Pediatric Primary Care (26 page)

3.  Listen, show respect and interest in activities.

4.  Encourage all family members to spend time playing with toddler.

5.  Help child express emotions.

6.  Keep family outings short.

7.  Do not expect child to share all toys.

8.  Help siblings resolve conflicts. Allow older children own space/things.

9.  Serve as role model for healthy habits and care.

D.  Health promotion.

1.  Nutrition.

a.  Eat meals as family.

b.  Allow toddler to self-feed with hands and utensils and drink from cup, not bottle.

c.  Provide healthy choices, allow experimentation, and do not force eating.

d.  Give two to three snacks/day, not as a reward; limit sugar.

e.  Avoid choking foods.

2.  Oral health.

a.  Never put to bed with a bottle.

b.  Brush teeth (allow imitation, but parent must do the job well).

c.  Investigate level of fluoride in child's water.

d.  Encourage making appointment with dentist.

3.  Injury prevention (expanded list in safety section).

a.  Maintain smoke-free environment.

b.  Check smoke and carbon monoxide detectors.

c.  Check car seat use.

d.  Reexamine home to ensure it is childproof.

e.  Supervise toddler closely, especially near dogs, lawnmowers, streets, and driveways.

f.  Ensure water safety.

g.  Use sunscreen.

h.  Discuss first-aid procedures.

E.  Community interaction.

1.  Assess needs of the family for appropriate referrals: financial assistance, Medicaid, housing, transportation.

2.  Refer child for appropriate developmental, physical, behavioral problems.

3.  Refer parent to support group if appropriate.

4.  Review childcare.

5.  Maintain community involvement by attending local activities.

BIBLIOGRAPHY

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Poison treatment in the home.
Pediatrics.
2003; 112:1182 -1185.

American Heart Association. Dietary recommendations for children and adolescents: a guide for practitioners.
Pediatrics.
2006;117(2):544 -559.

Belden AC, Thomas NR, Luby JL. Temper tantrums in healthy versus depressed and disruptive preschoolers: Defining tantrum behaviors associated with clinical problems.
J Pediatrics.
2008; 152:117.

Burns C, Brady M, Dunn A, et al.
Pediatric Primary Care.
3rd ed. Philadelphia, PA: W.B. Saunders; 2004.

Centers for Disease Control and Prevention. Recommended childhood and adolescent immunization schedule.
Morb Mortal WeeklyRep.
2003; 52:Q1-4.

Fox J, et al.
Primary Health Care of Children.
St. Louis: Mosby; 1997.

Gottesman MM. Nurturing the social and emotional development of children, a.k.a. discipline.
J Pediatr
Health Care.
2000;14:81-84.

Gottesman MM. Helping toddlers eat well.
J Pediatr Health Care.
2002;16:92-96.

Green M, Haggerty R, Weitzman M, et al.
Ambulatory Pediatrics.
5th ed. Philadelphia, PA: W.B. Saunders; 1999.

Haslam R. Screening scheme for developmental delay. In Behrman RE, Kliegman R, Jenson H, et al.:
Nelson
Textbook of Pediatrics.
17th ed. Philadelphia, PA: W.B. Saunders; 2004.

“HEAT: Early Childhood Parent Tips,” Healthy Eating and Activity Together. Cherry Hill, NJ: National Association of Pediatric Nurse Practitioners and The Napnap Foundation. 2007.

Howell, DM. et al. Toilet training.
Pediatrics in Review.
2010;31 262-263.

Joseph J, Hagan MD, eds.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. Elk Grove, IL: American Academy Of Pediatrics; 2010.

Ozonoff S, et al. A prospective study of the emergence of early behavioral signs of autism.
J Am Acad Child
Adolesc Psychiatry.
2010;49:256.

Peterson S, Siquam-Grant M. Impact of adopting lower fat food choices on nutrient intake of American children.
Pediatrics.
1997;100:e4.

Slade E, Winslow L. Spanking in early childhood and later behavior problems: a prospective study of infants and young toddlers.
Pediatrics.
2004;113(5):1321-1330.

Vazquez M, LaRussa P, Gershon A, et al. Effectiveness over time of varicella vaccine.
JAMA.
2004;291: 851-855.

Wardle J, Guthrie C, Sanderson S, et al. Food and activity preferences in children of lean and obese parents.
Intl J Obes Relat Metab Disord.
2001;25:971-977.

CHAPTER 14

Two-Year Visit

Frances K. Porcher

I.  GENERAL IMPRESSION

A.  Two-year old is very active, has good vocabulary, and is integral part of family.

II.  NUTRITION

A.  Quadruples birth weight by age 2 years.

B.  Average 2-year-old weighs 12.5-13.5 kg (26-28 lbs), is 85-90 cm (34-35 in.) tall, has head circumference of 48-50 cm (19-19.5 in.).

C.  Requires approximately 102 kcal/kg.

D.  Needs approximately 1.2 g/kg of protein, 500-800 mg of calcium, 10 mg iron.

E.  Fluoride supplement is necessary if water supply contains < 0.3 ppm fluoridation (see
Appendix B
).

F.  Requires 2-3 servings of protein, 2-4 servings of fruit, 3-5 servings of vegetables, 6-11 servings of grains, and 2 servings of milk each day.

G.  Limit juice to 4-6 oz/day. Offer skim, 1%, 2% milk versus whole milk.

H.  Offer 5-6 smaller nutritious meals or snacks each day.

I.  Start limiting fat intake to ≈ 30% of daily calories.

J.  Child's serving is about
of a standard adult serving.

K.  Needs structured mealtime environment.

L.  Has unpredictable eating habits (likes one food one day but not next day).

M.  Usually eats only 1-2 foods at meal.

N.  Feeds self, loves finger foods.

O.  Complete set of 20 primary teeth (second molars may not erupt until age 3 years).

P.  Assess child's risk for hyperlipidemia.

III.  ELIMINATION

A.  Regular elimination pattern is usually established with soft, formed stool daily or every other day and several urinations/day.

B.  Toilet training is major developmental task between ages 2½ and 3½ years.

C.  Ready for toilet training if bowel movements are regular, child interested in toileting.

IV.  SLEEP

A.  Should be able to sleep all night and maintain one nap/day.

B.  Important to have pleasant bedtime routine.

C.  Not uncommon to experience nighttime sleep awakenings, bedtime difficulties.

D.  May sleep in crib or small bed depending on child's size, climbing skills.

V.  GROWTH AND DEVELOPMENT

A.  Age of autonomy, egocentrism, negativism.

B.  Gains 4.5-6.6 lbs and 2.5-3.5 in./year from ages 2-5 years.

C.  Gross motor: runs without falling; kicks large ball; jumps; walks up/down stairs one step at a time.

D.  Fine motor: stacks 5-6 blocks; makes/imitates horizontal/circular strokes with crayon/large pencil; manipulates/solves single-piece puzzle; can unravel, undo, untie.

E.  Language: 50% of speech is understandable by stranger; has at least a 20-word vocabulary; uses 2-word phrases; understands more than says; understands and uses “I” and “you”; clearly verbalizes wants; follows 2-step commands.

F.  Fears bodily harm (limit intrusive procedures, approaches).

G.  Increasingly independent, loves to explore.