.  Keep sockets covered and cords out of sight.

7.  Have working smoke detector on every floor of the house.

E.  Drowning.

1.  Supervise closely near any water, including buckets.

2.  Fence swimming pools.

3.  Close bathroom doors and put lid down on toilet.

4.  Utilize life preservers in addition to above.

F.  Choking and suffocation.

1.  Do not give danger foods listed in nutrition section (including nuts, hot dogs, gum, hard candy).

2.  Only allow play with age-appropriate items (no small pieces).

3.  Discard old appliances/furniture or remove doors.

4.  Keep automatic garage door opener inaccessible.

5.  Select safe toy chests without heavy, hinged lid.

G.  Falls.

1.  Confine play in fenced areas.

2.  Supervise all climbing play.

3.  Place gates at top and bottom of stairs.

4.  Lock windows, screens, doors.

5.  Keep crib rails up and mattress at lowest level.

6.  Keep bumper pads and large stuffed animals out of crib or playpen (child may climb on top).

7.  Dress in safe clothing that will not catch or drag.

H.  Other injuries.

1.  Never leave children alone in a car or at home.

2.  Do not allow play near any machinery.

3.  Do not allow running with sharp objects, or with anything in the mouth.

4.  Teach children to avoid strange animals, especially ones that are eating.

5.  Avoid personalized clothing in a public place.

6.  Use safety glass and decals on large windows/doors.

7.  Remove guns from house.

VII.  IMMUNIZATIONS

A.  HIB #4 (if not previously given).

B.  PCV #4.

C.  IPV #3.

D.  DTaP #4.

E.  HepB #3 (if not previously given).

F.  MMR #1 (if not previously given; may see moved to 15 months to increase immunogenicity).

G.  Varivax (if not previously given; may see moved to 15 months to increase immunogenicity).

H.  Influenza seasonally.

VIII.  OTHER SCREENINGS IF RISK ASSESSMENT INDICATES

A.  Dental (ensure fluoride source).

B.  B/P: if high risk history.

C.  Vision: prematurity 32 weeks, family history of ophthalmologic problems (other than acuity).

D.  Hearing: caregiver concern, postnatal infection, head trauma, family history, certain syndromes associated with hearing loss.

E.  TB: exposure, born outside United States, HIV associated.

IX.  ANTICIPATORY GUIDANCE

A.  Primary responsibility of the PNP is to assist the parent in understanding and parenting this emerging person–the toddler–and his thoughts, behaviors, and needs, as well as attending to the parent's needs.

B.  Social competence.

1.  Give individual attention, create opportunities for exploration and physical action.

2.  Encourage self-care, self-expression, choices.

3.  Limit number of rules, but consistently enforce them.

4.  Suggest acceptable alternatives.

5.  Keep discipline brief.

6.  Allow assertiveness within limits, but no hitting, biting, or aggressive behavior.

7.  Reassure once negative behavior has stopped.

8.  Delay toilet training.

9.  Expect genital curiosity.

C.  Family relationships.

1.  Parent needs to take time for himself or herself and with partner.

2.  Pick up toddler, hold, cuddle, show affection.