TODDLER

 Psychosexual stage: Anal Stage

• Characteristics: Anus and rectum are the
center of pleasures (sensual satisfaction, self-
control).
• Major conflict: toilet-training
 Anal expulsive character - messy,
disorganized, reckless, careless, and defiant.
 Anal retentive character - neat, precise,
orderly, careful, stingy, withholding,
obstinate, meticulous, and passive-
aggressive.
 Nursing implications:
 Controlling and expelling of feces provide

pleasure and sense of control.

 Toilet training should be a pleasurable

experience.
 An appropriate praise can result in a personality

that is creative and productive.

 Help children achieve bowel and bladder control

without undue emphasis on its importance. If at

all possible, continue bowel and bladder training
while child is hospitalized.
 TODDLER
 Developmental Task: Autonomy vs. shame and doubt.
Child learns to be independent and make decisions for
self.
 Nursing Implications:
1. The child needs support, praise, and encouragement
to use newly acquired skills of independence.
2. Shaming or insulting the child will lead to unnecessary
dependence.
3. Provide opportunities for decision making, such as
offering choices of clothes to wear or toys to play
with.
4. Praise for ability to make decisions rather than
judging correctness of any one decision.
 Invention of new means through mental
combinations
 Age span: 18-24 months
 Nursing Implications:
o Transitional phase to the preoperational

thought period.
o Uses memory and imitation to act.
o Can solve basic problems
o Foresee maneuvers that will succeed or fail
o Good toys for this period: those with several

uses, such as blocks, colored plastic rings.

 Stage 1
 Age: 2-3 years
 Description: punishment/obedience orientation

(“heteronymous morality”).
 A deed is perceived as “wrong” if one is punished;

the activity is “right” if one is not punished.

 Child does right because a parent tells him or her

to and to avoid punishment

 Nursing implications: child needs help to

determine what are right actions. Give clear

instructions to avoid confusion.
 Growth slows considerably during
toddlerhood.
 The average weight gain is 1.8 to 2.7 kg (4-6

pounds).
 The birth weight is quadrupled by 2 ½ years

of age.
 The rate of increase in height also slows.
 The usual increment is an addition of 7.5 cm

(3 inches) per year and occurs mainly in

elongation of the legs rather than the trunk.
 The average height of a 2 year old is 86.6 cm
(34 inches).
 In general adult height is about twice the 2-

year-old child’s height.

 Visual acuity of 20/40 is considered

acceptable during the toddler years.

 The senses of hearing, smell, taste, and touch

become increasingly well developed,

coordinated with each other, and associated
with other experiences.
 15 months – steady growth in height and
weight
 Uses cup well by 15 months
 Builds a tower of 2 cubes by 15 months
 Holds crayon with fingers by 24 to 30 months
 Good hand-finger coordination by 30 months
 Copies a circle by 3 years
 Walks without help usually by 15 months
 Jumps in place by 18 months
 Goes up stairs (with 2 feet on each step) by

24 months
 Runs fairly well (wide stance) by 24 months
 Binocular vision well developed by 15 months
 Knows own name by 12 months; refers to self
 Follows simple directions by 2 years
 Identifies geometric forms by 18 months
 Uses short sentences by 18 months to 2

years
 Remembers and repeats 3 numbers by 3

years
 Able to speak 300 words by 2 years
 One of the major tasks of toddlerhood is toilet
training.
 Helping parents identify the right time to initiate
training can alleviate stress and anxiety for the child
that could prolong the toilet training process.
 Nighttime bladder control normally takes several
months to years after daytime training.
 Bowel training is usually accomplished before
bladder training because of its regularity and
predictability. There’s a stronger sensation for
defecation than for urination, and the sensation for
defecation can be brought to the child’s attention.
Physical readiness:
 1. voluntary control of anal and urethral

sphincters, usually, by 18-24 months of age.

 2. ability to stay dry for 2 hours, decreased

number of wet diapers, waking dry from nap.

 3. regular bowel movements
 4. gross motor skills of sitting, walking, and

squatting.
 5. fine motor skills to remove clothing.
 Mental readiness:
 1. recognizes urge to defecate or urinate.
 2. verbal or nonverbal communicative skills

to indicate when wet or has urge to defecate

or urinate.
 3. cognitive skills to imitate appropriate

behavior and follow directions.

 Psychologic Readiness:
 1. Expresses willingness to please parent.
 2. Able to sit on toilet for 5-10 minutes

without fussing or getting off.

 3. Curiosity about adults’ or older sibling’s
 toilet habits.
 4. Impatience with soiled or wet diapers;

desire to be changed immediately.

 Parental Readiness:
 1. recognizes child’s level of readiness.
 2. willing to invest the time required for toilet

training.
 3. absence of family stress or change, such as

divorce, moving new sibling, or imminent

vacation.
 1. selection of potty chair and/or use of the
toilet.
- a free standing potty chair allows children a
feeling of security.
- planting the feet firmly on the floor also
facilitates defecation.
- another option is a portable seat attached
to the regular toilet, which may ease the
transition from potty chair to regular toilet.
- Placing a small bench under the feet helps to
stabilize the child’s position.
 2. keep the potty chair in the bathroom and
to let the child observe the excreta being
flushed down the toilet to associate this
activity with usual practices.
 3. if a potty chair seat is not available, having

the child sit facing the toilet tank provides

added support.
 4. boys may begin toilet training in the

stand- up position or by sitting on a potty

chair or toilet.
 5. practice sessions should be limited to 5-
10 minutes.
 6. parent should stay with the child.
 7. sanitary habits should be employed after
every session.
 8. children should be praised for cooperative
behavior and/or successful evacuation.
 9. dress children in easily removed clothing;
using training pants, “pull-on” diapers or
panties.
 10. encourage imitation by watching others
 11. when the child begins to regular daytime
dryness, parents may experiment with
underwear during the day.
 12. frequent reminders and trips to the toilet

are necessary.
 13. do not wake the child during the night

and carry him to the bathroom.

 Note: regression is a normal part of toilet
training and does not mean failure but should
be viewed as a temporary setback to a more
comfortable place for the child.
- Is defined as the natural jealousy and resentment
of children to a new child in the family.
- The arrival of a new infant represents a crisis for
even the best prepared toddlers.
- It is not the infant that toddlers resent but the
changes that this additional sibling produces,
especially the separation from mother during
birth.
- Sibling rivalry tends to be most pronounced in
the firstborn, who experiences dethronement.
 A good time to start talking about the new baby
is when the toddler becomes aware of the
pregnancy and the changes taking place in the
home in anticipation of the new member.
 Parents should stress the activities that will take
place when the baby arrives home such as
diapering, bottle-or breastfeeding, bathing and
dressing. At the same time, parents should
emphasize which routines will stay the same,
such as reading stories or going to the park.
 If a toddler has no contact with an infant it is
a good idea to introduce them to one, if
feasible.
 A new sibling in the home is stressful, so any

additional stresses for the toddler should be

avoided or minimized.
 Pregnancy is an abstraction for toddlers. They

need concrete illustrations of how the baby is

growing inside the mother.
 Parents should alert the visitors of the
toddlers needs, by having a small presents on
hand for the toddler, and by including the
child in the visits as much as possible.
 The toddler can also help with the care of the

newborn by getting diapers and doing other

small tasks.
 Infants must be protected by parental

supervision of the interaction between the

siblings.
 Toddlers may assert their independence by
violently objecting to discipline.
 The best approach toward tapering temper
tantrums requires consistency and
developmentally appropriate expectations and
rewards.
 During tantrums ignore the behavior, provided
the behavior is not injurious to the child.
 Continue to be present to provide a feeling of
control and security to the child once the tantrum
has subsided. At this time, a toy or a favorite
activity can be substituted for the request.
 One of the more difficult aspects of rearing
children in this age group is their persistent
“no” response to every request.
 The negativism is not an expression of being

stubborn or insolent, but a necessary

assertion of self-control.
 Reduce the opportunities for a “no” answer.
 Children can also make choices. However, if

their response is negative parents should

make the choice for the child.
 Regression is the retreat from one’s present
pattern of functioning to past levels of
behavior.
 Any threat to their autonomy, such as illness,

hospitalization, separation, or adjustment to

a sibling, represents a need to revert to
earlier forms of behavior.
 When regression does occur, the best
approach is to ignore it while praising
existing patterns of appropriate behavior.
 Regression is a child’s way of saying, “I can’t
cope with this present stress and perfect this
skill as well, but I will if given patience and
understanding.” For this reason, it is
advisable not to attempt new areas of
learning when an additional crisis is present
or expected, such as beginning toilet training
shortly before a sibling is born or attempting
new areas of learning during a brief period of
hospitalization.
 Ritualism is toddler’s need to maintain
sameness and reliability; provide sense of
comfort.
 Toddlers like the same cup, dish, spoon every

time they eat. They may reject favorite food

simply because it is served in a different utensil.
 If one food touches the another, they often

refuse to eat it.

 Regular mealtime schedule also helps satisfy

their desire and need for predictability and

ritualism.
 Limit setting (letting the child know what they
are able to do and not do in a situation) is an
important part of toddler discipline.
 1. supportive and loving relationship between
parent and child.
 2. use of positive reinforcement to promote

desired behaviors.
 3. removing reinforcement to reduce and

eliminate undesired behaviors

 1. the sooner discipline is incorporated into
the child’s life, the easier it is.
 2. discuss discipline philosophies behind

closed doors, but when disciplining a child,

be unified and supportive of each other.
 3. avoid disciplining in the wrong place, with

the wrong motives, or with wrong timing; the

child will rebel every time.
 4. avoid threatening to discipline and then

not following through.

 5. if a rule is broken, corrective actions
should follow.
 6. expect respect in all interactions.
 7. follow discipline with love and positive

encouragement.
 8. allow crying, but not screaming.
 During the period form 12 to 18 months of age,
the growth rate slows, decreasing the child’s
need for calories, protein and fluid.
 However, the protein (1.2 g/kg) and caloric (102)
kcal/kg requirements are still relatively high to
meet the demands for muscle tissue growth and
high activity level.
 The need for minerals such as iron, calcium, and
phosphorus is still high, particularly when one
considers the poor food habits of children in this
age group and the increased mineralization
within bones.
 Physiologic anorexia
 –occur at 18 months of age.
 -toddlers become picky, fussy eaters with

strong taste preferences.

 Toddlers are increasingly aware of the
nonnutritive function of food : the pleasure of
eating, the social aspect of mealtime, and the
control of refusing food.
 If a family member refuses to eat something,
toddlers are likely to imitate the response.
 If the plate is overfilled, they are likely to
push it away, overwhelmed by its size.
 Mealtime is more closely associated with
psychologic components than with nutritional
status.
 Eating habits established in the first 2-3 years of
life tend to have a lasting effects on subsequent
years.
 Mealtime should be enjoyable rather than times
for discipline or family arguments.
 Substitution can be provided for foods that they
do not like. Although this practice should not
cater to all of their desires.
 Providing frequent nutritious planned snacks may
provide adequate caloric intake at this age.
 Do not force toddlers to eat food they are
reluctant to eat.
 Total sleep decreases only slightly during the
second year and averages about 12 hours a day.
 Most children take one nap a day, and by the end
of the second or third year many relinquish this
habit.
 Children reach an adult pattern of sleep at 3
years of age.
 Sleep problems are common, esp. going to bed
and falling asleep due to fear of separation.
 Bedtime rituals(e.g., same hour of sleep, snack,
quiet activity)are helpful.
 Transitional objects such as favorite stuffed
animal or blanket, can help ease the child’s
insecurity at bedtime.
 Regular Dental Examinations:
 The AAP section of pediatric Dentistry(2003)

now recommends that every child have an

oral health examination by a practitioner by 6
months of age.
 If the child is high risk for dental caries, an

initial visit to a dentist or pedodontist

(pediatric dentist) by age 6 months or within
6 months of the eruption of the first tooth is
recommended.
 Initial visit to the dentist should be
nontraumatizing like meeting the dentist,
seeing the equipment, and sitting in the
chair. If the child is cooperative, the dentist
may just look at the teeth but reserve a more
thorough examination for another visit.
 Modeling, in which the child observes

procedures performed on the parent or a

cooperative sibling, can also be effective.
 For effective cleaning, a small toothbrush
with soft, rounded, multi-tufted nylon
bristles that are short and uniform in length
is recommended.
 Toothbrushes are replaced as soon as the

bristles are frayed or bent.

 With young children, brushing may be more

accomplished using only water.

 When using toothpaste, children should
select the flavor they like to encourage the
brushing habit.
 Do dental flossing to remove the plaque and

debris from between teeth and below the

gum margin where brushing is ineffective.
 When brushing is impractical, the “swish-and

-swallow” method of cleaning the mouth will

be applied.
 Fluoride supplementation should be
considered for any child over the age of 6
months whose drinking water is deficient in
fluoride.
 Refined sugar, honey, molasses, corn syrup,
and dried fruits such as raisins are highly
cariogenic.
 - the frequency with which sugar is

consumed is more important than the total

amount eaten.
 - the form of sugar is important.
 Also called nursing bottle caries or bottle
mouth caries.
 This occurs when the child is routinely given

a bottle of milk or juice at nap-or bedtime or

uses the bottle as a pacifier while awake.
 Frequent nocturnal breastfeeding for

prolonged periods also leads to destruction

of the teeth.
 The practice of coating pacifiers in honey can

also contribute to caries and maybe a

potential source of botulism poisoning.
 Eliminating the bedtime bottle completely,
feeding the last bottle before bedtime.
 Substituting a bottle of water for milk or

juice.
 Not using the bottle as a pacifier.
 Never coating pacifiers in sweet substances.
 Putting juice in bottle, esp. commercially
available ready-to-use bottles, is
discouraged.
 Juice should always be offered in a cup to

avoid prolonging the bottle-feeding habit.

 Toddlers should be encouraged to drink from

a cup at first birthday and weaned from a

bottle by 14 months of age.
 Begins as imaginative and make-believe play;
may imitate adult in play.
 Provide blocks, wheel toys, push toys,

puzzles, crayons to develop motor

coordination abilities.
 Toddlers enjoy repetitive stories and short

songs with rhythm.

 Use federally approved car restraint.
 Supervise child while playing outside.
 Do not allow child to play behind a parked

car.
 Do not permit child to play in pile of leaves or

large cardboard container in trafficked area.

 Supervise tricycle riding.
 Lock fences and doors if not directly

supervising children.
 Teach child to obey pedestrian safety rules
 Obey traffic regulations; cross only at crosswalks
and only when traffic signal indicates it is safe.
 Stand back a step from the curb until it’s time to
cross.
 Look left, right, and left again and check for
turning cars before crossing the street
 Use sidewalks; when there is no sidewalk, walk
on the left, facing traffic.
 Wear light colors at night and attach fluorescent
material clothing
 Supervise closely when near any source of
water, including buckets.
 Keep bathroom doors closed and lid down on

toilet.
 Have fence around swimming pool and lock

gate.
 Teach swimming and water safety (this is,

however, not a substitute for safety)

 Turn pot handles toward back of stove
 Place electrical appliances toward back of
counter.
 Place guardrails in front of radiators, fireplaces,
or other heating elements.
 Place burning candles, incense, hot foods, and
cigarettes out of reach.
 Do not let table cloth hang within child’s reach.
 Do not let electric cord from iron, curling iron
or other appliance hang within child’s reach.
 Cover electrical outlets with protective plastic
caps
 Keep electrical wires hidden or out of reach.
 Do not allow child to play with electrical
appliance, wires or lighters.
 Stress danger of open flames; teach what “hot”
means.
 Always check bathwater temperature; adjust water
heater temperature to 120 degrees Fahrenheit
(48.9 degree Celsius) or lower; do not allow to
play with faucets.
 Apply a sunscreen when child is exposed to
sunlight.
 Place all potentially toxic agents out of reach
or in locked cabinet.
 Caution against eating non-edible items,

such as plants.
 Replace medications or poisons immediately;

replace child-guard caps properly.

 Administer medications as a drug, not as a

candy.
 Do not store large surplus toxic agents.
 Promptly discard empty poison containers;
never reuse to store a food item or other
poison.
 Teach child not to play in trash containers.
 Never remove labels from containers of toxic

substances.
 Do not store toxic liquids in containers not

specifically intended for their storage

 Keep screen in window, fasten securely, and
use guardrail.
 Place gates at top and bottom of stairs.
 Keep doors locked or use child-proof

doorknob covers at entry to stairs, high

porch, or other elevated area.
 Remove unsecured or scatter rugs
 Apply non-skid decals in bathtub or shower.
 Keep crib rails fully raised and mattress at

lowest level.
 Place carpeting under crib and in bathroom.
 Keep large toys and bumper pads out of crib

or playpen (child can use these as “stairs” to

climb out), then move to youth bed when
child is able to climb out of crib.
 Avoid using wheeled walkers, esp. near stairs

and floor furnace.

 Dress in safe clothing (soles that do not

“catch” on floor, tied shoelaces, pant legs that

do not touch floor)
 Keep child restrained in vehicles; never leave
unattended in shopping cart.
 Supervise at playgrounds; select play areas

with soft ground cover and safe equipment.

 Avoid large, round chunks of meat, such as
whole hotdogs (slice lengthwise into short
pieces)
 Avoid fish with bones, dried beans, and hard

candy, chewing gum, nuts, popcorn, grapes,

marshmallows.
 Choose large, sturdy toys without sharp

edges or small removable parts.

 Discard old refrigerators, ovens, and so on; if

storing an old appliance, remove the door.

 Select safe toy boxes or chests without heavy,
hinged lids.
 Remove drawstrings from clothing.
 Avoid giving sharp or pointed objects such as
knives, scissors, or toothpicks – esp. when
walking or running.
 Do not allow lollipops or similar objects in

mouth when walking or running.

 Teach safety precautions.
 Store all dangerous tools, garden equipment

and firearms in locked cabinet.

 Be alert to danger of supervised animals and

household pets.
 Teach child name, address, and phone
number and to ask for help from appropriate
people if lost; have identification on child.
 Teach stranger safety
 Avoid personalized clothing in public places
 Never go with a stranger
 Tell parents if anyone makes child feel

uncomfortable in any way

 Always listen to child’s concerns regarding

other’s behavior.
 Teach child to say “no” when confronted with

uncomfortable situations.