WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention

in Infants and Toddlers

reflexes automatically cause them to grasp and
pull the object into their mouth.
HEALTH PROMOTION OF - Caution parents to be certain nothing comes
AN INFANT within an infant’s reach that would not be safe to
put into the mouth. Using clothing without
decorative buttons, and checking toys and
I. PROMOTING INFANT rattles to ensure they have no small parts that
could snap off or fall out, are good steps for
SAFETY parents to follow. A test of whether a toy could
be dangerous if an infant puts it inside the mouth
Accidents are a leading cause of death in
is whether it fits inside a toilet paper roll. If it
children from 1 month through 24 years of age.
does, it is small enough to be aspirated.
They are second only to acute infections as a
cause of acute morbidity and physician visits
- When solid foods are introduced, encourage
(National Vital Statistics System [NVSS], 2009).
parents to offer small pieces of hot dogs or
grapes, not large chunks for this reason.
Most accidents in infancy occur because parents
Children under about 5 years should not be
either underestimate or overestimate a child’s
offered popcorn or peanuts because of this
ability. Nursing interventions that help parents
danger of aspiration.
become sensitive to their infant’s developmental
progress not only help establish sound
parent–child relationships but also guard infant 2. Fall Prevention
safety. - Falls are a second major cause of infant
accidents. As a preventive measure, no infant,
1. Aspiration Prevention beginning with a newborn, should be left
unattended on a raised surface. Normal wiggling
- Aspiration is a potential threat to infants
can bring a baby to the edge of a bed, couch, or
throughout the first year. Round, cylindrical
table top, resulting in a fall.
objects are more dangerous than square or
flexible objects in this regard. A 1-inch (3.2-cm)
- Teach parents to be prepared for their infant to
cylinder, such as a carrot or hot dog, is
roll over by 2 months of age. From that time on,
particularly dangerous because it can totally
they must be especially vigilant not to leave the
obstruct an infant’s airway. A deflated balloon
baby unattended on a changing table or counter.
can be sucked into the mouth, obstructing the
If the child sleeps in a crib, the mattress should
airway in the same way. Educate parents who
be lowered to its bottom position so the height of
feed their infant formula not to prop bottles. By
the side rails increases; rails should be 23⁄8
doing this, they are overestimating their infant’s
inches apart, narrow enough so children cannot
ability to push the bottle away, sit up, turn the
put their head between them. Two months is
head to the side, cough, and clear the airway if
about the maximum length of time infants can
milk should flow too rapidly into the mouth and
safely sleep in a bassinet; they need the
an infant begins to aspirate.
protection of a crib and high side rails before
they turn over.
- Other instances of aspiration occur because
parents underestimate their infant’s ability to
- All of these safety precautions apply to the
grasp and place objects in their mouth. Even a
hospital environment as well as to the home. Be
newborn can wiggle to a new position to reach
sure crib sides are raised and secure before
an attractive object such as a teddy bear with
anyone walks away from the crib, even for just a
small button eyes. Newborns’ grasp and sucking
moment. Also ensure that the space between
the mattress and headboard is small enough an

BONDOC, C.K. BSN 2-18

WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention
in Infants and Toddlers
infant’s head could not become trapped. Make
sure cords from nursing call bells or safety pins
are out of an infant’s reach.
3. Car Safety
- Teaching car safety for infants (as well as for
the whole family) is a vital preventive health
measure. Car seats should continue to be used
without interruption through the preschool age,
or until the child reaches 40 to 60 lb. If parents
are firm about keeping infants in car seats even
when they get fussy or impatient, children will
eventually become more comfortable in seats
than outside them. Infants up to 20 lb and 1 year
old should be placed in rear-facing seats in the
back seat because an inflating front-seat airbag
could suffocate an infant (AAP, 2009).
4. Safety with Siblings
- As infants become more fun to play with at
about 3 months, older brothers and sisters grow
more interested in interacting with them. You
may need to remind parents that children under
5 years of age, as a group, are not responsible
enough or knowledgeable enough about infants
to be left unattended with them. They might
introduce an unsafe toy or engage in play that is
too rough for an infant. Some preschoolers may
be so jealous of a new baby they will physically
harm an infant if left alone.
5. Bathing and Swimming Safety
- As babies begin to develop good back support,
many parents begin to bathe them in an adult
tub. Caution parents never to leave an infant
unattended in a tub, even when propped up out
of the water or sitting in a bath ring or bath seat.
Normal wiggling can easily cause a baby to slip
down under the water. This applies to a hospital
setting as well.
- Many communities offer infant swim programs
for babies as young as 6 months. If their child is
enrolled in one of these programs, parents may
BONDOC, C.K. BSN 2-18
become overconfident about their infant’s ability
to operate safely in water. Because children can
dog-paddle momentarily in a swimming pool
does not mean they can sustain that position for
any length of time in a bathtub or pool. Being
able to swim momentarily may also cause
children to lose their instinctive fear of water and
so be in more danger when around water than
children who are still naturally more cautious.
Such programs may also cause hypothermia
and spread microorganisms because infants this
age are not yet toilet-trained. Exposure to
chlorinated water can damage lung epithelium
that may be a precursor to childhood asthma.
6. Childproofing
- When infants begin teething at 5 to 6 months,
they chew on any object within reach to lessen
gum-line pain. Remind parents to check for
possible sources of lead paint, such as painted
cribs, playpen rails, or windowsills (Keefe,
2007). Paints safe for baby furniture should be
marked “Safe for use on surfaces that might be
chewed by children.” If an infant is going to be
allowed to play on the floor, parents should
move furniture in front of electrical fixtures or
buy protective caps for outlets. Infants are
especially fascinated by the holes and will probe
them with (often wet) fingers. Parents may need
to install safety gates at the top and bottom of
stairways as other safety measures.
- Urge parents to move all potentially poisonous
substances from bottom cupboards and store
them well out of their infant’s reach. Infants of
any age should not be left unattended in
carriages, highchairs, grocery shopping carts, or
strollers. Baby walkers are extremely dangerous
because infants can maneuver them near
stairways and fall the length of the stairs.
- When infants begin creeping, remind parents
to recheck bottom cupboards and stairways for
safety. When the child begins to walk, higher
areas, such as coffee tables, need to be cleared
of dangerous items. In a hospital setting, assess
low counter areas for dangerous objects. Do not
WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention
in Infants and Toddlers
leave possibly dangerous supplies in an infant’s
room.
- By 10 months, achievement of a pincer grasp
makes infants able to pick up very small objects.
Remind parents to check play areas or areas
such as table tops for pins or other sharp objects
that could be swallowed. Some of an infant’s
toys are now also 10 months old and need to be
checked to be certain they are still intact and
safe.
- Children who can walk may venture into the
street or a swimming pool if not carefully
supervised. Although they seem very
independent and able to take care of
themselves, their judgment about what is
dangerous is immature. In a hospital setting, a
12-month-old child can wander onto an elevator,
out of the hospital, or into a laboratory area, or
fall down a flight of stairs if not supervised.
II. PROMOTING
NUTRITIONAL HEALTH OF
AN INFANT
1. Recommended Dietary Reference
Intakes for an Infant
- Because children’s nutritional needs vary from
infancy through adolescence, the recommended
allowances of calories, protein, vitamins, and
minerals also vary with each period of
development.
- The entire first year of life is one of extremely
rapid growth, requiring a high-protein,
high-calorie intake.
- Both commercial formulas and breast milk
contain 20 calories/oz.
- Calorie allowances can be gradually reduced
during the first year to prevent babies from
becoming overweight (from 120 per kilogram of
body weight at birth to approximately 100 per
kilogram of body weight at the end of the first
year).
BONDOC, C.K. BSN 2-18
- Overweight babies during the first year are
more likely to become obese adults.
- Breastfed infants generally gain less weight
than formula-fed infants.
- Delaying the introduction of solid food until 4 to
6 months and avoiding sweet drinks for infants
can help prevent obesity in formula-fed infants.
2. Introduction of Solid Food
- From a nutritional standpoint, a normal
full-term infant can thrive on breast milk or a
commercial iron-fortified formula without the
addition of any solid food until 4 to 6 months.
- Delaying solid food until this time helps prevent
overwhelming an infant’s kidneys and may delay
the development of food allergies.
- Infants are physiologically ready for solid food
when nursing vigorously every 3 to 4 hours and
not satisfied or taking more than 32 oz (960 mL)
of formula a day.
- Infants are not ready to digest complex
starches until amylase is present in saliva at
approximately 2 to 3 months.
- Chewing movements do not begin until 7 to 9
months, so foods requiring chewing should not
be given until this age.
3. Techniques for Feeding Solid Food
- Teach parents to introduce new foods one at a
time and allow a child to eat each item for about
1 week to detect possible food allergies.
- Introducing foods one at a time helps establish
a sense of trust in infants.
- Babies have distinct taste preferences even at
young ages and may spit out food they don't
like.
- After the extrusion reflex fades (at
approximately 4 months), infants may still
appear to be spitting out food due to previous
bottle-feeding habits.
- Infants take different quantities of food
according to their preferences and needs.
- A newborn’s stomach can hold approximately 2
tablespoons (30 mL), and by 1 year, it can hold
no more than about 1 cup (240 mL). Hence,
when infants begin eating solid food, they rarely
take more than 2 tablespoons (30 mL) at a time.
WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention
in Infants and Toddlers
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keeping the original content:
III. PARENTAL CONCERNS
AND PROBLEMS RELATED
TO NORMAL INFANT
DEVELOPMENT
1. Teething
- Most infants have little difficulty with teething,
but some appear very distressed.
- Gums are sore and tender before a new tooth
breaks the surface.
- Pain can lead to resistance to chewing and
slight crankiness.
- High fever, seizures, vomiting, diarrhea, and
earache are not normal signs of teething and
require further evaluation.
- Over-the-counter medicines with benzocaine
should be discouraged.
- Acetaminophen (Tylenol) may be used for
teething discomfort, but parents should consult
with their infant’s health care provider.
2. Sleep Problems
- Sleep problems develop in early infancy due to
colic or an adjustment period to sleeping through
the night.
- Breastfed babies may wake more often than
formula-fed babies.
- Night waking and remaining awake for an hour
or more becomes common in late infancy.
- Suggestions for coping with night waking
include delaying bedtime, shortening afternoon
sleep, not responding immediately to infants at
night, and providing soft toys or music for quiet
play.
3. Colic
- Colic is paroxysmal abdominal pain occurring
in infants under 3 months, marked by loud,
intense crying.
BONDOC, C.K. BSN 2-18
- The cause of colic is unclear and may be
linked to overfeeding or swallowing too much air
while drinking.
- Formula-fed babies may be more prone to colic
than breastfed babies.
- Changing to bottles with collapsible disposable
bags, car rides, and soothing music boxes may
help.
- Antiflatulent agents like simethicone may be
tried but are not proven to be helpful.
4. Diaper Dermatitis
- Diaper dermatitis (diaper rash) may occur due
to infrequent diaper changes, contact with feces,
and prolonged exposure to urine.
- Frequent diaper changes, ointments like A&D
or Desitin, and exposing the diaper area to air
may alleviate the problem.
- Fungal (monilial or candidiasis) infection
should be suspected if lesions are bright red,
oozing, last longer than 3 days, and appear as
red pinpoint lesions.
5. Infant Caries (Baby-Bottle
Syndrome)
- Putting an infant to bed with a bottle can lead
to aspiration and decay of upper and lower
teeth.
- Baby-bottle syndrome occurs due to the
fermentation of carbohydrates in the bottle,
leading to demineralization of tooth enamel.
- Advise parents never to put their baby to bed
with a bottle; if necessary, fill it with water.
6. Obesity in Infants
- Obesity in infants is defined as weight greater
than the 90th to 95th percentile on a
standardized height/weight chart.
- Excessive calorie intake results in an increase
in the number of fat cells, which may persist into
adulthood.
- Prevention is crucial as reversing infant obesity
is difficult.
- Caution against overfeeding, and provide
balanced nutrition.
WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention
in Infants and Toddlers
- Infants should take no more than 32 oz of
formula daily; water can be substituted for
formula at one feeding.
- Adding a source of fiber to the diet, such as
whole-grain cereal and raw fruit, can help
reduce food intake.
- Caution against giving obese infants foods with
high amounts of refined sugars.
- Encourage parents to learn about balanced
nutrition for the entire family.
HEALTH PROMOTION OF
AN TODDLER
I. PROMOTING TODDLER
SAFETY
- Accidents are the major cause of death in
children of all ages, with accidental ingestions
(poisoning) being the most frequent in toddlers.
- Poisoning often results from the ingestion of
cleaning products or medicines like
acetaminophen.
- Aspiration or ingestion of small objects such as
watch or hearing aid batteries, pencil erasers, or
crayons poses a significant danger.
- Urging parents to childproof their home by
securing all poisonous products, drugs, and
small objects out of reach is crucial.
- Other common accidents in toddlers include
motor vehicle accidents, burns, falls, drowning,
and playground injuries.
- Toddlers' motor abilities outpace their
judgment, requiring constant supervision to
prevent serious injury.
1. Lead Screening
- The CDC aims to eliminate elevated blood
lead levels in children.
- Children aged 6 months to 6 years in
communities with buildings built before 1950
should be periodically tested for lead poisoning.
- Elevated lead levels can result from contact
with lead-based paint on surfaces such as
windowsills, paint chips, or furniture.
BONDOC, C.K. BSN 2-18
- Additional sources of lead poisoning include
soil, dust or fumes from home renovations,
lead-glazed pottery, lead-based gasoline, and
more.
2. Toddler Nutrition
- Parents may find it challenging to provide
adequate nutrition for toddlers due to varying
appetites and food preferences.
- While a toddler's daily food consumption
may vary, energy needs are generally met in a
positive environment.
- Sedentary children (1-3 years) should
consume 1000 kcal daily; active children may
need up to 1400 kcal daily.
- A balanced diet with a variety of foods
across three meals a day is recommended.
- Protein and carbohydrate needs are easily
met during the toddler period, and diets high in
sugar should be avoided.
- Fats generally should not be restricted for
children under 2 years old; after age 2, total fat
intake should be between 30% and 35% of
calories.
- Trans-fatty acids should be minimized, and
adequate calcium and phosphorus intake is
crucial for bone mineralization.
- Whole milk is recommended until age 2,
after which 2% milk can be introduced.
II. PARENTAL CONCERNS
ASSOCIATED WITH THE
TODDLER PERIOD
1. Toilet Training
- Toilet training is one of the biggest tasks a
toddler tries to achieve. There are so many
theories concerning toilet training that
understanding the procedure can become one of
the biggest tasks of this period for parents. Most
first-time parents ask when to start, when
training should be completed, and how to go
about it. The answer is that toilet training is an
individualized task for each child. It should begin
WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention
in Infants and Toddlers
and be completed according to a child’s ability to
accomplish it, not according to a set schedule.
- Before children can begin toilet training, they
must have reached three important
developmental levels, one physiologic and the
other two cognitive:
- They must have control of rectal and
urethral sphincters, usually achieved at the time
they walk well.
- They must have a cognitive understanding
of what it means to hold urine and stools until
they can release them at a certain place and
time.
- They must have a desire to delay
immediate gratification for a more socially
accepted action.
- Toilet training need not start this early,
however, because cognitively and socially, many
children do not understand what is being asked
of them until they are 2 or even 3 years old. The
markers of readiness are subtle, but as a rule
children are ready for toilet training when they
begin to be uncomfortable in wet diapers. They
demonstrate this by pulling or tugging at soiled
diapers; they may bring a parent a clean diaper
after they have soiled so they can be changed.
- Some toddlers smear or play with feces,
often at about the same time that toilet training is
started. This occurs because they have become
aware of body excretions but have no adult
values toward them; stools seem little different
from the modeling clay they play with. This
activity can be minimized by providing toddlers
with play substances of similar texture and by
changing diapers immediately after defecation.
Teach parents to accept this behavior for what it
is: enjoyment of the body and of the self, and the
discovery of a new substance. After a child is
fully toilet trained, this activity rarely persists.
2. Negativism
- As part of establishing their identities as
separate individuals, toddlers typically go
through a period of extreme negativism. They do
not want to do anything a parent wants them to
do. Their reply to every request is a very definite
“no.”
BONDOC, C.K. BSN 2-18
- It is easy for parents to believe their authority
is being questioned when this happens and to
worry children are becoming so disrespectful
they will have difficulty getting along in the world.
They can be baffled by the extreme change from
happy, cooperative infants who lived to please
them to irritating, uncooperative toddlers. They
may need some help to realize this is not only a
normal phenomenon of toddlerhood but also a
positive stage in development. This change
indicates that toddlers have learned they are
separate individuals with separate needs. It is
important that toddlers do this if they are to grow
up to be persons who are independent and able
to take care of their own needs and desires.
- A toddler’s “no” can best be eliminated by
limiting the number of questions asked of the
child. A father does not really mean, for
example, “Are you ready for dinner?” He means,
“Come to the table. It’s dinnertime.” A mother
asks, “Will you come take a bath now?” She
means, “It’s time for your bath.” Making a
statement instead of asking a question can
avoid a great many negative responses.
3. Discipline
- Some parents ask during the last part of the
infant year or the early toddler period when they
should start to discipline their child or when
toddlers are old enough to be punished. Remind
parents that “discipline” and “punishment” are
not interchangeable terms. Discipline means
setting rules or road signs so children know what
is expected of them. Punishment is a
consequence that results from a breakdown in
discipline, from the child’s disregard of the rules
that were learned.
- Parents should begin to instill some sense of
discipline early in life because part of it involves
setting safety limits and protecting others or
property: for example, a child must stay away
from the fireplace or heater; she must not go into
the street; she must not hit other children.
- “Timeout” is a technique to help children
learn that actions have consequences. To use
“timeout” effectively, parents first need to be
certain their child understands the rule they are
trying to enforce: for instance, “If you hit your
WEEK 15 MCHN Part 1 Health Promotion and Disease Prevention
in Infants and Toddlers
brother, you’ll have timeout.” Parents should ignoring it will make it ineffective and the child
give one warning. If the child repeats the will give it up.
behavior, parents select an area that is - True breath holding is a neurologic problem
non-stimulating, such as a corner of a room or a in which children, under stress, appear to
hallway. The child is directed to go immediately “forget” to breathe in or halt breathing after
to the “timeout” space. The child then sits there expiration, usually at the peak of anger. They
for a specified period of time. If the child cries or become so short of breath that they slump to the
shows any other disruptive behavior, the timeout floor. Breath holding can be mistaken for
period does not begin until there is quiet. When seizures because of the fall to the floor.
the specified time period has passed, the child - Temper tantrums occur as a natural
can return to the family. consequence of toddlers’ development (Taylor,
2007). They occur because toddlers are
4. Separation Anxiety independent enough to know what they want,
but they do not have the vocabulary or the
- Fear of being separated from parents begins
wisdom to express their feelings in a more
at about 6 months of age and persists
socially acceptable way.
throughout the preschool period. For this
- Tantrums may occur if parents are saying
reason, toddlers have difficulty accepting being
“no” too frequently in regard to such things as
separated from their primary caregiver to spend
touching the coffee table, getting dirty, using a
the day at a day care center or if they or their
spoon, or running and jumping so that children
primary caregiver is hospitalized.
feel constantly thwarted.
- Most toddlers react best to separation if a
- A tantrum may be a response to difficulty
regular babysitter is employed or the day care
making choices or decisions or to pressure from
center is one with consistent caregivers. Many
activities such as toilet training. Such children
are more comfortable if they are cared for in
need to express feelings in some way and do so
their own home. It helps if they have fair warning
with temper tantrums. These episodes are
that they will have a babysitter.
taxing for the parents; they are also
- It helps if parents say goodbye firmly, repeat
energy-consuming for children.
the explanation they will be there when the child
wakes in the morning, and then leave.
Prolonged goodbyes only lead to more crying.
Sneaking out prevents crying and may ease the
parents’ guilt, but it can strengthen fear of
abandonment so should be discouraged. This
applies to hospital visits as well.

5. Temper Tantrums
- Almost every toddler has a temper tantrum at
one time or another. The child may kick, scream,
stamp feet, shout “No, no, no,” lie on the floor,
flail arms and legs, and bang the head against
the floor. Children may even hold their breath
until they become cyanotic. If breath holding, the
child develops a distended chest (a halt after
inspiration), often air-filled cheeks, and
increasing distress as the child’s body registers
oxygen want. This is harmless breath holding;

BONDOC, C.K. BSN 2-18