Chapter 9: Toddlers & Preschoolers Development

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Welcome back to the Deep Dive.

So today we are doing something very specific, something specifically tailored for our Last Minute Lecture series.

Right.

If you are a nursing student currently, you know, just drowning in a sea of flashcards, or maybe you're just someone who is, I don't know, fascinatingly perplexed by how tiny humans manage to survive their own absolute lack of impulse control.

Oh, absolutely.

You are in the exact right place today.

It's good to be here.

And honestly,

surviving their own lack of impulse control might actually be the most accurate medical definition of a toddler I've ever heard.

Right.

It really just captures the essence of the demographic we're unpacking today.

It totally feels that way.

So today we're executing a comprehensive, really detailed review of chapter nine.

That is Toddlers and Preschoolers from Davis Advantage for Pediatric Nursing,

Critical Components of Nursing Care, the third edition.

We have just a tremendous amount of ground to cover because this isn't just about small adults.

It's about a completely unique developmental stage.

We really do.

And the mission here is, it's very specific.

We aren't just going to read the textbook charts to you.

No, please.

Though, I mean, we will cover the charts because you definitely need them for your exams.

Yeah.

But we're looking at that chaotic, magical, and frankly terrifying window between age one and age five.

Yeah.

This is meant to be a safe space for you to digest some very heavy pediatric content without, you know, the pressure of a lecture hall staring you down.

Yeah.

We want you to walk away actually understanding the why.

Exactly.

I really want to get to the why behind the nursing care because just looking through this material, I'm realizing that caring for a toddler isn't just pediatrics in general.

It's a completely different sport than caring for an infant or a school -aged kid.

Completely.

They are effectively their own species.

They really are.

We have this intersection of rapid physical growth.

The development of something called magical thinking.

Which we'll get into.

Right.

Which is an actual clinical term we will break down.

Yeah.

And then incredibly high safety risks.

From a nursing perspective, if you treat a three -year -old like a small adult

or even like a really large baby,

you are going to have a very, very difficult shift.

You really are.

You have to meet them exactly where they are developmentally.

So let's map out our road trip for this deep dive.

We are going to stick strictly to the chapter structure.

That way, if you're studying with the book open, you can easily follow along.

Perfect.

We'll start with growth and development.

So the theorists and those dreaded milestones.

Then we'll move into nursing assessment or as I like to call it, negotiating with a tiny terrorist.

Which is an art form.

It requires very specific strategies.

Definitely.

Then we have to tackle the absolute biggest section of this chapter, which is safety.

The text makes it incredibly clear that injury is the leading cause of death for this demographic.

Yes.

So that section is completely non -negotiable for exams.

Right.

We'll also cover pain management,

common challenges like potty training.

Always a fun one.

Nutrition and finally caregiver support and red flags.

Let's jump right in.

Okay.

We're starting with toddler growth and development.

We're talking specifically about ages one to three years.

This is the era of the terrible twos.

Although, you know, in the spirit of reframing, we try not to call them terrible anymore.

Fair enough.

The text actually encourages us to look at it through the lens of developmental theorists.

Because when you understand what is happening inside their brains, the behavior makes sense.

It's not just them being difficult on purpose.

Exactly.

It feels less personal and more inevitable.

It's just the developmental work they have to do.

Right.

So let's blame the theorists for the tantrums.

Let's start with Erickson.

This is a name that haunts literally every nursing student.

Eric Erickson.

Yes.

The stage here is shame and doubt.

This is the defining struggle of the toddler years.

If you understand this specific conflict, you understand the toddler.

So this is the internal engine that's driving them.

Completely.

The toddler is driven by a biological and psychological need for self -control.

For the very first time, they are realizing they are separate entities from their parents.

Okay.

They want to control their bodies, their toileting, their food choices, their toys.

The me -do -it phase where it takes 45 minutes to put on a single sock.

Precisely.

And here is the key takeaway for nurses and parents.

When they succeed at doing it themselves, even if it's incredibly imperfect, they gain confidence.

They gain autonomy.

They feel capable.

Right.

But if they are constantly criticized or restricted, or if the task is just way too hard and they fail repeatedly, they develop a profound sense of shame and doubt.

So that fierce independence isn't them just being bratty.

It's them actively trying to build a personality and a sense of self -worth.

Exactly.

They are building the foundation of their will.

If we crush that will now, we create a fearful dependent child.

If we support it, we create a confident one.

That makes so much sense.

Okay.

Moving to Piaget.

We are in the pre -operational stage.

So this stage spans age 2 to 7.

It covers both the toddler and preschool years we're discussing today.

And the two big concepts you need to lock in here for Piaget are magical thinking and egocentrism.

Magical thinking sounds whimsical, almost Disney -like.

But in a medical context, it sounds complicated.

This is the idea that their thoughts literally influence the real world, right?

Yes.

It's the genuine belief that if they think something, it can make it happen.

Give me an example.

Okay.

So a child might think, I wish my brother would go away because he took my toy.

And now he has a cold and is sick in bed.

Therefore, I caused this.

Oh, wow.

That's a really heavy burden for a two -year -old to carry.

It is huge.

And it has massive implications for how they view illness, which we will see more in the preschool section.

But they often view sickness as a direct result of their own bad thoughts or actions.

And then you have egocentrism.

Right.

And we really need to be clear here.

This isn't about being arrogant or selfish in the way adults use the word.

Right.

They aren't narcissists.

Exactly.

It means they literally, cognitively, cannot see a perspective other than their own.

Yeah.

Their brain just hasn't developed the hardware for empathy yet.

The classic example is the hide and seek game, isn't it?

That's the one.

If they cover their eyes, they think you can't see them.

Because they can't see you.

Right.

If they stand right in front of the TV, they assume you can see through them because they are looking at the TV.

They aren't trying to be annoying.

Their brain just hasn't developed the capacity for the concept of other yet.

Okay.

Let's briefly touch on Freud.

We are in the anal stage here.

Age one to three.

Freud focused on the satisfaction and pleasure derived from holding and releasing bowel movements.

Which aligns perfectly with the timeline for toilet training.

So it's all about control again.

Control over their own body functions.

It's the very first time they have something that is truly theirs to either give or withhold.

It becomes a major source of negotiation with parents.

And finally for the theorists, Kohlberg's moral development.

What is going on with their moral compass?

We are in the pre -conventional stage.

Do not expect a moral compass here.

Good to know.

Their reasoning is very, very basic.

It is based purely on obedience and the fear of punishment.

They do not have an internal sense of right and wrong yet.

So how do they decide what to do?

They just know, if I touch the hot stove, mom yells at me.

Yelling is bad.

So touching the stove is bad.

So they aren't refraining from touching the stove because they understand it's dangerous or because it's morally wrong.

They're just not touching it to avoid the negative consequence from the parent.

Exactly.

Which means if the parent isn't looking, the moral calculus often changes completely.

No parent equals no punishment equals I can touch the stove.

Precisely.

That is absolutely terrifying for safety.

It is.

Okay, let's get into the physical stuff.

The motor development milestones.

This is the checklist every single nursing student needs to burn into their brain.

It is.

And a tip for everyone studying, don't just memorize the list on a flash card.

Try to visualize the progression.

It helps it stick so much better.

You are watching a child go from horizontal to vertical and then to highly mobile.

Okay, let's walk through it chronologically.

Start us at 15 months.

What are we seeing?

At 15 months, the major headline is walking alone.

They are toddling.

The wide stance.

Wide stance.

Arms up in the air for balance.

If they aren't walking by 15 months, that is a red flag we're watching very closely.

They also begin to run.

That was very awkward.

And they can stand on their tiptoes.

Fast forward to 21 months.

They are really getting vertical.

They can climb stairs now, but they need to hold on to the rail or hold a hand.

They can't do the alternating feet thing yet.

No.

They put both feet on one step, pause, and then move to the next step.

And by two years.

Now they are refining it all.

Fine motor check.

They are building towers of four or more blocks.

Four blocks at two years.

Right.

Gross motor.

They are climbing on furniture, which is a massive safety issue we will talk about later.

And they can run and jump with two feet.

Then we hit age three.

Three years is a huge leap.

They can build towers of six or more blocks.

They can kick a ball without falling over.

They can turn a doorknob.

Which means absolutely no room in the house is safe anymore.

Correct.

Locks are required.

And the classic mnemonic for this age for your exams is three years to three wheels.

They can ride a tricycle.

If you remember nothing else, remember three years to three wheels.

Three years, three wheels.

Love that.

Let's look at language skills.

It feels like they go from zero to 60 in this specific window.

It's a rapid progression from pointing at things to actually naming them.

At 12 months, you're looking for about five words total.

Like mama, dada, ball.

Okay.

But by 18 months, that jumps to 50 words.

That is a massive acceleration in just six months.

It's an absolute explosion.

And then by two years, they were putting two to three word sentences together.

Yeah.

Want juice?

Daddy go.

No sleep.

And by three years old.

They can actually converse in two to three sentences.

And crucially, this is when they start using pronouns correctly, like I, me, and you.

Meaning they finally understand themselves as separate entities.

It circles right back to Ericsson.

Everything connects.

The language allows them to express that autonomy they are so desperately seeking.

Let's touch on cognitive and social emotional milestones for toddlers before we move on.

Cognitively, you're seeing object permanence fully established now.

If you hide a toy under a blanket,

they know it's still there.

They will actively search for it.

They don't just think it vanished into the ether.

Right.

They can sort colors and shapes.

You'll also see the very beginning of make -believe play.

And interestingly, this is when handedness starts to emerge.

Like whether they are left or right handed.

Yes.

And socially, the term parallel play is the one that always comes up in exams.

It's the defining social structure of toddlerhood.

Right.

Parallel play means they play near other kids, but not actually with them.

So literally just two toddlers sitting next to each other in a sandbox.

Yes.

One is banging a toy drum.

The other is stacking blocks.

They are completely aware of each other.

They might even mimic what the other one is doing.

But there is no collaboration.

No shared goal.

None.

They are just in their own little bubbles, parked next to each other.

Emotionally, the text says we see imitation, open affection, and a lot of defiance.

And jealousy.

Especially if a new sibling arrives during this time, which is common.

Separation anxiety is also a major, major factor here.

It persists until the end of the second year.

Okay.

Let's graduate to the preschoolers.

We are shifting gears to ages three to five.

They are a little studier, a little more verbal.

How did the theorists revisit this older group?

Ericsson shifts from autonomy to initiative versus guilt.

This is a subtle shift, but an important one.

They move from just saying, me do it, to actually wanting to assert power and control over their environment.

So what does that look like?

They want to plan and execute tasks.

They want to invent games with rules.

They want to help you cook dinner or sweep the floor.

So if they constantly fail at their big plans, or if the parent treats their help as just a nuisance because it takes longer.

They develop guilt.

They feel like they're a burden.

They develop a sense of dependence rather than taking initiative.

The goal for caregivers is to let them help, even if it makes a huge mess.

Got it.

And Piesha says they are still preoperational.

Yes, the magical thinking and egocentrism continue, but it gets a bit more complex.

This is vital for nurses to understand because it heavily affects how they view medical care.

Because of magical thinking,

a preschooler often views illness as a punishment.

A punishment?

Yes.

I hit my sister, I was bad, so now I have leukemia.

Or I didn't listen to mom when she told me to put my shoes on, so now I had to get a shot.

Oh, that is just heartbreaking.

It really is.

And as nurses, we have to correct that misconception explicitly.

You have to literally say to them, you are not sick because you are naughty.

You are sick because of a germ.

You have to absolve them of that guilt.

You do.

Otherwise, they carry it.

Freud moves to the phallic stage here.

Focus shifts to the genitals.

Masturbation is common and normal at this age, though it often freaks parents out when they catch it.

They also may view the opposite sex parent as a sexual object.

This is the Oedipus complex territory Freud talks about.

Competing for affection.

Right.

It's about competing for the affection of the opposite sex parent.

And Kohlberg?

Still pre -conventional.

Still very much that obedience and punishment orientation.

There is a really interesting clinical judgment moment here in the text regarding providing feedback to this age group.

It says we need to be very careful with our praise.

This is subtle, but incredibly important in practice.

You should say, good job regarding the behavior.

You should not say, good boy or good girl.

Why the distinction?

You want to separate the child's inherent worth from their actions.

If you say good boy when they do something well, the logical implication in their brain when they make a mistake is that they are a bad boy.

Oh, I see.

You want them to know, I'm a good kid, but I made a mistake.

Not, I am inherently bad because I spilled the juice.

It builds resilience.

That's a great tip.

Let's look at preschooler motor development.

This phase is all about refinement.

Exactly.

At three years old, they can dress themselves with some help.

They can go upstairs without help, and they are alternating feet now, not doing the two feet per step thing.

They can draw basic shapes like squares and circles.

Oh, and they can drink from a cup without a lid,

which saves a massive amount of laundry for the parents.

They can hop and stand on one foot for about five to ten seconds.

They can catch a bounce ball.

They can safely use child's scissors.

Their drawing evolves.

They can draw stick figures with two or more body parts.

They are pretty independent, brushing their own teeth, toileting completely alone, skipping.

They are riding a bicycle, usually with training wheels that get removed eventually, and swimming.

They are becoming physically competent little people.

Very much so.

Language and cognitive skills for preschoolers seem to get much more complex, too.

The big marker here for your assessment is intelligibility.

By age five, strangers should be able to clearly understand their speech.

If a stranger can't understand them by five, they likely need a speech evaluation.

And their sentence structure.

It grows.

Four words at age four, five or more words at age five.

They can tell stories, they use the future tense correctly, and they comprehend rhyming.

But the text has a huge warning here about literal interpretation.

Oh, yes.

This is a complete minefield for nurses.

You have to really watch what you say around them.

Preschoolers take everything literally.

Give me a clinical example of that.

Okay, if you tell a preschooler you are going to take their blood, they might literally think you're going to take all of it and leave them completely empty.

Like a deflated balloon.

Exactly like that.

Or if you say, we're going to use some dye for a contrast scan, they hear D -I -E and think they're going to die.

Oh, my God.

Or if you say, we need to put you to sleep for surgery, they might think of the family dog that was just put to sleep.

You really have to be specific.

Highly specific.

You say, I am going to take a tiny drop of blood,

or we're going to use some special medicine to see your tummy.

Cognitively, they can count to 10, but the text makes a point to say it's rote memory.

Right.

They can recite one, two, three, four, just like a song, but they don't really grasp the mathematical concept of quantity yet.

They can't hand you three blocks if you ask for three.

Sometimes they can, but higher numbers are just a song.

They can name colors, though.

They understand the concepts of same and different, and they ask why.

Constantly.

The never -ending why phase.

It's exhausting,

but it's how they map their entire world, and socially, we see a big shift here.

They move from parallel play to associative play.

This is playing with others.

Yes.

Now they are actually sharing toys.

They are following, at least loosely following, the same rules in a game.

There is real interaction.

They are learning negotiation skills.

But with that expanding imagination comes expanding fears.

Fear of the dark and fear of monsters is huge right now, because again, they cannot distinguish fantasy from reality.

So if they imagine a monster under the bed, that monster is real.

It is 100 % real to them.

You can't just logic it away by saying monsters aren't real.

You have to check into the bed with them.

And they have a high importance on body integrity.

This is super relevant for nursing.

This is fascinating.

They intensely fear mutilation.

A simple cut or a scrape can feel like an absolute catastrophe to a preschooler.

They genuinely think their insides are going to leak out through that tiny hole in their skin.

So that's why band -aids are magical.

Yes.

Band -aids don't just cover the wound for them.

They seal the leak.

They literally restore their body integrity.

That makes so much sense.

Never underestimate the power of a band -aid for a preschooler, even for a tiny scratch that isn't even bleeding.

A band -aid fixes the anxiety.

Okay, we know who we are dealing with now.

We have the psychological and physical profile.

Let's talk about how to actually assess them, the nursing assessment strategist.

It always starts with the health history.

You cover the standard basics, chief complaint, family history, medical history, which includes immunizations and any past surgeries.

And allergies.

And social history.

Yes.

Who lives in the home?

Do they go to daycare?

That informs your exposure risks.

And the review of systems focuses on the big three, eating, sleeping, and eliminating.

If those three things are working normally, you're usually in a fairly good place.

If even one is off, it cascades into the others.

Now, the physical exam.

I imagine you can't just walk in and do a standard head -to -toe on a squirming two -year -old.

No.

You will lose them immediately.

If you try to look in their ears first, the exam is over.

They just shut down?

They will scream, they will cry, they will thrash, and you absolutely won't be able to hear their harder lungs over the crying.

So what's the strategy when you walk in the room?

Least most invasive.

You leave the painful or scary things, like looking in the ears, mouth, or doing a genital exam for the absolute end.

Start quiet.

Start by listening to the heart and lungs while they are calm.

Maybe while they are playing with a toy or sitting on mom.

You really have to be an opportunist.

Completely.

If they are quiet and happy on mom's lap, get that stethoscope on them right then.

Don't worry about the specific order of the checklist.

Worry about the cooperation of the child.

There are some specific nuances mentioned for the head -to -toe exam in the book.

Let's run through them.

Hype.

Standing if they can stand properly.

But for young toddlers, we often measure recumbent meaning lying down.

Why is that?

Because of lordosis.

Lordosis.

Sway back.

Toddlers naturally have a pronounced curve in their lower spine and a little pot belly.

It throws off their standing measurements slightly until they grow and strengthen their core muscles.

Wait.

Minimal clothing.

A dry diaper or just underwear.

And you need to be quick before they try to jump off the scale.

Head circumference.

We routinely measure this until age two.

After age two, we only measure it if there are specific neurological concerns, like hydrocephalus.

And vitals.

I'm looking at the trends in table nine to one.

You'll notice the heart rate naturally slows down as they grow.

A toddler is typically 70 to 110 beats per minute.

A preschooler drops to about 65 to 110.

Because the heart is getting bigger.

Bigger and much more efficient.

Blood pressure also increases slightly as they age.

And there's a specific note here about the blood pressure cuff.

It scares them.

It squeezes their arm tight, which is alarming.

Use the hug analogy.

Tell the child the cuff is just going to give their arm a tight hug.

It really reduces the anxiety.

Let's talk about the anatomical differences.

There is a huge critical component box in the text about why children aren't just small adults.

This screams exam material to me.

It is fundamental physiology.

If you don't understand this, you will miss early warning signs of deterioration.

First, they have much larger heads in proportion to their bodies.

Which makes them a massive fall risk.

Exactly.

It completely changes their center of gravity.

They're literally top heavy.

It also means that when they do fall, head trauma is much more common because they tend to lead with their head.

What about body surface area?

They have a significantly larger body surface area to weight ratio compared to adults.

What does that mean clinically?

It makes them highly susceptible to temperature regulation issues.

They get cold faster.

They get hot faster.

It also deeply affects insensible fluid loss.

And the airway.

This is the scary one for a lot of people.

It is critical.

They have larger tongues and much smaller airways.

The risk of choking and mechanical obstruction is astronomically higher.

Because the tube is smaller.

Their airways are shorter, they are narrower, and they are more elastic.

More elastic?

Is that a bad thing?

In this context, yes.

It means the airway can collapse inward much more easily if they're working hard to breathe.

And because it's so narrow to begin with, a tiny amount of swelling -like from croup or RSV can occlude the airway significantly more than that same swelling would in an adult.

That makes sense.

And their chests?

Pliable.

Their ribs are still mostly cartilage, not fully calcified bone yet.

And they have very weak abdominal muscles.

Which is why they look like that.

That's why they're belly breathers.

And it's why they often look like they have a distended belly.

It's normal for the age.

Metabolic rates.

Higher.

They burn through energy and fluid much faster.

Which means they have higher baseline fluid requirements.

And they get dehydrated much, much faster than adults do when they are sick.

The text offers some pro tips for the assessment.

I love these practical on -the -floor hacks.

The first one is allow choices.

Yes, but forced choices.

Seek what?

You ask,

do you want the pulse locks on this finger or that finger?

You do not ask, can I put this on your finger?

Because the answer is always no.

Always no.

If you ask a yes no question, a toddler will say no.

Give them control over the details of the procedure.

Not whether the procedure happens at all.

Demonstrate on a parent first.

If mom lets the nurse listen to her heart, it must be a safe thing to do.

It builds trust instantly.

Modeling is everything at this age.

And where should the toddler sit during all this?

Right in the parent's lap.

That is their fortress of safety.

Do as much of the physical exam there as humanly possible.

And for preschoolers?

For preschoolers, you really need to start respecting their modesty.

They are becoming very aware of their bodies.

Don't just strip them down.

Explain what you are doing and keep them covered when you can.

There is a specific trick mentioned for the breath assessment.

The candle trick.

It's a classic.

Have them pretend your finger or the stethoscope is a birthday candle and ask them to blow it out.

Oh, to get a deep breath.

Yes.

It forces them to take a huge deep breath so you can actually listen to the lung sounds and the basses.

Otherwise, they tend to just take these rapid shallow sniffing breaths.

That is brilliant.

Okay.

Briefly on growth charts and screening tools.

Always use the CDC charts.

Your plot length, weight, and head circumference up to 36 months.

BMI starts being tracked after age two.

And developmental screening.

It is officially recommended at 9 months, 18 months, and 30 months.

The text mentions specific tools you need to know.

The ASQ, which is the ages and stages questionnaire.

The Denver Second and the SWYC.

What's the main goal of these?

Early detection.

The earlier we catch a developmental delay, the faster we intervene, and the better the long -term outcome.

All right.

Buckle up.

We are entering the safety and injury prevention section.

The text literally calls this mission critical.

It cannot be overstated.

Unintentional injury is the number one cause of death for this age group in the United States.

Not cancer.

Not a specific infection.

Injury.

That is a staggering statistic.

It puts so much responsibility on nursing education and prevention.

It really does.

For toddlers aged one to four, the leading causes of death overall are accidents, congenital malformations, and assault or homicide.

But accidents top the list by far.

And specifically within accidents.

Drowning is the leading cause of injury death for ages one to four.

Let's break down the specific interventions because we have to be the voice of reason for parents who are exhausted and just trying to survive the day.

Starting with crib safety.

Dropside cribs.

These were officially banned in 2011 because the mechanism could fail and actually trap or suffocate the child between the mattress and the rail.

But they are still out there.

People still hang them down.

They buy them at garage sales or thrift stores.

Nurses need to educate parents explicitly.

Do not use a dropside crib.

Ever.

And the general crib rules.

Side rail is always up when the child is in it.

Verify the slat width so their little heads don't get trapped.

And minimal bedding and toys to prevent suffocation risk.

No giant stuffed bears.

A crib is for sleeping, not for storing stuffed animals.

Moving to home safety.

Let's talk about burns.

It's not just about touching the hot stove.

You have to check bath water and food temps.

Hot water tanks in the home should be set to 120 degrees Fahrenheit, which is 48 .8 Celsius or lower.

Why 120 exactly?

Because at 140 degrees, a child's skin burns in literally seconds.

At 120 degrees, it takes several minutes to cause a severe burn.

It buys the parent reaction time.

Because their skin is different?

Their skin is much thinner than adult skin, so it burns deeper and faster.

Turn pot handles inward on the stove.

Basic but essential.

Toddlers naturally reach up to grab things they can't see.

If they grab a handle hanging over the edge, they pull boiling water or hot food right down onto their face and chest.

And holding kids while drinking coffee.

Never hold a child while carrying hot liquids.

They squirm, you spill, they get burned.

Gates at all stairs.

But importantly, and parents mess this up a lot, if the gate is at the top of the stairs, it must be secured directly to the wall with actual hardware.

Not just those pressure mounted ones.

Right, not pressure mounted.

A pressure gate can be pushed over by a strong, determined toddler.

And then the kid rides the heavy gate down the stairs like a surfboard.

It causes terrible injuries.

Look at your heavy furniture.

TVs, bookcases, dressers, you have to anchor them to the walls.

Toddlers love to pull out dresser drawers and use them like a ladder to climb.

And then the whole thing tips.

The dresser tips over, it happens in an instant, and it crushes them.

There is a really important note here about windows.

Window screens do not prevent falls.

They are designed only to keep bugs out, not to keep heavy kids in.

Do not trust them to hold a child's weight.

You need actual window guards.

Poisoning.

Lock the cabinets.

Keep all meds in their original childproof containers.

And every parent needs the person control number saved in their phone.

It's 1 -800 -222 -UNU -8222.

There is a specific alert in the text about hand sanitizer.

Yes.

It's everywhere now in every post and car.

But it is incredibly high in alcohol.

Even a tiny taste, literally a lick from a toddler, can cause acute alcohol poisoning in a 25 pound child.

Wow.

And there is a strict rule about medication language.

Medication is not candy.

Never ever call medicine candy just to get them to take it.

Because it works in the moment.

But if they find that bottle later, they will eat the whole thing because you told them it was candy.

Safety caps.

They are a deterrent.

They are not a guarantee.

Kids are smart and they have very nimble little fingers.

Do not rely solely on safety caps.

Lock them up.

Water and outdoor safety.

You mentioned drowning earlier is the leading cause of injury death.

It is silent and is incredibly fast.

Never leave them unattended near any water, even if they can swim.

Floatation devices are an absolute must.

And it's not just pools.

Right.

Remember, water includes bathtubs and even mop buckets.

A top heavy toddler can drown in two inches of water.

Because their head is so heavy, they fall in face first.

And they literally don't have the strength to push themselves back up.

And outdoors.

Bicycle helmets are completely mandatory.

Start the habit early so it's not a fight later.

Street safety.

Always holding hands.

No playing near curbs.

Playground rules.

No drawstrings on hoodies.

Why no drawstrings?

They're a massive strangulation hazard on slides.

They get caught at the top while the kid goes down.

And no trampolines.

No trampolines.

Oh, that's a huge buzzkill for families.

The text lists them as a very significant safety risk.

The American Academy of Pediatrics actually advises against all home trampolines.

Broken bones, head injuries, spinal injuries.

It's just high risk.

Our seats.

Keep them rear -facing as long as possible.

You have to follow state laws.

But from a purely safety standpoint, rear -facing is best because it fully supports their heavy head and fragile neck in a crash.

Booster seats always go in the back seat.

Okay, that was a heavy section, but so necessary.

Let's talk about pain assessment and management.

This is really tricky because, as you said, they can't always tell you what hurts.

Toddlers lack the cognitive ability to verbalize pain accurately until about age two.

And even then, they might not be able to localize it.

They just know they feel bad.

So the nurse has to be a detective.

What about physical signs, like elevated heart rate or blood pressure?

Those definitely happen, but there are poor standalone indicators.

Why?

Because extreme fear can also raise heart rate and blood pressure.

If a kid is absolutely terrified of the nurse or the room,

their vitals are up.

Is it pain or is it fear?

You don't know just from the monitor, so you have to look at behavioral signs.

Like furrowed brow.

Furrowed brow, an open mouth grimace, extreme restlessness, irritability.

The text also explicitly mentions silent pain.

Yes, this is very dangerous to miss.

Just because a child isn't crying does not mean they aren't hurting.

They might withdraw entirely, go very still, or even try to sleep just to escape the overwhelming pain.

So don't assume silence equals comfort.

Never assume that with pediatrics.

Let's break down the pain scales in table nine to two.

These are standard tools you need for clinicals.

First is the FLACC scale.

FLACC.

This is a purely behavioral scale.

It stands for face, legs, activity, cry, and consolability.

You score each of those categories from zero to two.

Who is this scale for?

Children age two months up to seven years or any child who is completely non -verbal.

You are strictly observing them.

You are not asking them questions.

If their legs are kicking restlessly, that's a score.

If they're arching their back, that's a score.

And then Wongdaker faces scale.

This is a self -report scale recommended for ages three to seven.

The child looks at a line of cartoon faces and points to the face that best matches how they feel.

There is a very specific warning here, though, about using faces.

You absolutely must ensure the child understands it is about pain, not sadness.

Oh, that makes sense.

A child might pick the crying, sad face simply because they are sad their mom left the room or sad to be in the hospital.

Not because their arm actually hurts.

You have to clarify.

Which face shows how much your tummy hurts?

What about pain management strategies once we assess it?

Medication choices.

Again, give those forced choices we talked about.

Do you want it with water or with apple juice, cup or syringe?

Never ask if they want it.

Never ask, do you want your medicine?

The answer will be no.

Non -pharmacologic methods.

Distraction is huge here.

Bubbles, blowing on a pinwheel, playing a video on an iPad.

Positioning helps, letting them sit on a parent's lap for the injection instead of pinning them to the table, touching and hugging.

Something called medical play.

This really helps with the fear component.

You use dolls or stuffed animals to demonstrate the procedures beforehand.

Because of that concrete thinking.

Exactly.

Concrete thinking means they need to actually see it to understand it.

If you put a little cast on a doll's arm first, they suddenly understand what's going to happen to their own arm.

It completely demystifies the terrifying equipment.

Let's move to common challenges.

These are the things parents constantly ask pediatric nurses about.

Potty training.

The big milestone.

Usually begins between two and three years of age.

How does a parent know they are actually ready?

It's not just about hitting a specific age.

It's physiological readiness.

Myelination of the spinal cord has to happen before they can physically control the sphincter.

So what are the outward signs of that?

Waking up with a dry diaper after a nap.

Or staying dry for a few hours at a time.

Having regular, predictable bowel movements.

Showing an active interest in the potty or following parents to the bathroom.

The physical ability to actually pull their pants up and down.

And being able to vocalize that they need to go.

Any education tips for caregivers?

Patience above all.

Practice sitting on the potty fully clothed first.

Make hand -washing fun with little songs.

Use praise and small rewards like stickers.

And accidents.

Never punish for accidents.

Punishment creates shame, which goes back to Erickson, and it will set the whole process back months.

And anatomy matters here for hygiene.

Teach girls to always wipe front to back to prevent urinary tract infections.

That is a crucial habit to establish for life.

Separation anxiety.

We touched on this.

It peaks around 10 to 18 months.

The solution is very counterintuitive for parents.

They want to soothe.

But the best method is to distract the child,

say a clear goodbye, and then leave quickly.

Don't drag out the goodbye.

Dragging it out makes it so much worse.

It validates their fear that leaving is a terrible, dangerous thing.

So just rip the band -aid off.

Yes.

Be consistent with your return.

Say, I love you.

I will be back right after nap time.

And then walk out the door.

Tantrums.

The absolute hallmark of the age group.

Very common from ages one to four.

The main triggers are basic.

Hunger,

extreme tiredness, frustration over a task, or illness.

It's basically an emotional circuit breaker popping because they are overwhelmed.

How do you coach a parent to manage a screaming toddler in the middle of the grocery store?

The caregiver absolutely must stay calm.

If the parent escalates and starts yelling, the child escalates further.

Venting your frustration just makes the kid more anxious.

So what do you do?

Timeouts can work.

The rule of thumb is one minute per year of age in a quiet, safe place.

But mostly, it's about prevention.

Maintain routines to prevent the triggers.

Don't take a hungry, exhausted toddler grocery shopping if you can possibly avoid it.

And sibling rivalry.

Jealousy is entirely normal.

The new baby is a literal threat to their resources, meaning their parents' attention.

Separate them if they are fighting.

Set firm rules like no hitting.

Don't chew sides in an argument.

And encourage sharing and apologizing.

Let's talk nutrition.

How do toddlers eat compared to older kids?

They are grazers.

They have very small stomachs.

They eat about seven small times a day.

Preschoolers eventually settle into a more standard three meals a day pattern.

There is a mention in the text of food jegs.

That's when a toddler only wants to eat one specific food like only chicken nuggets or only mac and cheese for three days straight.

And then on day four, they suddenly hate it and refuse to look at it.

That drives parents crazy.

It does, but it is totally normal.

Educate parents not to fight it too hard.

Look at their nutritional intake over a full week.

Not just one single day.

It usually balances out.

What about milk transitions?

Transition to whole milk at age one.

They absolutely need the fat content for brain development.

Specifically the myelin sheets we talked about for potty training.

That then switch later.

Switch to low -fat or skim milk at age two to help prevent childhood obesity.

Serving sizes.

The general rule of thumb is one tablespoon of food per year of age, per food group, or roughly half of the standard adult serving.

Parents almost always overestimate how much food a toddler actually needs to eat.

And juice.

Limit it strictly.

Four to six ounces a day, maximum.

Water is always best.

Too much juice directly leads to obesity and severe cavities.

It's just liquid sugar sitting on their teeth.

Speaking of cavities dental health.

The prevalence is shockingly high.

46 .2 % of kids have cavities in their primary teeth.

That is way too high.

The text mentions baby bottle carries.

This is caused by parents letting the child sleep with a bottle of milk or juice in the crib.

The liquid pools in the mouth and the sugar just sits on the teeth all night long, literally rotting them.

Water only in the crib, ever.

When should they first see a dentist?

By age one or whenever the very first tooth appears, whichever is first.

And toothpaste amounts.

I didn't realize this was so specific.

It's very specific because they swallow it.

For ages one to three,

just a smear of toothpaste about the size of a grain of rice.

You don't want them swallowing too much fluoride.

For ages three to six,

a pea -sized amount.

And start flossing as soon as two teeth touch each other.

We're heading into the home stretch here, promoting independence and caregiver support.

We want to encourage self -care.

Let them dress themselves, even if the outfit is completely mismatched or backwards.

It builds that Ericksonian autonomy.

Assign very age -appropriate chores like putting their blocks away to build a sense of responsibility.

Let's compare hospital versus home care.

When a child is admitted to the hospital, what is the nurse's primary role with the parents?

Orient them immediately.

The hospital is terrifying for a parent.

Explain every single piece of equipment step by step.

Encourage them to stay in the room and participate in basic care like bathing or feeding.

It calms the child immensely to have the parent do it.

But don't they get burnt out?

Yes.

So you also have to remind the parents to actively care for themselves.

Tell them to go eat a hot meal, get some sleep, take a shower.

Remind them they can't pour from an empty cup.

And for home care, specifically when they are sick.

Fever management is huge.

Make sure they have a working thermometer at home.

Teach them to dose medications like Tylenol by the child's weight, not their age.

And keep them hydrated.

Popsicles totally count as fluid intake.

What about the brat diet?

Bananas, rice, applesauce, toast.

I grew up on that when I was sick.

We all did.

It used to be the gold standard for upset stomachs.

The text notes it is okay for a very brief transition if they are actively vomiting, but it is nutritionally insufficient for long -term recovery.

It lacks protein.

No protein, no healthy fats.

Get them back to a normal, balanced diet as soon as they can possibly tolerate it.

Finally, critical alerts and red flags.

We touched on safety, but these are specific clinical red flags nurses must watch for.

First, child abuse assessment.

Nurses are mandatory reporters.

You absolutely need to look for bruises in non -bony areas.

Like where?

The torso, the ears, the neck, the inner thighs.

Toddlers fall all the time, so they bruise their shins and their foreheads naturally.

They do not naturally bruise their stomachs or their ears.

And the caregiver's story is important, right?

Look for inconsistency.

If the caregiver's story doesn't match the physical injury or it doesn't match the child's developmental level, that is a massive red flag.

Like saying the baby rolled.

Exactly.

If they say, oh, my two -month -old rolled off the changing table and broke their arm, two -month -olds do not roll.

You have to report that.

Respiratory distress symptom.

Watch for tet -chipny, which is fast breathing.

Retractions, where you can actually see the ribs pulling in with each breath.

Nasal flaring, grunting on exhalation, sitting in a tripod position to get more air.

If you see these, act immediately.

The respiratory reserve is incredibly small.

When to educate parents to call 911 versus just calling the PCP?

911 is for a blue face or extremities, not breathing, totally unresponsive, or excessive bleeding that won't stop.

The PCP is for things like general negative changes, signs of mild dehydration, or if they just can't get a fever down with meds.

We mentioned laundry pods briefly in safety, but it is listed here again as a very specific toxic warning.

Because the stats are terrifying.

Ninety -one point seven percent of all poison center calls regarding laundry pods involve children under the age of six.

Because they look like candy.

They look exactly like squishy candy or toys.

They are highly concentrated toxic chemicals, and they cause immediate respiratory distress and severe internal burns.

Keep them locked high up.

And disaster planning.

Families need a clear evacuation plan and a designated meeting place outside the home.

Why specifically point this out for toddlers?

Because young kids instinctively hide when they are scared.

If there's a fire and the smoke alarm goes off, a toddler might crawl under the bed or hide in the closet.

They need to be explicitly taught how to get out and where to go.

Wow, that brings us to the end of the chapter content.

We've gone all the way from the wobbly 15 -month -old to the highly verbal skipping five -year -old.

It's a massive, incredibly complex transformation.

And the nurse's role is to support both the child and the family through it all.

The text wraps up with a case study of a woman named Mary and her sons.

She's a single mom, works really hard, and she relies on fast food a lot because it's cheap and it's easy.

She worries her son isn't eating enough nutritious food.

This case study perfectly illustrates the real -world challenge of pediatric nursing.

It is so easy for us in a clinic to just say, hey, feed him more vegetables.

But it is incredibly hard for an exhausted, financially stressed single mom to actually execute that at 7 p .m.

So what's the nursing approach?

The nurse's role is highly supportive, non -judgmental education.

You help her find very small, manageable wins.

Maybe suggest just switching the soda to water or milk at dinner.

You don't lecture her.

You partner with her.

I love that.

So what does this all mean for you as a student?

It means toddlers and preschoolers are complex.

They are magical and they are incredibly accident prone.

They need patients, strict safety measures, and a lot of empathetic care.

And they need nurses who truly understand that a screaming no from a toddler isn't disrespect or bad parenting.

It is literally just development happening in real time.

Absolutely.

Before we wrap up, I want to leave you with a thought to mull over.

We spent this whole time talking about how these early developmental stages, building autonomy, navigating guilt, learning to share shape the child.

But think about how often we see these exact same unresolved conflicts playing out in adult patients.

Oh, that's a great point.

When you have a difficult adult patient who is constantly fighting you for control or dealing with deep shame over an illness, they are often just echoing those early Ericsson stages we just mapped out.

Understanding the toddler might just make you a much more empathetic nurse to the adults too.

It's all connected.

Stay curious about why people behave the way they do.

Thank you regarding your attention and dedication from the Last Minute Lecture Team.

Good luck on your exams.

See you next time.