pediatric nursing

1. Health Promotion of the
Infant and Toddler
Joy A. Shepard, PhD, RN-C, CNE
Joyce Buck, PhD(c), MSN, RN-C, CNE
1

2. Objectives
• Recognize major developmental milestones
• Describe the role of play
• Describe and plan nursing interventions to meet nutritional
needs
• Identify major health concerns
• Apply communication skills according to the child’s
developmental level
• Use anticipatory guidance to promote positive parenting,
child safety, and prevent injury
2

3. Nursing Diagnoses
• Readiness for Enhanced Knowledge
• Readiness for Enhanced Parenting
• Readiness for Enhanced Immunization Status
• Readiness for Enhanced Family Coping
• Deficient Knowledge
• Ineffective Family Therapeutic Regimen Management
• Ineffective Infant Feeding Pattern
• Risk for Aspiration
• Risk for Electrolyte Imbalance
• Risk for Infection
• Risk for Injury
• Risk for Falls
• Risk for Delayed Development
• Risk for Sudden Infant Death Syndrome
• Risk for Poisoning
3

4. Review: Developmental Age Groups
(pp. 81-82, Ball & Bindler)
•Neonate: First 28 days of life
•Infancy: Birth to 1 year
•Toddler: 1 to 3 years
•Preschooler: 3 to 6 years
•School-ager: 6 to 12 years
•Adolescent: 12 to 18 years

5. 5

6. Normal Infant Reflexes
(pp. 541-544 Lowdermilk text)
6

7. Protective Reflexes
•Blink
•Sneezing
•Coughing
•Do not outgrow
7

8. Sucking Reflex
(p. 541, Lowdermilk)
•Essential for normal life
•Sucks on anything placed
in mouth
•Well-coordinated with
swallowing by 32 – 34
weeks of gestation
•Disappears by 1 year
8

9. Rooting Reflex
(p. 541, Lowdermilk)
9
• Lightly stroke cheek, infant
turns towards stimuli, then
opens mouth
• Response helps infant find
nipple for feeding
• Reflex stronger when infant
hungry
• Disappears at
approximately 3-4 months

10. Palmar Grasp Reflex
(p. 541, Lowdermilk)
•Occurs when infant’s
palm is touched near
base of fingers
•Hand closes in tight fist
•Disappears by 3-4
months
10

11. Plantar Grasp Reflex
(p. 541, Lowdermilk)
• Similar to the palmar grasp
reflex
• Infant’s tendency to curl
toes downward over finger
when sole of foot is
touched
• Disappears by 8 months
11

12. Tonic Neck Reflex
(p. 541, Lowdermilk)
• “Fencer’s position”
• Posture assumed by infants in
a supine position when head is
turned to one side
• The extremities on the same
side extend
• Flexion occurs on the opposite
side
• Disappears by 3-4 months
12

13. Moro and Startle
(p. 542, Lowdermilk)
• In response to sudden
movement or loud noise
• Arms and legs extend and
the fingers fan outward, with
the thumb and forefinger
forming a C-shape
• Most significant reflex
• Disappears by 6 months
13

14. Stepping (Walking) Reflex
(p. 542, Lowdermilk)
• Newborns tend when held
upright to take steps in
response to feet touching a
hard surface
• Lift one foot and then the
other
• Disappears by 3-4 weeks
14

15. Babinski Reflex
(p. 543, Lowdermilk)
Baby's toes fan with dorsiflexion of big toe
**Disappears by 1 year**
15

16. Positive vs Negative Babinski
Reflex
16

17. Question
•Which infant reflex can help the new mother
learn to breast-feed?
•A. Tonic neck
•B. Rooting
•C. Palmar grasp
•D. Moro
17

18. Infant
(Chapter 7, Ball & Bindler)
18

19. Infancy (Chapter 7, Ball & Bindler)
• Infancy: Age birth to 1 year. Includes neonatal period (birth to 28
days)
• Dramatic growth and change
• Body systems immature
• Risks r/t immature body systems:
• More at risk for respiratory infection or aspiration (immature respiratory
system tiny, collapsible airways)
• More at risk for infection (immature immune system)
• More at risk for fluid and electrolyte imbalances (immature renal
system cannot concentrate urine efficiently) 19

20. Infancy
• Vital Signs:
• HR & respirations ↓; BP ↑(as infant gets older)
• Growth and Development:
• Best indication good health: steadily increasing growth
• Measured by: height, weight, head circumference, and weight-for-length
(BMI)
• Plot anthropometric data on growth chart to see if growth pattern
conforms to normal growth curves
• ~As the child grows, the growth rate slows~ 20

21. Infancy: Weight
• Weight:
• 1st 6 months—5 – 7 oz (140-
200 g)/ week
• 6-12 monthsslows
• 6 months—doubles birth
weight
• 12 months—triples birth
weight 21

22. Infancy: Height
• Height:
• 1st 6 months1.5 cm per
month
• 6-12 months1 cm per
month
• At 12 monthslength
increased by 50% 22

23. Infancy: Head Growth
• Head Growth:
• When the baby is born, head slightly larger than chest
• 1st 6 months1.5 cm per month
• 6-12 months1 cm per month
• 12 months—head circumference = chest circumference
• Fontanels accommodate rapidly growing brain:
• 2-3 months: posterior fontanel closes
• 12-18 months: anterior fontanel closes
23

24. Measurement of Head
Circumference
• Measuring tape that cannot
be stretched
• Securely and snugly wrap
tape around widest possible
circumference of head
• Position tape just above
eyebrows, above the ears,
and around the biggest part
of the back of the head
• Read measurement to
nearest 0.1cm 24

25. Infancy: Body Systems
• Neurologic System:
• Brain growth very rapid during 1st yr of life: brain doubles in
weight
• Brain growth depends on nutrition
• Without proper nutrition: developmental problems
• Rapid growth: increased number of synapses, myelination
• Cephalocaudal pattern
• Primitive reflexes replaced by purposeful movement 25

26. Infancy: Body Systems
• Immune System:
• Immature immune systems: Risk for Infection
• Newborn with very little own immunity; passive immunity if
breastfed
• Breastfeeding decreases: ear, respiratory tract, GI, and
urinary tract infections; diarrhea; sepsis
• First year of life: infant develops own immunity
• Immunizations: health promotion & disease prevention
26

27. Infancy: Motor Development
• Weight gain and muscle growth: increased control of
reflexes, increasingly coordinated movement
• Risk for Injury
• Anticipatory guidance: prevent accidents
• Milestones: screen for motor development problems
• Expected MilestonesFine (purposeful use of hands and
fingers) and Gross Motor: refer to chart
27

28. Infancy: Cognitive Development
• Piaget—Sensorimotor stage: birth to 2 years
• From reflexive activity to purposeful acts
• Egocentrism—Child at center of own little universe; views nothing but
himself
• Object Permanence: 9 months—Infant can locate object hidden from
view
• Play:
• Enhances growth & development
• Solitary play, but human interaction &
stimulation very important
• Make sure toys are age-appropriate
28

29. Infancy: Language
• Cries—first attempt at communication
• Distinguish normal from abnormal
• High-pitched—usually neurological problem
• Hearing and understanding (receptive speech) come
before expressive speech
• Language Developmental Milestones: refer to chart
29

30. 30

31. Infancy: Vision
• Acuity: 20/100 to 20/400 at birth. Focus on objects 8”-12"
from face at birth (en face position)
• Colors: High-contrast, primary colors
• 6 months of age—able to distinguish pastel colors
• Vision milestones: refer to chart
• Can assess “PERRL” but NOT “PERRLA” –
Accommodation (except with accommodative toys)
31

32. Nystagmus & Strabismus
(pp. 484; 490, Ball & Bindler)
• Young infants lack eye coordination
• Transient nystagmus or strabismus
normal variant until 4 months
• Alignment of eye important due to
correlation with brain development
• Nystagmus: involuntary rapid eye
movements
• Treatment: eyeglasses, surgery
of eye muscles
• Strabismus: misaligned eyes
• Treatment: Surgical correction,
optometric vision training
• Untreated: can lead to
amblyopia (lazy eye) (p. 519) 32
Normal: Reflections of light are symmetrical

33. Infancy: Hearing
•Acute at birth;
Mandatory newborn
hearing screening
•Hearing milestones:
refer to chart
33

34. Ear Exam
Pinna is pulled down and back to straighten ear canal in
children under 3 years.

35. Infancy: Psychosocial
• Erikson—Trust vs Mistrust
• Foundation of personality; establish sense of trust
• Related to feeding cycle
• Freud—Oral stage:
• Oral stimulation: source of pleasure and satisfaction
• Parent-Infant Attachment:
• One of most important features of psychosocial development
• Critical for normal development and survival; infant is active participant
• Stranger Anxiety: 6-7 mos; Infant cries, clings to parents, turns away from
strangers
• Separation Anxiety: 9 mos; 15-18 mos; inconsolable crying, distress,
when parents are not present
• Anticipatory guidance: health promotion, injury prevention
35

36. Review Question
•The pediatric RN would expect a 10-month-old
infant to respond to the staff upon admission to
the hospital in which manner?
A. Outward hostility
B. Frequent negativism
C. Occasional jealousy
D. Fear of strangers
36

37. Infancy: Sleep
(p. 180, Ball & Bindler)
• Newborn to 3 mos: 10 – 16 hours/ day
• Most infants begin to sleep for longer periods during the nights as they
get older
• Sleep patterns will be alternating the first year of life—sleep a lot at first,
then not sleeping as much
• Safe to Sleep Campaign—Helps prevent sudden infant death syndrome
(SIDS)
• Sudden, unexplained death of an infant younger than 1 yr old
• Fourth leading cause of death in infants < 12 mos
• “Safe to Sleep" campaign has reduced SIDS rate by 50%
http://www.nichd.nih.gov/health/topics/sids/Pages/default.aspx
37
See Risk Factors for SIDS (Box 20-1), p. 529

38. Safe Sleep Environment
(pp. 528-529, Ball & Bindler)
• Place infant on back to sleep, for
naps and at night
• Place infant on firm sleep surface
(e.g., safety approved crib
mattress with fitted sheet)
• NO soft surfaces (e.g., pillow,
quilt, sheepskin, or a waterbed)
• Keep soft objects out of infant’s
sleep area
• No pillows or “fluffy” items in the
crib (“Bare is Best”) 38

39. Crib Safety
• Distances between slats ≤ 2-3/8 inches wide
• No drop side rails
• Minimal gap (less than 2 fingerbreadths) between crib mattress
and interior of the crib
• Lead-free paint, no decorative enhancements, no elevated
cornerposts, child-proof latches
• Position crib at least 3 inches away from drapes, ribbons, blind
cords, and decorative wall hangings.
• http://www.thebabydepartment.com/nursery/crib-safety-
standards.aspx 39

40. 40
http://onsafety.cpsc.gov/blog/2011/06/14/the-new-crib-standard-questions-and-answers/

41. Apparent Life-Threatening Event (ALTE) /
Brief Resolved Unexplained Event (BRUE)
(p. 527, Ball & Bindler)
• Event that is frightening to the observer
• Infant younger than 1 yr
• Sudden, brief, less than 1 minute
• At least one of the following:
• Absent, decreased, or irregular breathing
• Color change (usually cyanosis, erythema, or pallor)
• Marked change in muscle tone (hyper- or hypotonia)
• Altered responsiveness
• Syndrome with a broad range of possible underlying causes
• Prematurity, GERD, pertussis, lower respiratory tract infections, sepsis, seizure, urinary tract
infection, child abuse/ Munchausen Syndrome by Proxy, miscellaneous
• Treatment: thorough history of the event and careful physical examination,
diagnostics, in-hospital observation (to determine and then treat underlying
cause); home cardiorespiratory monitor
41

42. Nutrition
• Utmost importance for growth
and development
• Breast milk or commercially
prepared formulas:
foundation of nutrition
throughout infancy
• Calorie needs: 95-110
kcal/kg/day
• Fluid needs: 100 ml/kg/day
• Output: At least 6 wet
diapers/day 42

43. Breastfeeding
(pp. 601-624, Lowdermilk)
• Breastfeeding
• Very important for infant health
• Recommended over formula
• Easier to digest, natural antibodies, less expensive
• Breastfed infants
• Gain less weight than bottle-fed infants
• Less chance: otitis media, obesity, NEC, type II DM, & cardiovascular
disease
• Contraindicated: Galactosemia; mother substance abuser,
taking certain prescribed drugs, has untreated active TB, or
is infected with human immunodeficiency virus (HIV)
43

44. 44

45. Bottlefeeding
(pp. 625-629, Lowermilk)
• Bottle feeding
• Formula meets energy and basic nutritional requirements
• Does not have disease-fighting antibodies
• Not as easily digested as breast milk (5-fold ↑risk NEC)
• Mothers who choose not to breast-feed should not be made
to feel guilty because of their choice
• Support should be given for selected feeding choice
• Proper preparation and storage of formula:
• Improper use: infection, hyponatremia, or malnutrition
• Ready-to-use preparations: never diluted; opened containers
refrigerated and used within 24 hours
• Do not microwave!
45

46. Weaning and Solid Food Introduction
(Table 14-2, p. 317)
• Weaning (6 to 12 months):
• NOT during stress; gradual: replacing one feeding at a time
• Solid Foods (4 to 6 months):
• Ready: can sit, extrusion reflex gone, can reach for objects and bring to mouth, can indicate
desire or refusal for food, and is able to safely move food to back of mouth and swallow
• Solids should be introduced one at a time in small amounts; wait at least 3 to 5 days before
introducing a new food; feed only from a spoon
• New recommendations: introduce peanut butter and other potential allergens at 4 to 6
months
• Any food, with the exception of honey, can be introduced @ 4 to 6 months as long as this is
done one at a time to see if there is any reaction to each food
• It should be the right texture; make sure it is pureed
• Include ample amounts of fruits and vegetables
• Salt, sugar, and spices should not be added
• Food Allergies
• Abdominal pain, diarrhea, nasal congestion, wheezing, cough, vomiting, and rashes 46

47. 47
Keep your sense of humor and enjoy
watching him make some tasty discoveries!

48. Caution
• Cow’s milk—not recommended until 12 months of age
• Inadequate iron & linoleic acid; excessive sodium, phosphorus, &
protein
• May cause kidney problems, digestive problems (GI bleeds),
dehydration, iron-deficiency, and allergies
• Avoid honey until at least 1 yr of age
• Infants cannot detoxify clostridium botulinum spores sometimes
present in honey – can lead to infant botulism
• AVOID hard & small food items: hot dogs, chunks of meat or
cheese, hard candy, raw vegetables or fruit chunks, whole grapes,
raisins, seeds, nuts, popcorn, peanut butter, chewing gum, lollipops,
and marshmallows - choking hazard 48
Risk for Aspiration

49. Review Question
•During a 4-month-old’s well child checkup, the nurse
discusses introduction of solid foods into the infant’s
diet. The parents are instructed to delay until after 1
year of age introduction of?
A. Strawberries.
B. Honey.
C. Wheat.
D. Peanut butter. 49

50. Immunizations
• Check CDC National Immunization Program site for up-to-date information:
• http://www.cdc.gov/vaccines/parents/index.html
• Informed consent
• Document: vaccine name, date of administration, expiration date, manufacturer
& lot number, administration site (anatomical), route, VIS publication date,
name/ initial
• Contraindications: severe allergic reaction (anaphylaxis), immunodeficiency,
known allergy to a vaccine component, encephalopathy
• Common side effects: redness or soreness at the site and a mild, low-grade
fever
• Give liquid acetaminophen (Tylenol) or ibuprofen—do not give aspirin to a
pediatric patient under age 19 during episodes of fever-causing or viral
illnesses (risk of Reye’s Syndrome) 50

51. 51

52. 52
Immunizations –> Substantially reduced child mortality and morbidity

53. 53

54. Review Question
• Which of the following sets of injections is typically
given at the 4-month checkup?
•A. DTaP, Hib, RV, IPV, PCV, and Hep B
•B. DTaP, RV, IPV, PCV, and Hep B
•C. DTaP, Hib, RV, IPV, and PCV
•D. DTaP, MMR, PVC, varicella, and Hep A
54

55. 55

56. Safety (REVIEW pp. 182-185,
Ball & Bindler)
• Accidental injury: One of the LEADING causes of death during
infancy
• Common causes: Suffocation and aspiration of small objects, motor
vehicle crashes, drowning, fire/ burns, poisoning, and falls (p. 7)
• Prevent asphyxiation—asphyxiation (suffocation) occurs when air
cannot get into or out of the lungs and oxygen supplies are depleted
• Choking: major concern in infancy and toddlerhood
• Substances or objects aspirated into airway
• Partial or complete obstruction of the lungs
• Strangulation: constriction of the neck; also blockage of nose & mouth by
airtight material
• All plastic bags or covers kept out of the infant’s reach
• NO latex balloons 56

57. Safety Cont’d….
• Burn safety—Temperature settings on hot water heaters
< 120 F. Test bath water with back of wrist. Turn cooking
handles toward the back of the stove. Cover outlets
• Prevent falls by restraining straps in high chairs. Never
leave baby unattended on a changing table or other high
surface, not even for a second. Infants begin to roll over
by themselves as early as 2 months of age. Fence all
stairways
57

58. Toddler
(Chapter 8, Ball & Bindler)
58

59. Toddler: 12-36 mos (1-3 yrs)
• Struggle for autonomy: develops sense of self separate from parent
• Growth slacks off: growth spurts and lags (step-like growth curve)
• Anthropometric Measurements:
• Toddler's height: increased 50% since birth
• ~3 inches per year
• Toddler's weight:
• Triples birth weight by age 1
• ~5 pounds per year
• Quadruples birth weight by age 2
• Head circumference: at 12 mos, head = chest
• 24 months: chest greater than the head
• American Academy of Pediatrics: plot ≤ 2 yrs (anterior fontanel closed)
• Microcephaly, macrocephaly
• CDC Birth to 36 mos growth chart: Head circumference-for-age
59

60. Toddler: Vital Signs & Physical
Characteristics
• HR: 80-120
• Respirations: 20-30
• BP: 88/45 (BP estimate: systolic 80 + [ 2x age]; diastolic 2/3s systolic)
• Affected by fever, dehydration, respiratory illnesses and drugs
• Measure BP at every provider’s office visit
• Physical Characteristics:
• Brain growing rapidly (good nutrition essential): 80% adult size by 2 yrs
• Whole milk until age 2, then 2% milk (need fat for brain development)
• Nervous system: continues to myelinate; fine motor control is refining
• Muscle tissue replacing adipose tissue (baby fat) present during infancy
• Gaining physical strength and ability
• Motor Development
• Gross Motor: refer to chart
• Fine Motor: refer to chart
60

61. Review Question
• A mother of a 15-month-old brings her son to the clinic.
While doing a nursing assessment, the mother makes the
following comments. Which comment merits further
investigation by the nurse?
A. “My son cries sometimes when I leave him at his
grandparent’s house.”
B. “My son always takes his blanket with him.”
C. “My son is not crawling yet.”
D. “My son likes to eat mashed potatoes.” 61

62. Toddler: Play & Language
• Parallel Play:
• Gross Motor:
• Ride-on toys; push and pull toys
• Fine Motor:
• Crayons--with supervision
• Tasks: fine & gross motor
development
• Language (refer to chart): ability
developing rapidly
• RECEPTIVE SPEECH before
EXPRESSIVE SPEECH
• Tantrums (pp. 193-194) 62

63. 63

64. • Vision:
• Toddler period—20/40-20/50
acuity level
• Screen for poor vision: clumsy,
running into things, won't follow
objects
• By age 3 – optometric eye
examination
• Depth perception continuing to
develop: inquisitiveness, poor
judgment, and occasional lack
of coordination
Toddler: Sensory
64
•Hearing: Should be able to hear
well; Whisper test
•Taste and Smell: well-developed;
less likely to taste something new
•Rest and Sleep: 10-12 hrs at night,
one or two daytime naps (very
individualistic)
Risk for Falls

65. Toddler: Toilet Training
• One of biggest tasks during this period (refer to “Toddler Characteristics”)
• Myelinization of spinal cord before child can voluntarily control bowel and
bladder sphincters (at least age 18 to 24 months)
• 24 to 30 months:
• Less negativity, usually more willing to please their parents
• Control of anal/ urethral sphincters--can voluntarily open and close them
• Signs of Toilet Training Readiness
• Must be able to stand and walk well, to pull pants up and down, to recognize
the need to eliminate and then be able to wait to go in the bathroom
• Bowel control: usually achieved before bladder control
• Daytime bladder control: before nighttime bladder control
• Parent: relaxed approach. Give guidance to sit on the toilet about 10 minutes
Praise efforts; never punish them
65

66. Signs of Toilet Training
Readiness
66

67. Toddler: Psychosocial
Development
• Erickson: Autonomy vs shame and doubt
• Autonomy--wanting to be in control. Conflict. Give them choices that
are appropriate
• Freud: Anal stage. Best example is toilet training; as their sphincters
become mature, they can assert control, autonomy over the bowel
• Moral development: Don’t know “right from wrong”
• No formed conscience: avoids punishment by controlling his or her
behavior
• Right and wrong are determined by the consequences of actions
• Negativism: refer to "Toddler Characteristics”
• Temper tantrums--refer to "Toddler Characteristics;” also, p. 193
• Ritualism: refer to "Toddler Characteristics" 67

68. Toddler
• Separation anxiety (15-18 mos):
• Peaks in the toddler period
• Stressful: Inform child honestly and clearly about a
separation shortly before it occurs
• Parallel Play:
• Plays alongside, but not with, other children
• Egocentric, shamelessly aggressive
• Lacks cognitive/ social skills for interacting or playing well
with others
68

69. Toddler
• Discipline:
• Role modeling (guiding behavior), ignoring, and/ or time out
(placing the child in a nonstimulating environment)
• Key ingredients: consistency, loving, immediate, realistic and
age-appropriate
• See “Families Want to Know: Positive Discipline,” p. 193
• Sibling rivalry:
• Make older child feel important, involved in care of younger
sibling
• Safety is concern
• Needs constant supervision: Child < 3-1/2 yrs should never be left
alone with an infant
69

70. Toddler Sensorimotor Phase, 1-2 yrs
(pp. 82-83, Ball & Bindler)
• Learning by physical trial and error; imitate older children and
adults
• Using all senses to explore environment; starting to think before
acting
• Rudimentary awareness of cause/ effect
• Rudimentary awareness of spatial relationships
• Object permanence--well established by toddler age
• Domestic mimicry--a toddler at this stage is often seen imitating
the parent of the same sex, performing household tasks 70

71. Toddler Preoperational Phase,
2-4 yrs (p. 83, Ball & Bindler)
• ↑Understanding time and space
• ↑Use of language
• Mental trial and error rather than physical
• Problem solving based on what they see or hear
• Egocentrism: views everything in relation to self; unable to consider another's
point of view
• Transductive reasoning: reasoning from one particular fact or case to
another similar fact or case; unrealistic understanding cause-and-effect
• Magical thinking: feels extremely powerful; believes thoughts or wishes cause
events to happen
• Animism: believes that inert objects such as stuffed animals are alive and
have wills of their own
• Centration: ability to consider only one aspect of a situation at a time
• Irreversibility: cannot see a process in reverse order
71

72. Toddler: Nutrition
• Rate of growth/ appetite slows: "Physiologic Anorexia"
• Calorie requirements: 1300 calories/day (~ 100 kcal/ kg/ day)
• Prone to anemia
• Well-balanced meals. Small/ more frequent feedings. Allow healthy,
nutritious choices
• Avoid junk foods, non-nutrient foods, concentrated sweets, fats, fast
foods
• Food jags: fixate on one food and want that food for an extended period
of time; usually passes with time
• Environment: sitting at table with family, minimal distractions (NO TV)
• Rest period before meal time to help increase appetite
• Do not give snacks to the child before meals
72

73. Toddler: Nutrition
• 2-3 servings milk group daily
• After 2 yrs, low-fat (2%) milk
• Milk intake: limit to 2 - 3 cups/day; can
lead to deficiencies (especially iron-
deficiency anemia)
• Limit juice: 6 ounces/ day
• If the toddler is overweight (85%-95%
BMI) or obese (>95% BMI), don't restrict
calories. Instead, promote a healthy diet
and encourage regular physical activity.
Cut down on portion sizes, and don't
offer too much milk, juice, or high-calorie
snacks
73

74. 74

75. Infant/ Toddler Dental Care
(pp. 133; 316, Ball & Bindler)
• Deciduous teeth:
• Age 6-10 months: Eruption of first teeth
• 12 months: 6-8 teeth
• No teeth eruption by 12 months think endocrine disorder
• Teething: cool liquids, cold teething rings, teething gel
• Dental hygiene—use a soft washcloth
• NO sodium fluoride toothpaste for children under age 2 (sodium fluoride is a
potent poison)
• After age 2: pea-sized amount of toothpaste per day, don’t allow to swallow
(must be carefully supervised)
• Fluoride drops (0.25 mg) recommended > 6 mos (with unfluoridated water)
• Dental fluorosis white spotted, yellow or brown stained and sometimes
crumbly teeth 75

76. Infant/ Toddler Dental Care
• 33 months old: complete set of 20 baby teeth (deciduous teeth)
• Healthy teeth:
• Diet: low in sweets (especially sticky sweets), high in nutritious foods
• Enough dietary calcium
• Taking care of teeth by brushing:
• By parent or parent-supervised, after each meal and at bedtime
• Soft bristle nylon brush or washcloth
• Flossing
• Prevent bottle caries (early childhood caries) or middle ear infections (otitis media):
• Wean from the bottle at one year
• Don’t allow the bottle (or tippy cup!) in bed
• Bottle of juice or formula should never go to bed with the infant
• First dental visit 6 months after first primary tooth erupts, or no later than 1 yr of
age; once or twice yearly afterwards 76

77. Infant/Toddler: Car Safety
• Car: Door locks
• Safety seats: http://www.buckleupnc.org/occupant-
restraint-laws/child-passenger-safety-law-summary/
• Children < 5 yrs, < 40 lbs restrained
in back seat (preferably center)
• Rear-facing child restraints for
children for a MINIMUM of 2 yrs &
reaches the highest weight/ height
allowed in the car seat
• When children outgrow rear-facing
seats: forward-facing car seats with
5-point harnesses until they reach
the upper weight or height limit of
the seat
77
Forward-facing (FF)
“toddler” / “combination”
seats are used only in the
forward-facing direction
and never for a child who
weighs less than 20 lbs or
is less than 2 yrs of age.
FF car seats generally fit
a child who weighs 20-40
lbs or more and up to 40”
tall.

78. Infant in Rear-Facing Only Car Seat
78
Infant seats can ONLY be used rear-facing

79. Why car seat chest clip placement
is so important….
• Mr. Bones (left) has dangerous
chest clip placement that could
lead to internal bleeding of vital
organs.
• Mr. Bones (right) has properly
placed chest clip; his organs
are protected by his rib cage.
• Please place your child's chest
clip properly with the top of
the chest clip being at
armpit level.
79

80. Toddler Safety
(pp. 196-197, Ball & Bindler)
• Fire and burns:
• No dangling cords from irons or
other small appliances
• Keep away from open fires and
heaters
• Electrical outlet covers
• Turn handles in on top of stove
• Water heaters 120 or less
• Preventing falls:
• Stairway gate
• Locks on doors and windows;
guards over screened windows
80

81. Toddler Safety
(pp. 196-197, Ball & Bindler)
• Water safety:
• NEVER leave a child alone in water (can drown in 1” of water)
• Preventing poisoning:
• Locks on cabinets; child-resistant containers;
• “Mr. Yuk” stickers, Poison Control Center number by every
telephone (800-222-1222)
• Firearm safety:
• Keeping guns locked up and unloaded
81

82. Toddler: Poisons
(pp. 433-436; 437-438,
Ball & Bindler)
• Poisoning – Ingestion of or exposure to toxic substances
• Children < 6 yrs more at risk due to developmental level
• Toddlers lack cognitive ability to know what is dangerous; caretakers
need to be on guard
• Most poisonings occur in the child’s home or homes of relatives or friends
• Most is oral ingestion: medications, household chemicals, cosmetics,
plants, and heavy metals
• Common toxic substances ingested by children include acetaminophen,
ibuprofen, aspirin, iron, hydrocarbons, corrosives, and/or lead
• Grandma’s purse: One pill can kill 82

83. Toddler: Poisons
• Primary prevention is key. See “Avoiding Childhood Poisoning,” p.
436
• Keep medicines, vitamins and household products out of sight and
reach—locked is better than high
• NO syrup of Ipecac; call Poison Control Center (800-222-1222) or
911
• Decontamination strategies (Emergency Department): reverse
toxicity by giving an antidote (e.g., N-acetylcysteine, glucagon,
naloxone); gastric lavage (with life-threatening ingestions and within
60 minutes of ingestion; must protect patient’s airway); gastric
decontamination with activated charcoal (1 g/ kg; often requires
placement of NG tube); whole bowel irrigation (prevents further
absorption of sustained-release medications) 83
See “Clinical Manifestations: Commonly Ingested Toxic Agents,” p. 435

84. Lead Poisoning
(pp. 437-438, Ball & Bindler)
• Ingestion, inhalation, or absorption through skin
• Primary source: deteriorating lead-based paint (structures built before 1978;
old toys/ from China, jewelry, and furniture coated with lead paint)
• Most harmful to children under the age of 6
• Lead affects every system of the body, ESPECIALLY the rapidly developing
brain and nervous system (causes irreversible CNS damage)
• Lead stored in the bones/ teeth; very difficult to remove from body (lead lines
on bones; blue-black gum lines)
• S/S: learning disabilities, developmental delays, decreased IQ scores,
behavioral problems (e.g., attention deficit hyperactivity disorder [ADHD],
oppositional/conduct disorders, & delinquency), seizures, hearing loss,
malformed bones, slowed body growth, loss of appetite, digestive issues,
and kidney damage
• Anemia: lead interferes with the production of hemoglobin (↓ H & H)
84

85. 85

86. Potential Sources of Lead
• Because the harm from lead
is irreversible, primary
prevention efforts that identify
and reduce or eliminate lead
hazards in children’s
environments before they are
exposed are critical
• Name sources of lead and
how these can be avoided
86

87. Lead Poisoning
(pp. 437-438, Ball & Bindler)
• Screening: 12 & 24 mos, or between 3-6 yrs
• Chelation therapy:
• Binds with lead, removes it from the blood (through urine and
stool)
• Oral/ IV; dose/type depends on blood lead level (BLL)
• Edetate Calcium Disodium (CaNa2EDTA), dimercaprol (BAL),
2,3 Dimercaptosuccinic Acid (DMSA), penicillamine
• Many repeated doses required
• Long-term follow-up essential
• Remove lead hazards in child’s environment 87

88. 88

89. 89