Chapter 26
Growth and Development of the
Toddler
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1
Physical Growth
 Weight increases steadily in spurts (slower rate than infant)
o Average weight gain = 3 to 5 lb per year
 Length/height increases steadily in spurts (slower rate than
infant)
o Average increase 3 in per year
o About ½ adult height by age 2
 Head size more proportional to body by age 3
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Physiologic Changes #1
 Neurologic system
o
Anterior fontanel closes by 18 months
o
Brain = 90% adult size by age 2
o
Increased myelination = improved coordination, balance, and sphincter control
 Respiratory system
o
Alveoli continue to increase in number
o
Trachea and airways remain small compared to adult
o
Tonsils and adenoids are relatively large
 Cardiovascular system
o
Heart rate decreases
o
Blood pressure increases
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Physiologic Changes #2
 Gastrointestinal system
o
Stomach increases in size
o
Small intestine grows in length
o
Less frequent stools—color varies with diet
o
Bowel control typically achieved by end of toddler period
 Genitourinary system
o
Bladder and kidney reach adult function by 16 to 24 months  bladder control fully
developed at 2 years of age
o
Bladder capacity increases
o
Urethra remains relatively short
 Musculoskeletal system
o
Muscles maturing
o
Swayback and pot belly until 3 years old
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Sensory Development
Hearing intact since birth
Visual acuity continues to improve
May prefer certain smells
May prefer certain textures (soft vs. scratchy
clothes)
Explore environment with all five senses!
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Developmental Theories

Data from Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: W.W. Norton and Company; Goldson, E., & Reynolds, A.
(2018). Chapter 3:

Child development and behavior. In W. W. Hay, Jr., M. J. Levin, R. R. Deterding, & M. J. Abzug. (Eds.), Current diagnosis and treatment:
Pediatrics (24th ed.,

pp. 67–97). New York, NY: McGraw-Hill Education.; and Piaget, J. (1969). The theory of stages in cognitive development. New York, NY:
McGraw-Hill.
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Emotional and Social Development
 Separation
o
Seeing oneself as separate from the parent
 Individuation
o
Forming a sense of self
o
Learning to control one’s environment
o
Leads to emotional lability
 Egocentrism
o
Focus on self
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7
Typical Toddler Behaviors
 May fear:
 Security item
 Gender difference awareness
o
Strangers
 Aggressive behaviors
o
Loss of parents
 Unclear body boundaries
o
Becomes more self-aware
o
Resists invasive procedures
 Separation anxiety may
reoccur
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Question #1
The nurse praises a 3-year-old child for using the
potty. Which of the following theorists focuses on the
satisfaction/frustration of expelling feces?
a. Piaget
b. Freud
c. Erickson
d. Kohlberg
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Answer to Question #1
b. Freud
Freud’s theory focuses on the satisfaction and/or
frustration of expelling feces (anal stage).
Rationale: Piaget’s theory focuses on development of
the senses of the toddler; Erickson’s theory focuses
on achievement of autonomy and self-control;
Kohlberg’s theory focuses on the moral development
of the toddler.
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Motor Skills
 Gross motor
 Fine motor
o
Initial walking with
“toddler” gait
o
Pushing or pulling a toy
o
Later includes:
 Running
 Climbing
 Jumping
 Throwing a ball
o
Progresses from holding
and pinching
o
Manages utensils
o
Holds crayon
o
Strings a bead
o
Works a puzzle
o
Uses a touch screen
 Pedaling a tricycle
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11
Speech Development
Receptive language
o Far more advanced in early toddlerhood than
expressive language
Telegraphic speech
Echolalia
Bilingual mixing language learning
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12
Encourage Age- Appropriate
Developmental Tasks
Hospitalized toddlers at play
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13
Promoting Growth and Development
Through Play
 Daily need:
 Play
 Major socializing medium at this
age
o
Egocentric
o
Do not like to share
o
30 minutes of structured
physical activity
o
1 to 3 hours of
unstructured physical
activity
 Parallel play
 Limit television
 Short attention span
 Encourage creative and physical
play
o
Change toys frequently
 Toys that engage multiple
senses
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Question #2
Is the following statement true or false?
A colorful simple board game that requires multiple
players to cooperate with each other for a common
goal would be the best type of toy for toddlers.
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Answer to Question #2
False. Toddlers tend to engage in parallel, solitary play and
are not likely to cooperate in a group game situation because
of their basic egocentric nature.
Rationale: The best toys for toddlers are familiar household
items, child-size household items, blocks, cars, plastic figures,
stuffed animals, dolls, doll beds, and carriages. Manipulative
toys with knobs and buttons that make things happen, shapes
to insert into matching holes, puzzles, chalk, buckets and
shovels, and floating toys are also recommended. Appropriate
gross motor toys include gyms, tricycles, pull toys, and
wagons.
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16
Sleep Requirements
 Sleeps through night, takes one daytime nap
o 18 month old: 13.5 hours of sleep per day
o 24 month old: 13 hours of sleep per day
o 3 year old: 12 hours of sleep per day
 Consistent bedtime rituals help the child prepare to sleep
 May discontinue daytime napping around 3 years of age
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17
Promoting Safety
 Increasing mobility REQUIRES increased vigilance
 Provide a childproof environment
 Use a safe car seat in back seat of the car
 Provide a safe home environment
o
Avoid tobacco smoke exposure  also for inc risk of AOM
o
Water safety (careful observation)
o
Prevent injury
o
Prevent poisoning
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18
Key Nutrients Provided by Fruits and
Vegetables
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Promoting Self-Feeding
 Child-sized spoon and fork with dull tines
 Appropriate portion size, type, and texture of the food
 Seat the toddler in a high chair or at a comfortable height in a
secure chair
 Include the toddler in family mealtimes; praise attempts at
self-feeding
 Never leave the toddler unattended while eating
 Minimize distractions during mealtime
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20
Toddler Safety During Mealtime
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21
Toddler Feeding
Picky eaters
Food jags
Physiologic anorexia
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Question #3
The nurse is planning a diet for a toddler that is rich in
vitamin A. Which of the following foods might the
nurse include?
a. Avocados
b. Corn
c. Strawberries
d. Carrots
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Answer to Question #3
d. Carrots. Carrots are rich in vitamin A.
Rationale: Avocados are rich in folate, corn is rich in
fiber, and strawberries are rich in vitamin C. Other
foods rich in vitamin A include apricots, cantaloupe,
spinach, mangos, dark greens, and sweet potatoes.
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24
Discipline
 Limit setting
 Negotiation
 Techniques to assist the toddler to learn problem solving
 Offer realistic choices
 Keep instructions simple
 Reinforce desirable behaviors
 Extinction and “Time-outs” for negative behaviors
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25
Common Developmental Concerns
 Weaning
The AAP recommends breastfeeding for at least 12 months, then for as long as is mutually agreeable to
mother and child (AAP, 2020a). Extending breastfeeding into toddlerhood is believed to be beneficial to the child.
Extended breastfeeding provides nutritional, immunologic, and emotional benefits to the child. Contrary to popular
belief, it is biologically possible to become pregnant while breastfeeding. Breastfeeding a newborn appropriately can
occur while continuing to nurse the older sibling.
Weaning from breastfeeding tends to occur earlier in the United States than in countries around the
world, despite recommendations on length of breastfeeding by a number of organizations. The National Association
of Pediatric Nurse Practitioners (NAPNAP) and most other professional organizations recommend breastfeeding for
at least 1 year (Busch et al., 2019). Weaning is a highly individualized decision. Educate the mother about the benefits
of extended breastfeeding and support her in her decision to wean at a given time.
Weaning from the bottle should occur by 12 to 15 months of age. Prolonged bottle-feeding is associated
with the development of dental caries. No-spill “sippy cups” contain a valve that requires sucking by the toddler in
order to obtain fluid, thus functioning similar to a baby bottle. Hence, no-spill sippy cups can also be associated with
dental caries and are not recommended (Hagan et al., 2017). Cups with spouts that do not contain valves are
acceptable. The 12- to 15-month-old is developmentally capable of consuming adequate fluid amounts using a cup.
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26
Common Developmental Concerns (cont)
 Thumb sucking and pacifiers
o
Infants bring their hands to their mouths and begin thumb sucking as a form of self-soothing (Sears & Sears, 2019c). This habit may
continue into the toddler years and beyond. The pacifier is used for the same reason. Toddlers may calm themselves in a stressful
situation by thumb sucking or sucking on a pacifier. Opinions about thumb and finger sucking and pacifier use are significantly
affected by family history and culture.
- For most children, there is no need to worry about a sucking habit until it is time for the permanent teeth to erupt. Prolonged and
frequent sucking in the withdrawn child is more likely to yield changes to the tooth and jaw structure than sucking that is primarily used
for self-soothing. Parents must sort through their own feelings about thumb sucking and pacifier use and then decide how they want to
handle the habit.
o
To ensure safety with pacifier use:
•
Use only one-piece pacifiers.
•
Replace worn out pacifiers with new ones.
•
Never tie a pacifier around a toddler’s neck.
 Parents may want to limit thumb sucking and pacifier use to bedtime, in the car, and in stressful situations. The parent should calmly
discuss these limits with the toddler and then remain consistent about enforcing them (Sears & Sears, 2019a, 2019c).
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Toilet Teaching Readiness Signs
 Has regular bowel movements (usually after 2 years old)
 Expresses knowledge of need to defecate or urinate
 Diaper is not always wet
 Willing to follow instructions
 Walks well alone
 Can pull down pants
 Follows caregiver to bathroom
 Climbs onto potty chair or toilet
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Minimizing Sibling Rivalry
Keep the toddler’s routine as close to normal as
possible
Minimize other changes in the household, if possible
Spend individual time with the toddler on a daily
basis
Involve the toddler in the care of the baby
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Parents as the First Teachers
Model social behaviors and gender roles
Facilitate language development by talking to and
reading with the child
Convey family cultural traditions and spiritual values
Provide emotional and psychological safety
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30
Choosing a Preschool
 Is child developmentally ready?
 Staff training
o
Early childhood development
o
CPR
 Appropriate adult-to-child ratio
 Disciplinary procedures are consistent with the parents’ values
 Parents are able to visit at any time
 School is childproofed inside and out
 Appropriate hygiene procedures are in place
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