CARE OF THE

TODDLER
 Definition:
The toddler age is the developmental
period that begins at one year & ends at
three. It is the time of intense
exploration of the environment as
children attempt to find out how things
work and how to control others through
temper tantrums, negativism and
obstinacy. It is an extremely important
period for developmental achievement
and intellectual growth.

 I - PHYSICAL GROWTH AND DEVELOPMENT

A. General Growth Parameters

1. Size increases in step like rather than linear patterns,
reflecting the growth spurts and lags characteristics of
toddlerhood.
a. Height
- The average toddler grows about 3 inches (7.5 cm) per year.
- The average 2-years-old is about 34 inches (86.5 cm) tall.
Height at 2 years is about haft the expected adult height.
b. Weight
- The average toddler gains from 4 to 6 lb (2 to 2.5 kg) per
year.
- The average 2-year-old weighs 27 lb (12.2 kg).
- Birth weight quadruples by 2 1/2 years.
c. Head circumference
- From ages 1 to 2 years, head circumference equals chest
circumference.
- From ages 1 to 2 years, head circumference equals chest
circumference.
- The total increase in head circumference in the second year
is 1 inch (2.5 cm), then the rate of increase slows to 1/2 inch (1.3
cm) per year until age 5 years.
d. Anterior fontanel
- closed at 1 1/2 years old\
e. Dentition - 20 teeth at 2 1/2 yrs old. Should start dental
care by 2 years old.

2. A toddler's characteristics protruding abdomen results from

underdeveloped abdominal muscles.
3. Bowleggedness typically persists through toddlerhood because
the leg muscles must bear the weight of the relatively large trunk.

Vital signs average:

temperature - 37.2 degree Centigrade (99 degree
Farenheight)
pulse - 110 beat/min
respiration - 25 breath/min
BP - 97/60 mmHg
 Appearance:
- appears chubby with short legs & a large head.
- have pronounced lumbar lordosis & a protruding
abdomen because he is beginning walker. As he walks
longer, this will correct itself naturally.

B. Nutrition
1. Nutritional requirements
a. Growth rate slows dramatically, thereby decreasing
the child's need for calories, protein, and fluid.
b. Calorie requirements are 102 kcal/kg/day
c. Protein requirements are 1.2 g/kg/day
d. Milk should be limited should be to no more than 1 qt
(about 1 L) daily to help ensure intake of iron-enriched
foods. Hematocrit should be used to screen for anemia.
e. Toddlers on vegetarian diets may not receive sufficient
plant proteins. They should be referred to a nutritionist.
2. Food preferences and patterns

a. By age 18 months, most toddlers eat the same foods

as the rest of the family.
b. At age 18 months, many toddlers experience
physiologic anorexia and become picky eaters, experiencing
food jags (wanting a specific food item, such as peanut
butter & jelly sandwiches for a period of days), eating
large amounts one day & very little the next.
c. Toddlers prefer to feed themselves & prefer small
portions of appetizing foods.
d. Toddlers prefer single foods instead of mixtures of
foods. A variety of foods should be offered, but the same
foods should be repeated often enough to allow the toddler
to recognized them.
e. Parents should encourage the use of utensils but be
aware that toddlers prefer to use fingers.
C. Sleep patterns
1. Total sleep requirements decrease during the second
year to an average of about 12 hours daily.
2. Most toddlers nap once a day until the end of the second
or third year.
3. Sleep problems are common & may result from fears of
separation.
4. Bedtime rituals & transitional objects that represent
security, such as blankets or stuffed toys, are helpful.

D. Dental health
1. Primary dentition (20 deciduous teeth) is completed by
age 2 1/2 years.
2. The first dental visit should occur before the toddler is 2
1/2 years old.
3. Parents should clean the toddler's teeth with a soft
toothbrush & water, and then floss the teeth. They
should not use toothpaste because toddlers dislike its
foaminess. Fluoridaded toothpaste is dangerous if
swallowed.
4. Toddlers require fluoride supplementation if the water
in their area is not fluoridaded.
5. Diet should be low in cariogenic foods, such as table
sugar, which promote dental caries.

E. Elimination
1. Stool appearance changes with additions to diet.
Highly colored foods (e.g., gelatin, beets, colored drinks,
and blueberries) may color stool.
2. Average urinary output during childhood is 500 to
1,000 ml/day.
Age of Achievement:
a. Bowel control – 18 months of age
b. Daytime bowel control – 2 ½ years of age
c. Night time bowel control – 3 years of age
 F. Sensory abilities

Visual acuity is fairly well established at 1 year

average acuity for the toddler are 20/70 at 18 months and
20/40 at 2 years. Accomodation to near and far objects is
fairly well developed by 18 months.
• The sense of hearing, taste, smell, and touch become
increasingly developed and associated with each other.
Hearing at 3 years old is at adult level.
• The taste buds of the toddler are sensitive to the
natural flavour of food at 3 years old prefers familiar odor
and tastes.
• Touch is a very important sense and a distressed
toddler is often soothed by tactile sensations.
 II - MOTOR DEVELOPMENT
AGE
GROSSMOTOR FINE MOTOR
scribbles
walks alone , loses balance,
A. G ROSS
15 months M OTOR DEVELOPMENT
creeps upstairs, throws
spontaneously, pulls
shoes & socks off,
objects to floor
builds a two block tower
runs & falls, walk upstairs
with one hand held, creeps
spoon-feeds self, turn
downstairs, sits on chair
18 months back pages, builds a 3 to
alone, pulls & pushes toy,
4 block tower
pulls & pushes toys, helps
remove clothes
goes up & down stairs with
tries to draw vertical &
both feet on one step, runs
circular strokes, turn
24 months well, puts on shoes, socks,
doorknobs, holds glass
pants, remove screw lids
in one hand
from jars
III - PSYCHOSOCIAL DEVEOPMENT

A. Overview (Erikson)
1. Erikson terms the pyschosocial crisis the child faces between
ages 1 and 3 as "autonomy versus shame and doubt"
a. The psychosocial theme is "to hold on; to let go",
b. The toddler had developed a sense of trust & is ready to give
up dependence to asset his budding sense of control & autonomy.
Parents who encourage the toddler to do so promote the
toddler's independence.
c. The toddler can develop a sense of shame & doubt if parents
keep him dependent in areas where the toddler can use newly
acquired skills or make the toddler feel inadequate when
attempting these skills.

2. The toddler begins to master social skills.

a. Individualization (differentiation of self from others)
b. separation from parent
c. control over bodily functions
d. communication with words
e. Socially acceptable behaviour the toddler
begins to learn that his own behaviour has
a predictable, reliable effect on others. The
toddlers learn to wait longer to gratify
needs.

f. Egocentric interaction with others.

(The toddler may not master some
interactive skills until adolescence when he
revisits uncomplicated tasks associated
with early periods of development. Erikson
refers to
this as the “psychosocial moratorium”)
3.The toddler often uses “NO” even
when he means “YES” to assert
independence (negativistic behaviour)

4. A toddler often continues to seek a

familiar security object, such as a
blanket, during times of uncertainty
and stress.
B. Fears

1. Common fears of toddlers include:

a. loss of parents (known as separation anxiety)
b. stranger anxiety
c. Loud noises (e.g. vacuum cleaner)
d. going to sleep
e. large animals
2. Emotional support, comfort, and simple explanations
may allay a toddler’s fear.
C. Play and toys
1. Toddlers engage in parallel play, which is play alongside, not with,
others (play beside the children next to them).
2. A short attention span causes toddlers to change toys frequently.

a. Purposes of toys in toddlers:

- To enhance locomotion skills (push-pull toys)
- To encourage imitation, language development, and gross & fine
motor skills.
b. Toys should be safe (still no detachable or small parts).

Examples of safe appropriate toys are:

Dolls & housekeeping toys
Play phones & cloth books
Appropriate rocking horses and “riding” trucks, finger paints, play
clay, large-piece wooden or plastic puzzles, and large blocks.
Discipline

1. Unrestricted freedom is a threat to a toddler’s security

despite limit testing.
2. Tell child specifically why discipline is necessary.
3. Discipline measures should be:
a. consistent
b. initiated after misbehavior, not the child
c. planned in advance
d. oriented to behavior, not the child
4. Private and not shame- inducing
5. Avoid power struggles with toddler.
a. Parents should carry them out in a safe, non stimulating
area.
b. Duration should be 1 minute per year. Parents can use
audible timer to monitor duration.
PSYCHOSEXUAL DEVELOPMENT
Overview (Freud)

1. The anal stage of development extends from age 8

months to 4 years
2. The erogenous zone consists of the anus and buttocks,
and sexual activity centers on the expulsion and retention
of body waste.
a. The toddler’s focus shifts from the oral to the anal area,
with emphasis on bowel control as he gains
neuromuscular control over the anal sphincter.
b. the toddler experiences both satisfaction and frustration
as he gains control over withholding and expelling
containing and releasing.
c. The conflict between “holding on” and “letting go”
gradually resolves as bowel training progresses;
resolution occurs once
Manifestation:

1. Sexuality begins to develop.

a. Masturbation can result from body exploration.
b. Learned words may be associated with anatomy and
elimination.
c. Sex differences become evident.
2. Toilet training is a major task of toddlerhood.
a. Readiness is unusual before age 18 months.
b. Bowel training is accomplished before bladder
training usually does not occur until age 4 to 6.
c. The training “potty” should offer security; the toddler’s
feet should reach the floor.
COGNITIVE DEVELOPMENT

Overview (Piaget)
1. Sensorimotor Stage. This stage, lasts between ages 12
and 24 months, involves two substages.
a. Substage 1 (12 to 18 months) – Tertiary circular
reactions involve trial-and-error experimentation and
relentless exploration. (This stage overlaps with substage
5 in infancy)
b. Substage 2 (18 to 24 months) – Mental combinations
appear, allowing the toddler to devise new means for
accomplishing tasks.
reasoning
 Language

AGE LANGUAGE

15 months Uses expressive jargon (specialized language

which is only understood by a specific group)
Has 4 to 6 words vocabulary
18 months Have at least 10 words vocabulary

24 months Has 300 word words vocabulary, uses 2-3 word

phrases, uses pronouns

30 months Can say first & last names, uses appropriate

pronouns & plurals, has vocabulary of over 900
words
SPIRITUAL DEVELOPMENT
•Have only a vague idea on God and religious teachings. Routines
such as praying before meals or at bedtime can be very important
and comforting.

MORAL DEVELOPMENT

A. Overview (Kohlberg)
1. A toddler is typically at the first substage of the preconventional
stage, which is oriented toward punishment and obedience. The
toddler bases judgment on avoiding punishment or obtaining a
reward.
2. Discipline patterns affect a toddler’s oral development.
a. Physical punishment and withholding privileges tend to give
the toddler a negative view of morals.
b. Withholding love and affection as a form of punishment leads to
feeling of guilt.
B. Appropriate discipline measures include providing simple
explanations why certain behaviours are unacceptable, praising
appropriate behaviour, and using distraction to avoid
unacceptable behaviours.
Behavioural traits:

1. Negativism/ negativistic behaviour – the negative

response to requests
- the words “no” or “me do” can be sole vocabulary
- uses “yes” to “no” when he means assert independence
- the best way to decrease the number of “no’s” is to
decrease the number of questions that can lead to a “no
response”.
- emotions become strongly expressed, usually in rapid
mood swings. One minute toddlers can be engrossed in
an activity, and in the next minute they might be
violently angry because they are unable to manipulate
a toy or open a door
2. Ritualism – the need to maintain sameness and
reliability provides a sense of comfort. Toddlers can
venture out with security when they know that
familiar people, places, and routines still exist.
Without the comfortable rituals, there is little
opportunity to exert autonomy. Consequently,
dependency and regression occur.

3. Headstrong – because they are slowly moving out of

infancy and more closely defining their own.
4. The independent activity naturally active, mobile
curious which makes them vulnerable to accidents to
set limits and exert external control whenever
necessary.
 Remember: Love and consistency are the two most
important concepts in child rearing.
5. They are rigid, repetitive, and ritualistic and
stereotype in their behaviour. When things are
rearranged or are strange, or persons or places are
unfamiliar, toddler go into temper tantrums in order to
control self and others.
6. Toddlers may use tantrums to assert independence.
Caregivers can best deal with them by “extinction”
(ignoring them) or direct them to activities that they
can master.
7. Toddlers have very poor sense of time. Their schedules
revolve around their activities, not around the clock.
8. Adults should talk to very young children at eye level. The
great disparity in size between an adult and a toddler can
cause fear in the later.
9. It is the critical period for toilet training.

Signs of the toddler’s readiness for toilet training:

1. Stays dry for 2 hours, with regular bowel movements

2. Can sit, walk, and squat
3. Can verbalize the desire to void or defecate
4. Exhibits a willingness to please parents
5. Wants to have soiled diapers changed immediately

 Note: Toilet training should not be initiated during times of

stress, such as the birth of a new baby, a move, a divorce, or
a vacation.
ILLNESS AND HOSPITALIZATION

A. Reactions to illness
1. The concept of body image, especially body boundaries,
is poorly defined in toddlers. Therefore, intrusive
procedures are extremely anxiety-producing.
2. Toddlers react to pain similarly to infants, and
previous-experiences may affect toddlers as well. They
may also get upset if they only perceive that they will
experience pain.

B. Reactions to hospitalization
1. In response to stressful events, such as hospitalization,
the toddler’s primary defense mechanism is regression
2. The toddler may also sense a loss of control related to
physical restriction, a loss of routine & rituals,
dependency, and fear of bodily injury or pain.

3. Separation affects most toddlers, who view it as

abandonment (18 months is the peak age for
separation anxiety). Hospitalization may promote
separation anxiety, which has three distinct phases:

a. Protest. The toddler verbally cries for parents,

verbally or physically attacks others, attempts to find
parents, clings to parents, and is inconsolable.
Screams, cries, kicks, bites, hits strangers, tries to
escape to find parents.
b. Despair. The toddler is disinterested in the
environment and play & shows passivity, depression,
and loss of appetite. Become apathetic, mournful,
withdrawn, tries to comfort self with rocking, head
banging, thumb sucking, regresses, does not physically
resist procedure.

c. Detachment (denial). The toddler makes a

superficial adjustment and shows apparent interest,
but remains detached. This phase usually occurs after
prolonged separation and is rarely seen in hospitalized
children. After prolonged separation shows interest in
environment, appears happy, friendly, forms superficial
relationships with strangers, ignores mothers as if
forgotten, does not cry when she leaves.
Problems Associated with the Toddler Period

1. Toilet Training
When to start toilet training? Begin toilet training
when children are ready (18-24 months). Before they
can begin toilet training, they must reach the two
important developmental levels:

a. Physiologic – they must have a control on rectal &

urethral sphincters.
b. Cognitive – they must have a cognitive understanding
of what it means to be hold (urine & stools until they
can release them at a certain place of time.
Ways and Measures:

1. Some parents begin toilet training by sitting him on

a potty chair.
2. Introduce the concept of urinating in the bathroom,
especially when the child sees their parents or older
children in the family using the toilet.
3. Train at regular intervals such as when the child
wakes up in the morning, after breakfast,
midmorning, before lunch & after lunch and so forth.
4. If the child does urinate or defecate, he should be
praised.
5. Some parents wake up children during the night and
carry them to the bathroom to void.
2. Dawdling
A child who dawdles is one who lingers or dilly
dallies with his food during meal. He may be
trying to get attention or may not be feeling at all.
Often times, he is given which are too large.

Management:
a. The best advice is to have him regularly checked
by a paediatrician and to avoid fussing over.
b. Let the child enjoy eating.
3. Ritualistic Behaviour
 Although toddlers spend a great deal of time every day
investigating new ways to do things & doing thing, they have
never done before, they also enjoy ritualistic patterns.
 They will use only their spoon at meal time, only “their
washcloths at bath time”. They will not go outside unless
mother or father locates their favourite cap.

4. Negativism
 As part of establishing their identities as separate
individual, toddlers typically go through a period of extreme
negativism. They do not want to do anything that a parent
wants them to do. Their reply is a very definite “NO”.
 This extreme negativism in their child will pass after it
runs it course. The more parents attempt to make the child
obey them the more the child is likely to resist.
Management:

a. A toddlers “NO” can best be eliminated by limiting the

number of questions asked to the child. For example,
“Will you come to take a bath now?” she means “It’s
time for your bath, making statement instead of asking
the question, can avoid a great many negative
responses.
b. A toddler needs to experience in making choices. To
provide the opportunity to do this, a parent might give
a secondary choice. Example “It’s bath time now” but
they says, “Do you want to take your duck or your toy
boat into the tub with you?”
5. Temper Tantrum
Almost every toddler has a temper tantrum at one time
or another. The child may kick, scream, stamp feet and
shout no, and lie on the floor. Children may even hold
their breath until they become cyanotic and slump to
the floor.
Temper tantrums are natural consequences of toddler’s
development. They are independent enough to know
what they want, but they do not have vocabulary.

Management
a. The best approach is for parents to tell the child
simply than they disapprove of the tantrums & then
ignore it.
Nursing Care:

A. Meet nutritional needs

 Assess parents ability and or teach parent to meet toddler’s need
 Give meats, fish, eggs, vegetables and fruits
 Accept developmental deterrents
 Physiologic anorexia resulting from decreased growth rate, food jags,
negativism, ritualism, need to explore, smearing

Management:
1. Use small plate, portions and utensils
2. Offer choices when possible
3. Offer nutritious snacks between meals. Instruct parent not to offer
snacks within 1 hour of a meal to avoid decreasing toddler’s appetite.
4. Add powdered milk to soup and sauces if milk intake has lessened.
5. Toddlers are at risk for aspirating small food items such as peanuts.
They can also choke on raw carrots, celery and hotdogs.
6. Remind parents not to use food as a reward or a punishment.
Toddlers should sit at a table or in a high chair to eat, to minimize the chance
of choking and to foster positive eating patterns.
B. Protect from injury
 Assess parents ability and or teach parents how to prevent
accidents

1. Poisoning – because toddlers are very mobile and curious

keep all toxic substances and medicines in locked cavinet,
do not offer medicine as candy, keep original labels on all
toxic substances, use syrup of ipecac prn, call Poison
Control Center

 Management: identify the poison

a. Corrosive
Example: Muriatic acid, acetone, paint thinner, petroleum
distales
 Don’t induce vomiting
 Give mineral oil 1-2 tbsp./ cooking oil/ Johnson baby oil, as
substitute to prevent adhesion of intestine
b. Non-corrosive
 Induce vomiting
 Gag reflex stimulation
 Syrup of ipecac – an oral emetic to cause vomiting after
drug overdose or poisoning
 Child – 15 cc + water
 Adult – 30 cc
 Less than 1 year = 5 to 10 ml followed by glass of H2O;
repeat dosage one time if vomiting does not occur in 20
minutes
c. Unknown
 Give universal antidote, charcoal (absorb the poison,
preventing from going down to the intestines
 Acid –alkaline (milk of magnesia)
 Alkaline-acid (vinegar, fruit juices, tea)
2. Motor vehicles – restrained in approved car seat,
even when car is parked, supervise or place in enclosed
area when outside. Do not allow child to play outside
unsupervised.
3. Burns – teach “hot” when near stoves, open flames,
radiator etc. Monitor toddlers carefully when they near
lit candles.
4. Falls – keep crib rails fully raised and crib at lowest
level, lock doors leading to steps, keep away from open
windows, supervise toddler at play
5. Suffocation – enclose swimming pool with fence,
supervise closely when near swimming water, teach
how to swimming.
6.Bodily injury – offer sturdy toys with no sharp edges,
do not allow to run with pencils or sharp objects, keep
dangerous tools & other equipment in locked area.
c. Protect from infection – because toddlers are very
prone to upper respiratory infection due to close
proximity of trachea and bronchi resulting to rapid
transmission of infectious agents.

d. Protect from dehydration

- Assess from dehydration (DHN): sunken eyeballs,
dry skin, depressed fontanels, decrease urinary output
- Offer variety of clear fluids in small amount
- Assess how much fluids are retained by observing
frequency and amount of vomiting and diarrhea
- continue feeding
- seek health care if vomiting and/ or diarrhea persist
or worsen
Meet developmental needs
1. Allow to explore under supervision in a controlled
environment
2. Allow to gain control of body
a. Self-feeding
b. Undressing and dressing
c. Hygiene: brushing of teeth, bathing
3. Help to gain control of body functions – toilet training.
Begin training when the child demonstrates clues to
readiness for toilet training.
4. Help to tolerate frustration by setting realistic limits &
maintaining consistency
5. Reward positive behaviour with praise and affection
6. Discipline consistently, immediately and
appropriately, use corporal punishment (spanking)
thoughtfully, never anger, for toddler’s safety
7. Know developmental milestones, encourage and
reward their achievement, avoid unrealistic goals
8. Offer appropriate play materials
9. Know when to seek health/ medical guidance or
supervision

F. Meet developmental needs during

hospitalization
1. Encourage parental participation in care
2. Use toddlers vocabulary for objects and body functions
3. Ask parents to leave favourite toys and / or blanket
4. Continue home routine and rituals when possible
5. Accept regressive behaviour
6. Allow as much mobility as possible
7. Offer age-appropriate diversional
play and play activities.
8. Offer therapeutic play materials –
banging toys, stethoscope, blood
pressure cuff
9. Administer medications in medicine
cup or allow themselves to take drugs,
never use force. Offer choices, when
administering medications.
 The approach to examination of the toddler is
important in order to elicit cooperation. The toddler may
accept parts of the examination best when seated on the
parent’s lap.