TODDLERS

When children learn to walk, they are called toddlers. Usually this term is applied to one and two-year-old children. This is a stage in the growth of a child and not a specific age. The toddler stage is very important in a child's life. It is the time between infancy and childhood when a child learns and grows in many ways. Everything that happens to the toddler is meaningful. With each stage or skill the child masters, a new stage begins. This growth is unique to each child. Children have their own time-table. During the toddler stage, most children learn to walk, talk, solve problems, relate to others, and more. One major task for the toddler is to learn to be independent. That is why toddlers want to do things for themselves, have their own ideas about how things should happen, and use "no" many times each day.

The toddler stage is characterized by much growth and change, mood swings, and some negativity. Toddlers are long on will and short on skill. This is why they are often frustrated and "misbehave." Some adults call the toddler stage "the terrible twos." Toddlers, bursting with energy and ideas, need to explore their environment and begin defining themselves as separate people. They want to be independent and yet they are still very dependent. One of the family day care provider's greatest challenges is to balance toddlers' need for in-dependence with their need for discipline. Toddlers are very concerned with their own needs and ideas. This is why we cannot expect them to share.

Toddlers sometimes get frustrated because they do not have the language skills to express themselves. Often they have difficulty separating themselves from their parents and other people who are important to them. Adults who work with toddlers often find it helpful to appreciate toddlers' need to do things their way.

Usually between two and one half and three years of age, children begin to take an interest

in being toilet trained, and by age three they are ready to be known as preschoolers. By this age, most children are toilet trained, have developed verbal skills, are continuing to be more independent, and are taking an active interest in the world around them.

The toddler stage can be a difficult for adults and toddlers. An understanding of this stage of development can make it more fun for everyone. This fact sheet lists some of the characteristics of toddlers. These characteristics are listed for three main areas: physical (body), social (getting along with others) and emotional (feelings), and intellectual (thinking and language) development. Remember that all toddlers are different and reach the various stages at different times.

ASSESSMENT FOR A TODDLER

General Considerations

Undress down to diaper Examine in parent's lap Examiner must be flexible, especially in the sequence of the exam Begin with portions requiring calm patient Save less tolerated portions for later Examine areas of complaint at the end Use toys, games, stickers, and pictures to distract the toddler Allow toddler to touch the equipment Use the instrument on parent or toy first Vital Signs

General Appearance

Physical examination begins with inspection of general appearance to form an overall impression of a child’s health and well-being and to pinpoint specific areas that will need detailed assessment.

Appear well and well-nourished Height and weight is proportional Normal skin and posture Clean, relaxed, and active No body odors and no symptoms

of a specific illness Breathes easily Extremities should move

spontaneously, with good muscle tone; should not be flaccid or move only to stimuli   

Should respond to environmental stimuli or presence of a stranger; should not be listless, obtunded or lethargic

Easily comforted or calmed by caretaker (i.e., speaking softly, holding child, or offering a pacifier)

Should maintain eye contact with objects or people; should not have a “nobody home” or glassy-eyed stare

Speech/Cry should be present, strong and spontaneous; should not be weak, muffled, or hoarse

Techniques:

Before beginning the examination establish a good rapport with the child

Assess from across the room; allow child to remain on caregiver’s lap Use bright lights or toys to measure interactiveness Have caregiver assist with assessment if appropriate Leave intrusive procedures such as assessment of the genitalia, ears,

and throat until last Give generous praise for cooperation

Vital signs

Body Temperature: 97 - 100.4 F Respiratory Rate: 20-30 cpmHeart rate: 80-130 bpmSystolic Blood Pressure: 80-110 mmHg

Techniques:

Allow toddler to touch the equipment.

Use the instrument on parent or toy first.

Tympanic membrane temperature is ideal. (2 seconds registration)

Straighten the ear canal by pulling down the earlobe - child younger than age 2

Pulling up the pinna - child older than age 2 For axillary recording, hold the child’s arm down to the side to keep it

in place. For rectal recording, insert the thermometer not over 1 inch, and hold

it in place for 5 minutes. Take the heart and respiratory rate at rest, when the child is

undisturbed and not crying. In taking the blood pressure, offer a good explanation because

wrapping their arm and applying pressure can be frightening. Cuff should be no more than 2/3 and not less than one-half the length

of their upper arm. Lower extremity blood pressure can be obtained by wrapping the cuff

over the thigh and palpating or auscultating the popliteal pulse. The systolic pressure in the thigh tends to be 10 to 40 mmHg higher

for children older than 1 year. Pay attention to pulse pressure. Either unusually wide or narrow ranges

may suggest congenital heart disease.

For younger children and infants, heart rates are easier to obtain by palpating the brachial pulse or auscultating the apical pulse in the area of the left nipple

Take the rate for 15 seconds and multiply by 4; irregular rates may be taken for 30 seconds and multiplied by 2

For children < 8 years old, observe abdominal movement for respiratory rates; alternative methods are placing your hand on the back or abdomen while counting rate or auscultating rate with a stethoscope (usually done at the same time that heart rate is being taken)

To obtain a respiratory rate, count the number of respiration for 30 seconds and multiply by 2

Weight and Height

Gains only about 5 to 6 lb (2.5 kg) and 5 in (12 cm) a year during the toddler period

Average 15-month-old girl weighs about 22 lbs (10 kg) and stands 31 in (79 cm) tall. Boys tend to be about a pound heavier at 15 months but about the same height

By age 2, both will stand about 34 in tall (86 cm) and weigh about 27-28 lbs (12.25 to 12.7 kg) on average

Child changes from a plump baby into a leaner, more muscular little girl or boy

Techniques:

If the toddler cannot stand properly, let him sit on the weighing scale Remove diapers and weigh in nude Always keep a protective hand on the toddler while on weighing scale. Always cover scales with scale paper before weighing to prevent

spread of infection from one child to another Children older than 2 years are weighed on standing scale, in street

clothes (no shoes), or, if in hospital, in a gown or pajamas Wear the same clothing for serial weights

Take the weight at the same time each day (preferably before breakfast) on the same scale for greatest accuracy

Measure height by using stadiometer or height charts Plot weight and height on a standard graph for interpretation of

findings

Head, Chest, and Abdominal Circumference

Increases only about 2 cm during second year Head circumference = Chest circumference

at 6 months – 1 year Chest circumference > Head

circumference by age 2 Abdominal circumference has little

changes

Techniques:

Place a flexible measuring tape where the toddler's head has the largest circumference — just above his eyebrows and ears, around the back of his head where it slopes up prominently from his neck

Measure at every visit until 24-36 months of age

Observe head for shape, symmetry, tilt, lesions, contusions, and hair abnormalities

Chest circumference is measured at the nipple line Abdominal circumference is measured at the level of the umbilicus

Body Contour

Prominent abdomen because abdominal muscles are not yet strong enough to support abdominal contents

Presence of lordosis(forward curve of the spine at the sacral area) Waddle or walk with a wide stance

Techniques:

Observe the shape of the abdomen while the toddler is playing Observe how the toddler walks

Skin

May have minor lesions from mosquito bites or from flea bites May have ecchymotic spots on lower extremities from bumping into

objects during active play Ecchymotic spots on upper extremities are less common and may

suggest coagulation problem No lesions, scratch marks, or excessive dryness Skin has good turgor, normal in temperature, and not dry

Techniques:

Skin is assessed in conjunction with the examination of each body region

Assess temperature, color, dryness, texture, turgor, and presence of any lesions that may reveal a communicable illness of childhood

Assess skin turgor by gently pinching the skin. If the ridge of the tissue does not immediately return to place, this suggests that the child is poorly hydrated

As necessary, remove and replace adhesive bandages and other dressings that could hide important findings

There should be adequate lighting especially when assessing dark-skinned children

Head

Most children have a prominent occipital outgrowth No presence of nits and head lice No crusting, scaling, weeping, and round circular areas in the scalp No presence of tenderness and pain Hair is well distributed, uniform in color, and has a good texture

Techniques:

Slide a hand over the scalp to assess for irregular configurations or tenderness

Assess the texture and cleanliness of hair. Oily hair suggests a lack of adequate personal hygiene

Assess the color and distribution of hair. Hair with stripes of dark and light color indicates protein deficiency. Patches of hair loss (alopecia) suggests fungal infection, child abuse or drug reaction.

Eyes

Symmetric and not too wide or narrow-spaced in relation to nose

No signs of redness, crusting, squinting, and frequent blinking Neither sunken nor protruding from the socket No yellowing of sclera Eye globe is not tense Eyelids should completely close when eyes close Lids retract far enough when eyes open Inner lining of the lower eyelid should be pink and moist Eyes have good alignment Eyes can focus in all fields of vision Pupil constricts in response to light Red reflex is present

Techniques:

Note position and spacing of eyes, palpebral fissures, color, sclera and conjunctiva, eyelids, papillary size, and discharge

To assess the tenseness of eye globe, palpate each eye globe with the eyelid closed

Observe the blinking of the toddler to assess the eyelids Examine the inner lining of the lower eyelid by pulling the lid down

slightly with a fingertip Do not initiate a blink reflex by touching the cornea with a wisp of

cotton. Assess eye alignment using Hirschberg’s test and cover test Assess the eye’s focus in all fields of vision by moving a light in

different direction and asking the child to follow this light To assess pupil constriction, approach the child’s eye from the

forehead using a light. Shine a flashlight or ophthalmoscope light into the pupil to test the red

reflex

Nose

No flaring in the nostrils Mucous membranes is pink Septum is in midline Both sides of the nose are patent Sinuses are not fully developed Sense of smell is not fully developed

Techniques:

Inspect the appearance, color, symmetry, and discharges of the nose

Observe the mucous membranes by using an otoscope light To test for the nose’s air patency, gently press one nostril closed and

ask child to breathe; repeat to the opposite side.

Ears

Properly aligned (inner canthus is aligned with the top of the pinna)

If there are discharge it should be in normal amount and appearance (dark brown)

No pain and tenderness No redness of ear lobes Translucent membrane is pinkish

gray Tympanic membrane is not red

and bulging No ulcerations inside Good hearing appraisal

Techniques:

Inspect appearance and placement Palpate pinnae, tragus, mastoid to test for pain To examine the ear canal, straighten it by pulling the pinna gently

down and back in the child under 2 years of age and up and back in the older child.

Otoscopic exam in parent's lap. Select otoscope tip appropriate for the toddler.

Pneumatic otoscopy if suspect otitis media Appraisal can be done grossly by assessing the response to questions

Mouth

Lips are symmetric and pink Facial muscles are mobile By age 2-1/2, most children have all

20 of their baby or primary teeth. The second molars are the last to appear usually coming in between 20 and 30 months.

Teeth is in good condition Gums are not tender and edematous Buccal membrane is pink and no

lesions

Tongues is positioned in midline, smooth, moist, and no fasciculations No lesions under the tongue Uvula is in the midline Tonsils are normal in size, not red, and has no pus

Techniques:

Inspect the appearance of the lips, teeth, gums, buccal membrane, tongue, uvula, and tonsils

Ask the child to frown or smile to evaluate the mobility of facial muscles

To assess tongue, ask child to stick out the tongue Use tongue blade to press down or forward the back of the tongue Use tongue blade to initiate gag reflex Do not depress the tongue of the child who is suspected to have

epiglottis.

Neck

Neck is symmetric Trachea is in midline No swelling of lymph nodes Fair flexion, extension, and rotation

Techniques:

Inspect the symmetry, color, and appearance of the neck in a suitable position.

Palpate the lymph nodes in the neck. Ask the child to move to the head through flexion (touch chin to chest)

and extension (raise chin as high as possible), and turn it right and left (rotation) to see that as child does this easily.

Chest

Chest is symmetric Respiration is not difficult Anteroposterior diameter is wider than the lateral diameter

Techniques:

Inspect both front and back surfaces of the chest for symmetry of appearance and motion

Inspect for retractions or indentation of intercostal spaces or the suprasternal and substernal areas that reflect difficult repirations

Assess the proportion of anteroposterior to lateral diameter.

Breasts

May be equal or slightly unequal in size Symmetric in position and color No discharges

Techniques:

Inspection of breast is easy if a child sits on an examining table or on mother’s lap, arms at the side, with both breasts exposed.

Lungs

Respiration rate is normal, easy, and relaxed

No vibrations in lung Lung tissue is hyperresonant because of

the thinness of the chest wall Lower anterior lobe of right lung and

space over the heart is dull Normal diaphgragmatic excursion Longer inspiration than expiration

Techniques:

Assess the rate of respirations and if accesory muscles are necessary for effective ventilation

Palpate lungs for vibrations Percuss the lung tissue Auscultate breath sounds by using the diaphragm of a stethoscope

over each lung lobe while a child inhales and exhales (preferably with mouth open). Listen both anteriorly and posteriorly; compare left side with the right side for equal findings.

Heart and heart sounds

Percussion of heart is flat Heart rate is normal

No thrills and other unusual heart sounds

Techniques:

Listen to heart sounds early in examination, before a child begins to cry, because it is almost impossible to evaluate heart sounds over the sound of crying

Allowing a parent to hold a child while listening to the heart reduces fear

Inspect if there is a point on the chest where the heartbeat can be observed. This is the Point of Maximal Impulse.

Percuss the left side of the chest to discern the left side of the heart. Listen to the heart in all areas; assess rate and compare this to the

child’s age to determine if it is a normal rate.

Abdomen

Symmetric and prominent abdomen No lesions/scar Presence of normal bowel sounds occuring at 5-10 seconds No bruit and irregular sounds No tender area

Techniques:

Inspect the symmetry and contour first Auscultate bowel sounds before palpating because palpating may alter

bowel movement and therefore disturb bowel sounds Use the bell of the stethoscope for ausculatation of the bowel sounds Palpate the abdomen in a systematic manner to include all four

quadrants. First palpate lightly, then deeply Ascertain whether any area is tender by watching the child’s face while

palpating. Palpate the umbilicus to try to identify the presence of hernia. Decrease ticklishness

Genitorectal and Inguinal area

No protruding hemorrhaidal tissue in rectum No fissures in rectum No unusual lesion, swelling, discharges in the female and male

genitalia No bulging in inguinal area No swelling in femoral nodes

Techniques:

Males: observe, gently retract foreskin to visualize urethral meatus, confirm bilaterally descended testicles, palpate for inguinal/femoral hernias

Females: visual inspection of external genitalia sufficient Inspect the appearance of the rectum Observe the groin area for any bulging Palpate femoral nodes

Extremities

Good color and warm in upper and lower extremities Nails are pink, smooth, and convex Nails are hard to touch and not so brittle Less than 5 seconds of fingernails refill Elbow, wrist, and shoulder joints is in normal range of motion Ankle, knee, and hip joints is in normal range of motion No swelling in joints Radial pulse is present No webbing of fingers and toes Walk with a wide-baised gait

Techniques:

Assess the appearance of the upper and lower extremities Assess the color, contour, and shape of the fingernails Press against a fingernail, release the pressure, and time the refilling

interval Test the movement of the joints Palpate the pulse present in the extremities

Back

Symmetric No deviations in spinal cord No hemangioma and dimpling No tenderness

Techniques:

Inspect the appearance and symmetry of the back Observe the spinal cord and its alignment Palpate each vertebra as for the presence of pain

Body Systems

Respirations slow slightly but continue to be mainly abdominal. The heart rate slows from 110 to 90 bpm, blood pressure increases to

about 99/64 mmHg. The brain develops to about 90% of its adult size. In the respiratory system, the lumens of vessels enlarge progressively

so the threat of lower respiratory infection becomes less. Stomach secretions become more acid; therefore, gastrointestinal

infections also become less common. Stomach capacity increases to the point a child can eat three meals a

day. Control of the urinary and anal sphincters becomes possible with

complete myelination of the spinal cord so toilet training is possible. IgG and IgM antibody production becomes mature at 2 years of age.

The passive immunity obtained during intauterine life is no longer operative.

SUMMARY OF THE GROWTH AND DEVELOPMENT OF A TODDLER

PHYSICAL DEVELOPMENT

ONE-YEAR-OLD CHILDREN

They may grow less quickly than during infancy. They may eat less, but they tend to eat frequently throughout the day. Most walk without support by 14 months. Most walk backward and up steps by 22 months. They get better at feeding themselves, although spills should still be

expected. They drink from a cup with help. They can stack blocks. They can scribble.

TWO-YEAR-OLD CHILDREN

Children are generally more active than at any other point in their lives.

They walk, run, climb, walk up and down stairs alone, and dig. They throw balls and kick them forward. They jump with two feet together. They stand on tip toes. They take things apart and put them back together. They like to screw

and unscrew lids. They feel discomfort with wet or soiled diapers. They start to show an interest in toilet training.

SOCIAL AND EMOTIONAL DEVELOPMENT

ONE-YEAR-OLD CHILDREN

They want to do things independently. Temper tantrums are common. They enjoy playing by themselves or beside (not with) other children. They have difficulty sharing toys. They may be possessive. They cannot remember rules. They view themselves as the center of the world. They become increasingly more self-aware. They begin to express new

emotions such as jealousy, affection, pride, and shame.

They show increasing fears. They may continuously ask for their parents. They have rapid mood shifts. Their emotions are usually very intense

but short-lived. Routines are very important.

TWO-YEAR-OLD CHILDREN

They begin to play simple pretend games. Their fantasy play is very short and simple. It does not involve others.

They are generally very self-centered and sharing is still difficult. They enjoy playing near other children.

They try to assert themselves by saying "no." They sometimes do the opposite of what is asked. They like to imitate the behavior of adults and others. They want to

help with household tasks. They become frustrated easily. They refuse help. They still need security. They are more sure of themselves than one-year-old children.

INTELLECTUAL DEVELOPMENT

ONE-YEAR-OLD CHILDREN

They are curious. They point to objects that they want. They imitate animal sounds. They name familiar people and objects. They combine two words to form a basic sentence. They use the pronouns me and mine. They use "no" frequently. They name body parts and familiar pictures. They use objects for their intended purpose. They begin to include a second person in pretend play. Their attention span is short. They can hold a pencil and scribble. They are very active. Because of their developing imagination, they have trouble knowing

what is real and what is pretend.

TWO-YEAR-OLD CHILDREN

They follow simple directions.

They use three or more words in combination. They express their feelings and wishes. They use objects to represent other objects. They still have a very limited attention span. They can memorize short rhymes. They join in simple songs. They begin to think about doing something before doing it. They have trouble making choices, but they want to make choices.

ACTIVITIES TO TRY

1. Take some time to watch your toddlers playing. Notice the differences in their physical development: height, weight, how they relate to you and to other children, and their energy levels. Some children seem to never sit still, while others seem happy to sit down with a book.

2. Toddlers learn by exploring and experimenting. They love to do things over and over. Some activities that toddlers enjoy are listed below.

ONE-YEAR-OLD CHILDREN

Roll a ball to them to catch. Provide blocks for them to build with. Provide safe mirrors for them to look at themselves in. Talk with them

about their reflections in the mirror. Let them fill containers over and over again. Have them listen and move to music. Play hide and seek. Let them push or pull a favorite toy. Provide wheeled toys without pedals. Look at picture books with them and talk about the pictures. Talk about the size, shape, and texture of everyday objects. Make comparisons such as "this ball is bigger than that ball." Talk about cause-and-effect relationships such as "if you push this

block, the whole pile of blocks will fall over."

TWO-YEAR-OLD CHILDREN

Encourage toddlers to run, jump, and climb outside. Sing simple songs with them. Sing and act out songs with simple movements. Play pat-a-cake. Teach them simple finger plays.

Tell them simple, short stories (especially those about themselves or other two-year-old children).

Let them pound a toy workbench. Let them play in a sandbox. Give them water to measure and pour. Let them stack blocks and other objects. Provide things that can be taken apart and put back together (such as

pop beads). Ask children to name things in the pictures of picture books. Give them

the correct word if they cannot think of it. Give them simple directions to follow. Play matching games and use simple puzzles with them. Encourage pretending by providing dolls, housekeeping toys, dress-up

clothes, and toy telephones. Introduce art activities such as scribbling and/or painting with crayons,

chalk, and paint. Provide play dough and finger paint. Begin toilet training when the toddler is ready. Also, begin teaching

hand washing and tooth brushing. Encourage the development of routines.

REQUIREMENTIN

NCM 101

SUBMITTED BY:

AMPUAN, HAFSAH

BASHER, SITTIE SUBAYNEH

DITUCALAN, YAZIEL ASIYAH

GUINAR, PRINCESS HAEBA

HABIB, AISA ALYANNA B.

SUBMITTED TO:

PROF. NURHAIPHA SAMPAL