MOVEMENT AND MOTOR DEVELOPMENT

PLAY

Play is a pleasurable activity engaged in for its own sake. Infant play is initiated by parents or caregivers, such as hanging brightly colored mobiles for the infant to see, talking and singing to the infant, providing toys like rattles, using infant swings or walking the infant in strollers, and playing peek-a-boo. As infants approach 6 to 12 months, parents can place the infant on their stomach on the floor and place toys slightly out of reach to promote crawling. They can teach the infant the names of body parts, food, and people and provide large toys that can be pushed or pulled.¹⁴

LANGUAGE AND COMMUNICATION

Infants can understand language and develop speech patterns before they are able to articulate sounds. Parents and caregivers can speak to infants with the expectation that they will begin to understand the meaning of words.

Infants begin to vocalize and repeat sounds through cooing within the first few months of life. Cooing is a gurgling, musical vocalization. The infant hears the sound of their own voice and attempts to repeat sounds they find entertaining. They also start to learn the rhythm of conversation, taking turns as they respond when the other person’s vocalization pauses. Initially, cooing consists of vowel sounds like “oooo.” The next stage of vocalizations is babbling, where infants add consonants and repeat syllables such as “nananananana.” By 12 to 13 months, infants speak their first words. At one year old, a typical infant has a vocabulary of about 50 words, which expands to around 200 words by toddlerhood.¹⁵

EMOTIONAL REGULATION

Infants rely on their caregivers to assist them with emotional regulation, the process of noticing, managing, and responding to one’s emotions. For example, an infant may display frustration through crying, which prompts a response from the parents or caregivers. Parents and caregivers recognize the emotion and use techniques like holding the infant, speaking calmly, or providing distraction to help reduce the intensity, duration, and frequency of the emotion. Over time, the infant may also learn to self-soothe through actions such as sucking on a finger or pacifier.¹⁶

Parents can help infants become aware of emotions by naming them and asking questions. For example, while reading a book, a parent might ask, “Why is the turtle sad in this picture?” Parents and caregivers can also model positive coping strategies. For instance, a mother who feels overwhelmed might say, “Mommy is feeling a little frustrated right now, so I’m going to take a deep breath to calm down,” while gently rocking the baby and maintaining a soothing tone of voice. This demonstrates a calming technique. Parents and caregivers who assist their children in regulating emotions are more likely to have children who are less fearful and fussy, express positive emotions, are easier to soothe, are more engaged in environmental exploration, and have enhanced social skills in their toddler and preschool years.¹⁷

MOVEMENT AND MOTOR DEVELOPMENT

Toddlers are highly active and develop skills such as walking, running, and pulling or pushing toys. They also learn to climb stairs with assistance, help undress themselves, drink from a cup, and use a spoon.²⁰

Toilet training is a major accomplishment at this age due to their expanding cognitive and physical development.²¹ Before a child can be toilet trained, they must be able to sense the urge to urinate and defecate, understand what those feelings mean, and be able to communicate their toileting needs to the parent or caregiver. During toilet training, toddlers learn some urges must be controlled and there is a time and place for certain activities. Nurses can help parents understand the basic concepts of toilet training and reinforce teaching to help the child develop a sense of confidence during this training.^22,23 Health teaching about toilet training is further discussed in the “Health Promotion and Anticipatory Guidance” subsection of the “Nursing and Medical Care for the Developing Child” section.

PLAY

Play is essential for toddler development by helping toddlers learn; build relationships; and use physical skills, social skills, language, and communication. Play provides sensory, physical and cognitive experiences that build connections in the brain. Toddlers typically do unstructured play, meaning it happens based on the toddler’s interest at the time. Unstructured play is important because it allows toddlers to lead play activities, follow their own interests, explore the environment, make decisions, and use their imagination. For example, a toddler might open and close drawers, turn containers upside down, or hide objects in a variety of places. Toddlers also like to play the same game or read the same book many times. Repeating activities allows toddlers to master skills and understand cause and effect. Toddlers are full of energy so physical activities in a safe environment are important. Toddler play varies in pace and focus. For example, if walking outside, a toddler may look at something quickly and move on or they may stop and explore an object for an extended period of time. By age three, toddlers also enjoy “pretend” games like dress-up and playing house. Imaginative and creative play allows toddlers to express and explore emotions like frustration, sadness, and anger.²⁷

LANGUAGE

Toddlers add a significant number of words to their vocabulary by age two. By about 18 months, they string multiple words together. Toddlers start to convey a whole idea with a few words, such as “Give baby ball” and later expand these short phrases to whole sentences. Toddlers also display echolalia (repeating words and phrases spoken by others) as a normal part of language development and learning. For example, if a parent asks a toddler, “Do you want milk?” the toddler exhibiting echolalia may reply, “Milk, milk,” rather than saying “Yes.” Echolalia generally subsides by age three. If echolalia continues beyond age three, echolalia may be a sign of an underlying developmental delay.^28,29,30

EMOTIONAL REGULATION

By age one, toddlers begin to understand that parents and caregivers can help them regulate their emotions. They also start to associate specific emotions with certain situations and may withdraw from upsetting stimuli. Parents and caregivers can support emotional regulation by helping toddlers label their emotions with age-appropriate language and modeling positive coping techniques.³⁴

MOVEMENT AND MOTOR DEVELOPMENT

Preschoolers need daily exercise and activities that include creativity and free movement. Exercise improves physical and visual awareness, while gross motor skills develop as children engage the large muscles of their body. Around age three, children enjoy simple movements such as hopping, jumping, running back and forth, throwing a ball underhand, and catching large or bounced balls. By age four, they become more adventurous. They often enjoy climbing and activities like kicking a ball toward a target, bouncing a ball under control, hopping on one foot four times, and descending stairs with one foot per step. Around age five, children sprint and enjoy racing, kick a rolling ball, skip with alternating feet, roller skate, jump rope, ride a two-wheeled bike with training wheels, and climb. Preschoolers often struggle to sit still, which can affect family mealtimes. Parents should allow preschoolers to leave the table when they finish eating.³⁸

By age three, children are still developing fine motor skills, often struggling to pick up small objects with their thumb and forefinger and having difficulty placing pieces in a puzzle but are adept at building block towers. By age four, coordination has improved, and by age five, children demonstrate smoother, more coordinated movement with their hands, arms, and body.³⁹

PLAY

Upon entering preschool, children gain opportunities to play with new peers and develop social skills. Initially, preschoolers may play in a solitary manner, but they progress to parallel play where they play with similar toys independently but near other children. Associative play follows, involving sharing objects and making up games and rules with other children, but the child is still focused on their own actions. Finally, in cooperative play, children shift their focus to other children’s actions and work together for a common goal.⁴⁷ See Figure 13.7⁴⁸ for an image of children exhibiting cooperative play as they work together to build a castle made of blocks.

Figure 13.7

Cooperative Play.

Play provides preschoolers sensory, cognitive, and physical experiences that are essential for development. Different kinds of play help preschoolers develop and learn in many different ways⁴⁹:

• Dramatic and pretend play: Preschoolers like to dress-up or act out confusing or scary scenarios to try different roles and explore emotions.
• Messy play: Play with paints, water, sand, or dirt develops senses like touch and smell and gives preschoolers the chance to explore textures, smells, and colors.
• Physical play: Jumping, running, kicking balls, and climbing over playground equipment develops strength, coordination, and balance. It also helps preschoolers test the limits of their physical abilities.
• Singing, reading books, and repeating riddles and silly rhymes: These types of activities help to improve language and vocabulary and develop a child’s sense of humor.
• Sorting games: Activities like sorting blocks help to build basic math skills.
• Outdoor play: Jumping in puddles, looking at insects, running down hills, and lying in the grass are good activities for toddlers’ physical health and self-confidence and allow them to explore the natural environment.
• Simple board games: Board games give preschoolers a chance to learn how to take turns, follow rules, count, and play fair.

LANGUAGE

Literacy is the understanding of language, encompassing reading, writing, listening, and speaking. Children develop literacy through opportunities to speak, interact with active language partners, and be read to. Parents and caregivers can support preschoolers’ cognitive and language growth by encouraging exploration to develop symbolic thought and engaging as active language partners. By the age of three, a preschooler’s language should be understandable to strangers. Stuttering is common in early childhood and usually resolves on its own; parents should avoid overcorrecting it.⁵⁰

EMOTIONAL REGULATION

Preschoolers are able to understand and differentiate between appropriate and inappropriate expressions of their emotions, but they may struggle to express their feelings verbally. Parents can support their children by helping them recognize their emotions, identify triggers, and learn to manage them effectively. Modeling appropriate emotional regulation allows children to learn by observation, while validating their emotions creates a safe environment for expression. In contrast, emotional dismissal, where a parent ignores or denies a child’s emotions, hinders emotional development.⁵² For example, if a child cries when it is time to leave their friends at preschool, a parent can acknowledge the emotion by saying, “You are feeling sad about leaving your friends,” rather than dismissing it with, “Why are you crying? You are fine.”

Emotions also play a big role in peer relations. Children who are able to control emotional responses are more likely to show social competence. Moody, negative children experience greater peer rejection, while emotionally positive children are more popular among their peers.⁵³

MOVEMENT AND MOTOR DEVELOPMENT

During the early school-aged years, children gain greater control over their body movements, enhancing both their gross and fine motor skills. An example of a gross motor skill is riding a bike, while tying one’s shoes is an example of a fine motor skill.⁵⁸

Children should be active for at least 60 minutes every day to foster both short-term and long-term health and to prevent chronic diseases. School-aged children may participate in organized team sports, such as soccer, baseball, or basketball, or more individual sports such as karate or gymnastics. Research shows that participation in organized sports varies based on a child’s age, sex, location, and family income. Children who participate in sports often experience physical, psychological, and social benefits and are less likely to engage in problem behaviors.⁵⁹

PLAY

School-aged children need plenty of time for unstructured and structured play. Self-directed, unstructured play lets children decide what they want to play and how to do it. Unstructured play is valuable because it encourages children to explore ideas, think creatively, and develop hobbies. Structured play, such as participating in organized team sports or other extracurricular activities, helps children develop problem-solving skills, learn about their physical and emotional limits, and develop friendships.⁶⁵

LANGUAGE

By the time children enter kindergarten, they have mastered the foundational elements of language, including a broad vocabulary and basic grammatical rules. By fifth grade, their vocabulary expands to approximately 40,000 words, and they become increasingly skilled at expressing their thoughts and emotions. This growing sophistication is reflected in their enjoyment of telling jokes, especially simple jokes with punchlines or involving wordplay, such as “knock-knock” jokes.⁷⁰

EMOTIONAL REGULATION

Children begin the school-aged years relatively dependent on their parents but grow increasingly autonomous as they approach adolescence, particularly in decision-making and self-care. At age eight, children may start to argue with their parents, but these disagreements are usually resolved through reasoning about family rules and expectations. With an understanding of right and wrong and the consequences of their actions, defiance is typically rare. However, as a child reaches age 12, their emotions become more intense and variable as their need for autonomy develops. They typically express their own desires and often test limits set by their parents.⁷¹

MOVEMENT AND MOTOR DEVELOPMENT

Prior to the adolescent growth spurt, boys and girls are generally similar in strength. However, after puberty, males typically become physically stronger than females due to increases in bone density and muscle mass. As their limbs lengthen, adolescents may experience clumsiness in their movements. However, as their brain adapts to these changes, this awkwardness usually resolves. Regular physical activity can help teens improve their strength and coordination.⁷⁹

SEXUAL DEVELOPMENT

Healthy sexual development involves a combination of physical development, psychosocial interactions, and the formation of a positive sexual identity. Teens strive to become comfortable with their changing bodies and begin making decisions about which, if any, sexual activities they wish to engage in. Sexual development is shaped by a complex interaction of physical and cognitive changes, along with social expectations. As they mature physically, adolescents often compare their own characteristics to those of their peers or to idealized body images portrayed in the media, such as fashion models or athletes.⁸⁹

As sex hormones cause biological changes to occur in the reproductive system, they also trigger sexual thoughts. Sexual interest is a natural part of adolescence. Although cultural values, beliefs, and expectations influence sexual behaviors, peers are also very influential.⁹⁰

Many early romantic relationships begin with nonsexual interactions, such as messaging and phone calls. By age 12 or 13, some teens begin dating and experimenting with kissing, touching, and other sexual activities such as oral sex. Adolescents aged 14 to 16, when educated on the consequences of unprotected sex, sexually transmitted infections, and pregnancy, typically understand the risks. However, they may lack the ability to apply this knowledge in real-life peer situations or act responsibly in the heat of the moment. By age of 17, many adolescents report experiencing sexual intercourse, often influenced by peer pressure.⁹¹

Becoming a sexually healthy adult is a developmental task of adolescence, requiring the integration of psychological, physical, cultural, spiritual, societal, and educational factors. Healthy adult relationships are more likely to develop when an adolescent’s sexual development is not shamed but instead acknowledged as a normal part of growth, accompanied by open communication and guidance regarding the risks of unintended pregnancies and sexually transmitted infections (STIs) from unprotected vaginal intercourse, as well as the risks of STIs from various forms of unprotected sex, such as anal and oral sex. Nurses can support adolescents by providing education on these topics, empowering them to make informed and healthy decisions regarding sexual activity.⁹²

EMOTIONAL REGULATION

Emotionally, adolescents may seem rude, short-tempered, and moody as they navigate their evolving sense of identity. They may fluctuate between setting high expectations for themselves and experiencing self-doubt, which can contribute to anxiety, depression, or eating disorders. Some teens turn to chemical substances, such as alcohol or marijuana, to cope with their emotions. However, the use of these substances is risky as they can impair judgment and increase the likelihood of engaging in other dangerous behaviors, such as driving under the influence or participating in unprotected sexual activity.⁹³

In adolescence, a renewed egocentrism may emerge. For example, a teen with a small pimple on their face might perceive it as huge and highly noticeable, mistakenly believing that others share their critical perceptions about their appearance.⁹⁴

MORAL DEVELOPMENT

As adolescents gain more independence, their understanding of morality becomes more complex, and they begin to consider what is right or wrong in more nuanced ways. As their cognitive, emotional, and psychosocial development matures, adolescents expand their moral reasoning and apply these principles to their daily lives.⁹⁵

From middle childhood into early adolescence, the child begins to care about how situations impact others, and they want to please others and feel accepted (i.e., Kohlberg’s theory regarding conventional morality). Adolescents often begin to use abstract reasoning to justify behavior (i.e., Kohlberg’s theory regarding postconventional morality).⁹⁶

In terms of moral decision-making, younger children are heavily influenced by their family members, cultural beliefs, and religious traditions, while adolescents experience an increased influence from peers, as friendships become central to their lives. Furthermore, a teen’s ability to think abstractly allows them to recognize that rules and laws are created by society. They may begin questioning the absolute authority of parents, schools, government, and other traditional institutions. Adolescents also begin engaging in relativistic thinking, questioning others’ assertions and moving away from accepting information as absolute truth. They begin to differentiate between rules based on common sense (e.g., don’t touch a hot stove) and those crafted from cultural standards (e.g., following dress code standards in specific situations). This shift in thinking often leads to a period of questioning authority across various domains.⁹⁷

Nurses teach parents and caregivers how to support their teen through the various challenges of adolescence by offering emotional support, positive coping strategies, guidance, and understanding. Teaching topics include the following:

• Provide Emotional Support and Validation: Adolescence is a time of emotional ups and downs, so it’s important for caregivers to listen without judgment and validate their teen’s feelings. Offering reassurance and understanding help teens navigate the stress of body changes, social pressures, and identity formation.
• Foster Open Communication: Create an environment where the teen feels comfortable talking about their thoughts, fears, and experiences. Open, non-judgmental conversations about puberty, relationships, and peer pressure can help teens feel more confident and less isolated.
• Model Healthy Body Image: Because body image is a significant concern during puberty, caregivers can model positive body image behaviors by focusing on health and self-acceptance rather than appearance. Encouraging physical activity and healthy eating habits can also promote physical well-being.
• Respect Their Growing Need for Independence: As teens seek more autonomy, caregivers can support their growing independence by giving them opportunities to make decisions, take on responsibilities, and solve problems on their own, while still providing guidance and boundaries.
• Help Manage Social Pressures: Adolescents may struggle with peer pressure, and caregivers can help by offering advice on handling situations involving alcohol, drugs, or unhealthy relationships. Encourage teens to make decisions based on their values rather than fitting in with the crowd.
• Provide Age-Appropriate Information Regarding Puberty: Caregivers should ensure that their teens have accurate information about puberty, sexuality, and relationships. Having honest conversations about these topics can prevent confusion and anxiety.
• Acknowledge the Impact of Puberty: Recognize that the physical, emotional, and cognitive changes teens experience can affect their self-esteem and behavior. Offering empathy during this period can make a big difference in how teens cope with their developing identity.
• Provide Chemical Substance Education: Educating adolescents about the risks of substance use and its effects on their physical and emotional health can help them make more informed decisions. Caregivers should also discuss the potential consequences of risky behaviors, such as impaired judgment leading to driving under the influence or unprotected sexual activity.
• Encourage Positive Activities: Helping adolescents engage in extracurricular activities, hobbies, or sports can provide a constructive outlet for their energy and emotions. These activities also promote self-esteem and a sense of belonging.
• Seek Professional Support: If an adolescent struggles with emotional challenges or substance use, caregivers should consider seeking help from a mental health professional or counselor. Therapy and support groups can offer additional tools for managing emotions and addressing risky behaviors.
• Set Clear Boundaries and Expectations: While fostering independence, caregivers should maintain consistent boundaries and rules regarding substance use and risky behaviors. Clear expectations, coupled with appropriate consequences, can help adolescents feel more secure and guided during this challenging period.
• Model Healthy Coping Mechanisms: By demonstrating positive ways to manage stress, anxiety, and emotions—such as exercise, mindfulness, or talking about feelings—caregivers can encourage adolescents to adopt these strategies themselves.

INFANT BEHAVIORS

Health teaching about expected infant behaviors and suggested parent responses include the following topics^35,36,37:

• Crying is normal for healthy babies, especially in the late afternoon and evening.

  • When your baby cries, check and address common causes such as being hungry, tired, having a wet or soiled diaper, or being uncomfortable.
  • Notice what helps calm your baby when they are crying, such as stroking them on the head, sucking on a pacifier or finger, rocking, or holding them while swaying.
  • Contact your pediatrician if your infant cries excessively.
• As babies grow, they become more aware of the world around them. They will begin to explore their world by lifting their head and turning their head to the side. Babies give cues they would like to bond with you, such as making eye contact, cooing, laughing, or smiling at you and looking interested. When you respond to your baby’s behavior with a smile, touch, or cuddle, your baby feels the world is a safe place to play, learn, and explore.
• During playtime, place your baby on their stomach for “tummy time” for a few minutes they are awake to develop their neck muscles. See Figure 13.11³⁸ for an image of tummy time. Supervise them at all times during tummy time and do not allow them to sleep on their tummy.
• Between the ages of six to eight months, infants often develop stranger anxiety and separation anxiety. Separation anxiety peaks around 14 months and then decreases.

  • When leaving your infant with a caregiver, firmly say “goodbye” and promptly leave the area. Do not sneak away without saying goodbye, as this can increase the infant’s anxiety.

Figure 13.11

Tummy Time.

INFANT ROUTINE CARE AND HEALTH PROMOTION

Common teaching points and suggested caregiver actions regarding routine infant care include the following^39,40,41:

• Develop a routine for napping, feeding, playing, and bathing. When your baby is awake, hold and cuddle with them, talk and read to them, and sing simple songs to them.
• Infants sleep about 16 hours per day, but their sleep patterns are unpredictable. Put your baby to bed lying on their back when they are drowsy but still awake so they learn to fall asleep on their own.
• Clean your baby’s mouth and teeth with a soft wet cloth or toothbrush twice daily to prevent tooth decay. Teething begins about 4 to 7 months of age, typically with the bottom two front teeth followed by the top two front teeth. You may notice more drooling or the baby’s desire to chew on things. Teething may cause periods of irritability with disrupted sleeping and eating patterns. To provide comfort, parents can rub the baby’s gums with a clean finger or provide something safe for them to chew on such as a wet or frozen washcloth. Ask your pediatrician about administering acetaminophen for teething pain.⁴²
• Maintain your health as a parent so that you can safely care for your family. Wash your hands frequently and avoid exposure to others who are ill. Keep your vaccinations up-to-date according to CDC recommendations. It is common for women to feel down or depressed after having a baby. If you have had feelings of depression, hopelessness, or little interest in doing things, notify your health care provider.
• Community agencies are available if you have concerns about your living situation. (See the previous “Family Wellness” subsection for resources.)

INFANT NUTRITION

Nutrition in infancy affects both physical and cognitive development. Common teaching points regarding infant feeding and caregiver actions include the following^43,44:

• Feed your baby solely breastmilk or formula until they are about six months old.
• Watch for hunger cues such as putting their hand in their mouth, rooting, or fussing. Crying is a late sign of hunger.
• Monitor the number of wet diapers and bowel movements every day. You will know your baby is getting enough to eat if they have at least five wet diapers and three bowel movements every day.
• If you are breastfeeding, do so on demand (as your baby indicates they are hungry) or at least every three hours. Eat a healthy diet and continue to take your prenatal vitamins. Avoid drinking alcohol if you are breastfeeding. Administer vitamin D drops to your baby as prescribed.
• If your baby is formula-fed, follow the manufacturer’s instructions carefully. Expect babies to eat six to eight times a day, but if they continue to be hungry, you can feed them more. Prepare, heat, and store formula safely. Do not heat formula in the microwave because hotspots can burn your baby’s mouth. Instead, warm bottles in a container of hot water. Always hold the bottle while you’re feeding the baby; don’t prop the bottle on something because this can cause choking.
• You can begin supplementing with solid food, juice, or water when your baby is six months old. Introduce one “single-ingredient” new food every three to five days and watch for reactions such as a rash, hives, or shortness of breath. Within a few months, babies should be eating a variety of foods such as cereal, vegetables, fruits, eggs, meat, and fish. To prevent choking, foods should be soft, easy to swallow, and cut into small pieces. Foods to avoid because of their potential to cause choking include hot dogs; nuts; seeds; chunks of meat or cheese; whole grapes; popcorn; chunks of peanut butter; raw vegetables; large fruit chunks, such as apple chunks; and hard, gooey, or sticky candy. Babies do not need added salt and sugar. A sippy cup of water can be introduced around five to six months. A spoon can be introduced around six months, although the infant will not necessarily be adept at its use yet.⁴⁵

INFANT SAFETY

Common teaching points regarding safety include the following topics^46,47,48:

• Never shake a baby. Their neck muscles are too weak to support their head, so shaking can cause brain damage and death or serious disability.
• Use a rear-facing infant car seat placed in the back seat of a vehicle. Never place an infant car seat in the front seat of a vehicle that has a passenger air bag unless there is a feature to turn off the airbag. Keep the car seat at the correct angle (based on the indicator on the car seat) to keep the baby’s airway clear. Fasten the car seat firmly in the vehicle so it does not move more than an inch in any direction. Remove bulky clothing such as a winter coat. Place the baby’s back and buttocks firmly against the car seat. The harness straps should come out of the seat at the level of the baby’s shoulders and should fit snugly. Position the chest clip at the baby’s chest between their nipples. Children of all ages should stay in the car seat while traveling. If the infant becomes fussy or needs to be fed, stop the car and take them out of the car seat. Avoid providing extra toys that could potentially become projectiles in a collision. Only attach accessory pieces provided by the manufacturer and avoid aftermarket accessories such as pads.
• Never leave the baby alone in a vehicle. Temperatures can quickly rise in a vehicle and cause death.
• Place the infant on their back on top of one sheet in their crib to sleep. Don’t put soft objects like pillows, blankets, stuffed animals, or bumper pads in the crib because these items can cause suffocation. Do not share a bed with the baby due to the risk of accidentally rolling onto the infant causing suffocation. The baby should sleep in their crib in the parent’s room until they are at least six months old.
• Keep hanging cords, strings, and necklaces away from the infant to prevent strangulation.
• There are several safety actions to take to prevent injuries from falls. Keep your hand on the baby while changing their clothes or diapers to prevent them from rolling off the surface. Use a safety strap in swings, high chairs, shopping carts, carriers, and strollers. Place infant seats on the floor, not on a high surface, because infants may move the seat by kicking. Keep cribs and furniture away from windows because infants can crawl and climb and fall out the window. Use a stationary activity center instead of walkers because infants can fall down stairs or tip over in walkers. Secure heavy furniture and televisions to the wall to prevent them tipping on the baby.
• To prevent choking, closely supervise infants at all times. By age three to four months, they put objects into their mouth to explore and learn, but these objects can be choking hazards. Keep objects small enough to fit through a toilet paper tube away from infants until they are about age three to prevent choking. Infants should be fed sitting up and not lying down.
• Prevent burns with several safety actions. Set the hot water heater at 120 degrees or lower and check the bath water temperature before placing the baby in it. Store button batteries, matches, and lighters out of reach because if swallowed, saliva creates an electric current that causes burns. Place barriers around furnaces and fireplaces and teach children to stay three feet away from stoves. Cook on back burners on a stove and turn handles facing the back. Ensure a working smoke detector and carbon monoxide detector are on every level of the residence and in every sleeping area to warn occupants in case of a fire or carbon monoxide presence. Test the alarms periodically to make sure they work and change the batteries every six months.
• Infants can drown in as little as an inch of water. Closely supervise infants near or in water. Empty small pools or buckets of liquid when not in use. Infants can be introduced to swimming at age six months.
• To prevent illness, do not smoke in the home or the car. This prevents secondhand smoke exposure. Test your home for radon and mold.
• Know cardiopulmonary resuscitation (CPR) and have emergency numbers displayed in a visible location.

TODDLER BEHAVIORS

Toddlers begin to explore their environment and develop autonomy. Specific toddler behaviors that are a part of normal development, as well as pertinent caregiver teaching points, are listed below^50,51,52:

• As toddlers learn about their independence and autonomy, they may frequently say “No,” scream, throw things, or have tantrums. They may run away when you call them, creating a safety concern in outdoor settings.

  • Be patient with your child and try to meet their needs in a loving and positive way.
  • When possible, don’t ask questions that can be answered “Yes” or “No,” but instead offer a choice between two options that are acceptable to you.
  • Use simple, clear words and phrases to promote language development and improve communication.
  • Set clear, age-appropriate rules and be consistent with consequences. Use timeouts lasting one minute per year of age as a consequence. Avoid physical punishment such as spanking because it can damage your child’s physical and mental health. Reward good behavior with positive reinforcement.
• As toddlers learn how to deal with feelings of frustration, anger, and other negative emotions, they may hit, bite, or scream. They may bang their head for self-soothing.

  • Help toddlers name their emotions, use positive coping strategies like distraction, and avoid distressing situations when feasible. Head banging may occur but typically resolves on its own; talk with your health care provider about concerns.
• Egocentrism is common for toddlers, and they often have difficulty sharing as they learn how to interact with their peers.

  • Use a timer to help a group of toddlers learn how to share toys, while also respecting a toddler’s “favorite” items and explaining how other people also have favorite things.
• Toddlers may have trouble sleeping.

  • Establish routines for naptime and bedtime. Provide a favorite toy for self-soothing during sleep time. If they awaken during the night, provide brief reassurance.

Tantrums

A specific toddler behavior is a tantrum, a brief episode where a toddler expresses anger or frustration with behaviors such as screaming, flailing, going limp, crying, throwing objects, or holding their breath. However, none of the tantrum behaviors are a threat to the child’s well-being. A tantrum lasts from 30 seconds to three minutes, and the toddler otherwise demonstrates normal behavior between tantrums. On average, toddlers have one tantrum per day, and the frequency and intensity of tantrums decrease as they grow older. Tantrums begin around two years of age and dissipate as children learn to effectively verbally communicate their needs. Tantrums are often triggered by fatigue, hunger, illness, or frustration. Toddlers may learn they can manipulate others into getting what they want or avoiding something they don’t want by having a tantrum.⁵³ See Figure 13.12⁵⁴ for an image of a tantrum.

Figure 13.12

Tantrum.

Nurses help parents understand tantrums and teach them techniques for managing them with positive parenting. Remind parents that tantrums are a normal part of child development, and when a toddler demonstrates tantrum behaviors, they are not trying to be “bad,” nor does it mean the parents are bad parents. Parents should try to identify factors that trigger tantrums, such as hunger and fatigue, and avoid them if possible. Illness can also cause tantrum behavior. Parents can use the following techniques to help a child manage tantrums⁵⁵:

• Remain calm and state the rule or expectation quietly and firmly.
• Ignore the tantrum behavior. Leave the room if it is safe to do so.
• Use distraction to focus the child’s attention on an alternative activity.
• Meet the child’s physical and safety needs without giving in to their demands.
• Modify the child’s environment to avoid conflict and tantrums.
• Use time-outs of one minute per the child’s year of age to allow the child to calm down.
• Avoid physical punishment because it teaches that physical force is a way to get what one wants. Physical punishment may also increase the severity or duration of the tantrum.
• If a child is self-injurious, damages property, has tantrums lasting longer than 25 minutes, or has more than five tantrums daily, notify the pediatrician for further evaluation. Potential causes include visual and hearing impairments, lead neurotoxicity, or mental health conditions.
• Use positive parenting behaviors.

TODDLER ROUTINE CARE AND HEALTH PROMOTION

TODDLER NUTRITION

Toddlers may be picky eaters. Around 12 months old, toddlers often slow in their eating patterns because their growth rate slows. They may go for a few days without eating much. Parents are encouraged to serve one to two tablespoons of each type of food and add more if they still appear hungry. Toddlers may vary what they want to eat each day, so parents should allow toddlers to make simple choices. Parents are encouraged to offer their toddler a variety of foods about every two to three hours, or about five or six times a day, equaling about three meals and two to three snacks every day. Toddlers should drink between 16 ounces and 24 ounces of milk daily for healthy bone development and about 16 to 32 ounces of water per day. If a parent has concerns about their child’s food intake, they should contact their pediatrician.⁶⁵

TODDLER SAFETY

Toddlers must be supervised at all times because their judgment is not as developed as their ability to move around in their environment. They move quickly and are able to access objects and environments that place them in danger from the following types of accidents due to their increased mobility:

• Wandering off and getting lost
• Getting hit by a car
• Falling down the stairs
• Drowning in as little as an inch of water

• Cover electrical outlets.
• Ensure smoke alarms and carbon monoxide detectors are installed in every level of the home and test them monthly.
• Keep medications, vitamins, and supplements out of reach. Use childproof lids when possible. Keep the United States poison help number (800-222-1222) in a visible location in case a child ingests a harmful substance.
• If firearms are present in the home, keep them locked, unloaded, and inaccessible to children. Store ammunition in a separate location.
• Adjust the crib mattress to the lowest setting in case the toddler climbs out of bed.
• Empty small pools and buckets of fluids when not in use to prevent drowning. Supervise children at all times near water (for example, bathtubs, pools, ponds, lakes, whirlpools, or the ocean). Ensure backyard pools are fenced and the gate locked when not in use.
• Keep sharp objects, candles, and matches out of reach.
• Place knob covers on stove panels to prevent toddlers from turning them on, and when cooking, keep pot/pan handles turned towards the back of the stove.

EARLY CHILDHOOD ROUTINE CARE AND HEALTH PROMOTION

By age four, children can typically get dressed, undressed, and go to the bathroom independently, although they may have incontinence at night. Preschoolers are very physically active but also need time to rest, play quietly, and use their imaginations. Make-believe and dress-up are important types of play for this age. Parents should provide opportunities for preschoolers to play with friends. Preschoolers may have imaginary friends whom they view as helpful, or they may blame for poor behavior. Screen time should be limited to 60 minutes per day of quality children’s programming. Parents should read books as a way to talk together, and they should ask questions about the story as the child learns to read to enhance reading comprehension.⁷⁰

Parents should assign daily chores based on the child’s developmental level to build their sense of accomplishment and self-confidence. For example, a preschooler can help make their bed, put their toys away, or put dirty clothes in the clothes basket.⁷¹

Preschoolers need about 10 to 13 hours of sleep each day, including naps. If the child no longer takes naps, schedule a quiet time during the day. It is common for preschoolers to not want to go to bed and to wake up in the middle of the night. Sometimes sleep can be interrupted by nightmares, night terrors, and sleepwalking. Nightmares are frightening dreams that usually awaken the sleeper. Night terrors are similar to nightmares in that the child appears to wake up, but they are very upset, often screaming, and are not consolable and not aware that someone is trying to help them feel better. Eventually, the child goes back to sleep and doesn’t usually remember the night terror when they awaken in the morning. Sleepwalking, also known as somnambulism, is a sleep disorder that causes individuals to walk or perform other activities while they are still asleep. Parents can be instructed to gently guide children who are sleepwalking back to bed. If they awaken, they may be confused or disoriented for several minutes but are not likely to remember the incident in the morning.^72,73,74

Most children lose their first primary tooth around age six and then continue to lose primary teeth for the next six years as their permanent teeth grow in. Parents should continue to reinforce the importance of brushing and flossing teeth twice daily to prevent cavities and schedule semi-annual dental appointments.^75,76

Regular vision screening before the age of three and treatment before age six can help prevent vision loss. See Figure 13.13⁷⁷ for an image of a child with glasses. It can sometimes be difficult to discern if a child is having vision problems, but parents should report signs such as tilting of the head, squinting, irritability when asked to complete tasks that require long-distance vision, rubbing the eyes, shutting and covering one eye, excessive blinking, and headaches.

Figure 13.13

Vision.

Two common childhood eye conditions are functional amblyopia and strabismus. Functional amblyopia, also called lazy eye, is caused by imbalanced eye muscles and occurs when one eye is not used as much as the other eye. Initial treatment is patching of the dominant eye to build muscle strength in the weaker (lazy) eye. Strabismus is misalignment of the eyes, causing them to point in different directions.

EARLY CHILDHOOD NUTRITION

Preschoolers often have a reduced appetite because they have a slower growth rate at this age. Parents should provide healthy food choices, especially fruits and vegetables, and allow the child to decide how much to eat. Foods and drinks high in added sugars and saturated fat should be limited.⁷⁸

Proper nutrition is extremely important because children are learning life-long habits that affect their growth, development, and health. The most important way to encourage children to eat healthy foods is to repeatedly offer them. Parents can make foods more enticing by offering vegetables with dip or sauce, giving small servings, and involving children in meal preparation. The following tips help parents set up a healthy eating routine for their families⁷⁹:

• Eat together as a family as much as possible. Keep mealtimes enjoyable.
• Maintain a schedule of specific times for meals and snacks rather than eating all day.
• Keep healthy foods on the counter where they can easily be seen and accessed throughout the day.
• Offer healthy food choices and water before treats for each meal and snack.
• Limit the number of high sugar, salty, processed, and unhealthy fat foods present in the home.
• Set an example of choosing healthy foods and allow your child to observe these choices.
• Don’t pressure your child to finish all food on their plate because it teaches them to ignore their own satiety signals.
• Do not use food as a reward or punishment as this can contribute to the development of unhealthy eating habits or disorders later in life.

EARLY CHILDHOOD SAFETY

As children becomes more independent in the early childhood years, it is important to teach parents and children the following tips for staying safe^80,81:

• Children should continue to be in a forward-facing car seat with a harness until they reach the top height or weight limit recommended by the car seat’s manufacturer. At that point, they can switch to a booster seat, but it should still be placed in the back seat of the vehicle.
• Teach children why it is important to stay off the road and out of traffic when playing. Tell them not to play in the street or run after stray balls.
• When a child is riding a bicycle, ensure they are wearing a well-fitting helmet. Teach them to stay on the sidewalk and away from the street unless they are riding with an adult.
• Teach children how to swim and to wear life jackets during water sports. Supervise them at all times when they are in or around bodies of water.
• Teach children how to be safe around strangers.
• Develop a family plan for exiting the residence in the event of a fire and establish a meeting place after exiting.
• Keep medications and firearms out of reach and locked up.

SCHOOL-AGE BEHAVIORS

School-aged children are in regular contact with the larger world outside their family. Physical, social, and mental skills develop quickly, and friendships become more important. This is a critical time for children to develop confidence in all areas of life, including friendships, schoolwork, and hobbies.⁸²

SCHOOL-AGE ROUTINE CARE AND HEALTH PROMOTION

Parents can help children meet their physical needs with good nutrition, structured sleep, and daily exercise. School-aged children should get 9-12 hours of sleep at night and at least an hour of physical activity daily.⁸³

A parent can build their relationship with their child by talking to them about school, friends, and goals for the future. They should schedule activities they can do together. Parents can talk to their children about respecting others, helping others in the community, and problem-solving when they have disputes with others. Parents teach children right and wrong and provide guidance on how to handle hypothetical situations such as if friends try to pressure them into risky behaviors like smoking, drinking alcohol, or using illicit drugs.⁸⁴

Children learn responsibility by independently completing chores that parents assign and then monitor to ensure the assigned tasks are completed thoroughly and accurately. Clear rules combined with effective discipline help the child understand what is expected behavior and what happens when they do not fulfill their responsibilities. Parents should provide praise that focuses on behavior or a task the child accomplished, rather than on a trait the child can’t change (such as intelligence). Time-outs can still be used as a discipline strategy during the school-aged years to help the child calm down and reflect on their behavior.⁸⁵

Scoliosis

Scoliosis is an abnormal lateral curve that can become evident during physical examination after age 11. See Figure 13.14⁸⁶ for an image of scoliosis. Additional symptoms of scoliosis include the following⁸⁷:

• One shoulder and/or hip is higher than the other
• One scapula protrudes more than the other
• One side of the rib cage is higher when bending over
• At its most extreme, children can experience back pain or dyspnea

Figure 13.14

Scoliosis.

If scoliosis is suspected, an X-ray of the spine is ordered. Treatment is based on the severity of the scoliosis and if the child is still growing. Treatment choices include observation and waiting, back bracing, surgery, and/or physical therapy. Nurses can also recommend a support group to help a child or teen cope with this chronic condition and its treatment.

SCHOOL-AGE NUTRITION

Children should avoid food choices with excessive fat, sugar, and salt. The average American child consumes almost two pounds of sugar a week, which can lead to childhood obesity. Be aware of hidden sugar in juices, cereals, granola bars, ketchup, and crackers. Children who grow accustomed to high-fat, very sweet, and salty flavors may have trouble eating healthy foods with subtle flavors such as fruits and vegetables because they won’t be as appealing to them.⁸⁸

SCHOOL-AGE SAFETY

School-aged children gain independence and are not always with their parents. Parents can initiate safety plans by knowing where their children are, when they will return, and how to contact them. Many children get home from school before their parents get home from work. It is important to have clear rules and plans for when the child is home alone. Parents should also get to know the parents of their children’s friends and their contact numbers, and make sure a responsible adult will be present during planned activities.⁸⁹

Using a bike for transportation helps school-aged children gain more independence, but brings additional safety risks due to injuries. Helmets should be worn when riding a bike, snowmobile, or all-terrain vehicle, as well as when participating in activities such as contact sports, skateboarding, or using inline skates to minimize the risk of head injuries.⁹⁰

Sports are beneficial for children physically, mentally, and socially. Children should have a pre-participation exam, also called a sports physical, before participating in sports to evaluate their health. The health care provider clears the child for participation in sports provided they do not have any underlying health concerns. Children should drink water before and during sports activities, and adults should be present to enforce safety rules. Children should have at least ten weeks off from any one sport in a year to help prevent repetitive use injuries.⁹¹

Some sports carry the risk of concussion. Symptoms of a concussion may show up immediately or weeks after an injury and include the following⁹²:

• Mental changes like confusion, forgetfulness, or concentration issues
• Loss of consciousness
• Behavior or personality changes
• Vision changes
• Light or noise sensitivity
• Headache or dizziness
• Nausea

Firearms are a leading cause of death in children in the United States. Parents should teach gun safety to young children, as well as to not touch a gun without an adult present. Children should know to immediately tell an adult if they see a gun at school or other location. If guns are present in the home, they should be locked, unloaded, located out of reach of children, and the guns and ammunition should be stored separately.⁹⁴

School-aged children should travel in the back seat of a vehicle in a booster seat until they fit properly into a seat belt. For a seat belt to fit properly, the lap belt must lie snugly across the upper thighs, not the stomach. The shoulder belt should lie snug across the shoulder and chest and not cross their neck or face.⁹⁵

As children grow older, they should learn about fire safety. Families should have a safety plan and practice what to do in case of fire. If they hear a smoke alarm, children should know to get low and get out of the house. Families should have a planned meeting place in case of evacuation.⁹⁶

ADOLESCENT BEHAVIORS

Adolescence is a time of many physical, mental, emotional, and social changes. Puberty begins, and some teens may worry about physical changes in their bodies and how they are viewed by others. They become more independent and make more of their own choices about friends, sports, studying, and academics. They desire independence and often test limits set by parents. Their emotions often become more intense and variable and sometimes might seem rude or short-tempered. They typically express less affection toward parents, but parents still serve a vital role in guiding and protecting them. When conflict occurs, parents should be clear about goals and expectations (such as getting good grades, keeping their room clean, and showing respect), but allow the teen to provide input on how to reach these goals (such as when and how to study or clean).⁹⁸

Some teens develop mental health problems such as depression, anxiety, or eating disorders. Parents should pay attention to changes in their teen’s behavior and watch for warning signs of mental health conditions. If a teen seems particularly sad or depressed, parents should ask if they have had suicidal thoughts. Suicide is the third leading cause of death among youth 15 through 24 years of age. Parents should seek professional mental health assistance for their teens as needed.⁹⁹

ADOLESCENT ROUTINE CARE AND HEALTH PROMOTION

Teens need about nine to ten hours of sleep each night, but most don’t get enough sleep. Melatonin levels naturally rise later at night and fall later in the morning in teens than in children and adults, which may explain why many teens stay up late and struggle with awakening in the morning. A lack of sleep can make it difficult for teens to pay attention, can increase feelings of irritability and depression, and can increase impulsive behavior.¹⁰⁰ Parents can help promote sleep hygiene by not allowing television sets in the teen’s bedroom and by setting limits for screen time before bedtime, including cell phones, computers, video games, and other devices.¹⁰¹

Teens should be encouraged to be physically active for at least an hour every day. They can join a sports team or an individual sport or help with household activities like mowing the lawn or walking the dog to stay active.¹⁰²

ADOLESCENT NUTRITION

Dietary choices and habits established during adolescence greatly influence their future health, yet many studies report that teens consume few fruits and vegetables and are not receiving the calcium, iron, vitamins, or minerals necessary for healthy development. One of the reasons for poor nutrition can be related to anxiety about their body image. How adolescents feel about their bodies can affect how they feel about themselves as a whole. If a teen experiences sudden increases in height and weight, they may adjust their eating habits to lose weight. They are simultaneously bombarded by messages in the media related to ideal body image, appearance, attractiveness, weight, and eating, and some teens may experience teasing by their peers, which causes additional anxiety about their weight and appearance.¹⁰³

Mealtime is very important for families. Eating together can help parents guide teens in making healthier choices about the foods they eat, promote healthy attitudes about weight and appearance, and allow family members time to talk with each other and maintain good relationships.¹⁰⁴

ADOLESCENT SAFETY

Most injuries sustained by adolescents are related to risky behavior such as reckless or distracted driving, alcohol and illicit drug use, and unprotected sex. These are discussed in more detail in the subsections below.¹⁰⁵