Pediatric Primary Care (24 page)

I.  NUTRITION

A.  Requirements: Growth slows in toddlerhood, decreasing energy needs to 102 kcal/kg/day, 1.2 g of protein/kg/day, fluids to 115 mL/kg/day; growth may average only 4.5 lbs/year.

1.  Servings should be 1-2 tablespoons of each food for each year of life, or about 1/4–1/3 of adult servings.

2.  Milk (whole until age 2) should be limited to 24 oz/day (16 oz is adequate), due to lack of iron and interference with intake of other nutrients. Calcium requirements are 500 mg/day; vitamin D 200 iu/day.

3.  Limit fat to 30% of diet; protein 15-20%, carbohydrates to 55%.

4.  Screen for anemia if appropriate: (large amounts of cow's milk/day, especially bottle; diet deficient in other iron-rich foods).

B.  Eating habits.

1.  Understanding toddlers.

a.  Lifelong eating habits, food preferences, and activity level have roots in the early self-feeding experiences of toddlers.

b.  They are able to recognize themselves as separate from others and need to explore independence by testing limits, including feeding limits.

c.  They recognize the newness and difference of foods and also crave the comfort of rituals.

d.  Toddlers often have appetite slumps or are sporadic eaters. If at day-care, they may only eat well at midday with the other children, so the parent rarely sees them eat! Or they may need 2 days to get all of the food groups in!

2.  Promoting good habits: Now is the time to help your child develop healthy eating habits and make good choices. As they become more independent:

a.  Be a good role model. Eat meals as a family, without TV, at regularly scheduled times.

b.  Provide nutritious snacks 2-3 times/day, not as a reward; limit sugar.

c.  Allow choices and experimentation; do not force. Offer new foods several times in order to give the child an opportunity to learn to accept and to like it.

d.  Allow toddler to self-feed with hands or utensils. Use cup, not bottle.

e.  Limit fruit juice to 4-6 oz/day.

f.  Serve appropriately sized portions, examples:

•  1/2 piece of fresh or V cup canned (preferably in its own juice) fruit.

•  2 tablespoons cooked vegetables.

•  1 tablespoon smooth peanut butter (thinly spread on cracker or bread).

•  1/2 egg, 2 tablespoons ground meat.

•  1/3 cup yogurt, 1/2 cup milk.

•  1-2 crackers, 1/4-1/2 slice of bread.

3.  Safe eating.

a.  Sit when eating; avoid eating in the car.

b.  Avoid screaming, fighting, tickling while eating.

c.  Avoid foods that can cause choking:

•  Popcorn.

•  Hot dogs, chunks of meat.

•  Globs of peanut butter with or without bread.

•  Large seeds, nuts, especially peanuts (or foods containing nuts).

•  Hard candy, jelly beans.

•  Large chunks of raw vegetables or fruits.

•  Whole grapes.

•  Chewing gum.

•  Carrot sticks.

II.  ELIMINATION: TOILET TRAINING

A.  Attempting to toilet train a child younger than 24 months of age is generally unadvisable; however, most children begin to show some interest between the ages of 18-24 months.

1.  Parents are encouraged to watch the child for signs of readiness:

a.  Child is dry at least 2 hours at a time during the day or is dry after naps.

b.  Bowel movements become regular and predictable.

c.  Facial expressions, posture, or words reveal that the child is about to urinate or have a bowel movement. This is one of the most crucial signs–to be able to tell
prior to the incident
, not just after the event, which is an earlier skill.

d.  Child asks to wear grown-up underwear.

e.  Child asks to use the potty chair or toilet.

f.  Child seems uncomfortable with soiled diapers and wants to be changed.

g.  Child is able to follow simple directions.

h.  Child is able to walk to and from the bathroom and help undress.

2.  Parents are encouraged to introduce children to the “business” of toileting: allow to observe older children/parents when appropriate; obtain potty chair and allow to sit on it; allow to flush the toilet.

3.  Discourage parents from considering toilet training if the child is under stress–should not suppress their desire to use the potty, but should not pressure them in any way to train, nor be surprised if they regress. Stress factors include:

a.  New sibling arriving.

b.  Moving houses.

c.  Family crisis such as death, major illness.

4.  Encourage use of proper names for body parts and for products of elimination. Without making bowel movements sound “dirty” or “nasty,” teach children that we do not play with feces.

5.  Pick a potty chair that offers foot support either in the chair itself or because it is low to the floor. Read books about pottying together with the child.

6.  Try to make pottying routine. Everyone generally goes first thing in the morning, before bed, before bath, after meals. Try for a few minutes, but don't fight about it as that undoubtedly will hinder the process.

7.  Positive reinforcement and sensing the child's readiness and pace of learning are essential for success.

III.  SLEEP

A.  Requirements.

1.  Averages 12 hours total/day.

2.  One to two naps/day; may have difficulty combining morning and afternoon naps.

B.  Difficulty with sleep.

1.  Common, especially going to sleep and falling asleep.

2.  May be due to separation anxiety and independence issues.

C.  Strategies to assist sleep.

1.  Bedtime rituals: standard sleep time, snack, quiet activity.

2.  Utilizing transitional objects such as special toy, blanket.

3.  Place child in bed while
awake.

4.  Check on child at progressively longer intervals.

5.  Comfort, but do not feed, rock, place in bed with parent.

6.  Ideally, institute above strategies prior to child being able to climb out of crib.

IV.  GROWTH AND DEVELOPMENT

A.  Physical growth slows.

1.  Average increases in second year of life: 5 lbs, height 3", OFC 1".

2.  Anterior fontanel closes by 18 months.

3.  Head is in smaller proportion to the body.

4.  Physique duck-like: lordotic, pot-bellied, bow-legged.

5.  Vision binocular (true strabismus should be referred).

6.  14 teeth averaged by 18 months.

7.  Immune system much better developed, but passive immunities from mother gone (especially if not breastfed) and just beginning increased exposure to antigens in environment.

B.  Development.

1.  Physical. Utilizing newly developed locomotion skills and wanting to control the environment. Toddlers push and carry large objects; put themselves into spaces such as boxes, cabinets, and under tables; delight in repetitive throwing and retrieving; scribbling. Handedness is established.

2.  Speech. By 18 months understands much of language spoken to him, but commands very few words. Largest jump in language is in second half of second year.

3.  Emotional/social. Toddlers strive for independence, i.e., autonomy, and are looking for admiration and positive reinforcement of newly found skills. Still experience dependency needs (separation anxiety) during this quest. Beginning body image development. Negativism is a part of individualization. May be becoming aware of gender.

4.  Cognitive (intellectual). Toddlers are beginning to work on causality with an increase in physical abilities and memory development. Starting to see objects symbolically. Imagination begins.