Toddler

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					                                                          NUR 471 FNP I class notes   1




      NUR 471 Family Nurse Practitioner I - Toddlers
                                    Spring 2012

Toddlers – usually defined as 12-24 months old; Preschoolers as 2-5 years

Well Child visit schedule
Bright Futures by AAP - http://brightfutures.aap.org/about.html
     12 months
     15 months
     18 months
     24 months

(See Burns chapter 6 and Hay chapter 2)

Toddlers - Growth
• Weight triples (birth wt) by one year
• Weight quadruples by 30 months
• Weight gain slows between 2-3 years
• Toddlers begin walking @ 12-15 months
• Typical toddler is top heavy, bowlegged, and with a protruding abdomen

Toddler - Development
• Vision 20/70 by 2-3 years
• 15 months will scribble
• 18 months – tower of 2 blocks
• Enclosed circle by 3 years
Toddler - Anticipatory Guidance
• Discuss dental hygiene – teeth brushing, 1st dental exam, bottle usage
• Discuss reportable signs/symptoms of illness
• Discuss age/weight appropriate medication administration
• Review developmental milestones
Anticipatory Guidance
Nutrition
• Cow’s milk, egg whites, orange juice, small amounts of honey or peanut butter OK
  after 12 months
• No nuts, raisins, popcorn, gum due to high aspiration potential
• Hot dogs should be cut into small triangles
• Work on discontinuing bottle after 15 months
• Start cup and spoon after 12 months
                                                        NUR 471 FNP I class notes    2



Communication
• 15 – 18 months
   • Vocalizes/gestures or speaks words to communicate (3-10)
   • Points to body parts
   • Understand simple commands
• 24 months
   • Vocabulary of at least 20 words
   • Uses 2-word phrases
   • Comprehension is greater than verbal capacity

Oral hygiene (20 primary teeth at age 2)
    Teeth brushing
    Bottle usage

Healthy weight
   Limit television viewing; reading
   Physical activity/limit inactivity
   Safe play

Sleep
   • 24 hour need 12-14 hours
   • Nocturnal sleep 11-12 hours
   • Naps – 2 naps until about 18 mos then 1 nap

Safety and Injury Prevention
• Safety – child proofing of home
• Electrical/Fire
• Plastic bags
• Crib to bed transition
• Car seat and helmet safety
• Hazardous materials/Poison control
• Firearm
• Climbing/Door locks
• Water

Immunizations
• Review each visit: According to CDC Recommended Immunization Schedule
  http://www.cdc.gov/vaccines/recs/schedules/downloads/child/0-18yrs-pocket-pr.pdf

Screenings
Iron deficiency anemia
• Hgb/Hct usually screened at 9-12 mos.
• Most common anemia in childhood (acquired microcytic/hypochromic anemia- low
  MCV/MCHC)
                                                              NUR 471 FNP I class notes       3


• Onset between 6-24 months
• Symptoms: pale, irritability, recurrent infections, PICA, decreased exercise tolerance,
  systolic ejection murmur (chronic)

• Refer if:
   – No improvement after treatment with iron supplement (recheck 1-4 weeks
     depending on severity)
   – Hgb less than 7 (immediately)
   – If suspect chronic iron def. anemia with neurocognitive or cardiac symptoms

Lead screen
• Major source; lead based paint and lead contaminated dust found in deteriorating
  building
   • Frequently unrecognized since few symptoms early (children under 6 at highest
       risk)
   • Can cause learning and behavioral problems, lethargy (if high: seizures, coma,
       death)
   • Screened if considered high risk (lead level >10 on finger stick do blood draw;
       10-14 class II – recheck in 6 months)
• Other sources for exposure;
  • Hobbies – stained glass
  • Work – working on/recycling auto batteries
  • Drinking water – lead pipes/solder/brass fixtures (houses built before 1946)
  • Home remedies – Arzacon, greta (used for upset stomachs, pay-loo-ah
      (rashes/fevers)

Basic Personal Risk for Lead
• Does your child live in/regularly visit a house or child care facility built before 1950?
• Does your child live in/regularly visit a house/child care facility built before 1977
  that’s been recently remodeled?
• Does your child have a sibling or playmate who has/had lead poisoning?
Selective Screening
    Hearing - if not already done
    Vision - if concerns, abnormal exam or at-risk
    Autism
    TB screen
      • Number of cases in children < 15 yrs has increased 40% since 1987
      • Risk Factors:
        • Close contact with adult with pulmonary TB
        • HIV infection or immunosuppression
        • Diabetes mellitus
        • Renal disease
        • Malnutrition/Poverty/Over-crowded living
   Mantoux given (live vaccine such as MMR and VAR suppress the reactivity of TB-
                                                           NUR 471 FNP I class notes    4


   postpone TB for 6 weeks if possible, or give TB and hold MMR until TB is read)

Failure to Thrive (see previous notes – Infant)

Injury Prevention
Child Abuse and Neglect
• Parental risk factors
   – Hx of being abused as child
   – Poor socialization or lack of trust in others
   – Poor coping with stress, anger and frustration
   – Substance abuse or mental illness with psychosis
   – Member of fringe group cults or sects
• Child Risk Factors
   – Age less than 3 years
   – Infants separated from mothers at birth
   – Born with congenital anomalies
   – Chronic illness
   – Foster children
Most common trigger events?

Accidental
• Splash
• Insect bites – looks like multiple scars
• Black eye from frontal head contusion
• Mongolian spots
• Coining/Cupping
Common Problems
Amblyopia
  • Decrease in vision in one or both eyes for which no organic cause can be detected.
  • Severity of visual loss depends on nature of visual deprivation, age of onset,
    consistency, severity, and duration (treatment rarely effective after 8 years of age)
  • Form of deprivation or absence of stimulation of the immature visual system

Other vision problems
  • Cataract
  • Strabismus
  • Anisometropia (one eye out of focus)

The Picky Eater (grazing)

Temper tantrums and discipline
   Clinging typical at 18 months
   Conflict situations
   Distraction
                                                NUR 471 FNP I class notes   5


      Positive versus negative reinforcement
      Care givers consistency
      Breath-holding spells

Sleep problems (see handout)
   • Behavioral insomnia
   • Sleep (night) terrors
   • Somnambulism (sleep walking)
   • Restless legs syndrome
   • Snoring and Obstructive Sleep Apnea

Toilet Training

Child care

Dental Care/Common Problems
  • Dental Caries
  • Maxillary Frenum
  • Frenum
  • Malocclusion

				
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