Chapter 18: The Preschool Child: Growth, Development & Care

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Welcome back to The Deep Dive.

If you've been with us for the last few episodes, you know we've been tracking the incredible, sometimes messy and always fascinating journey of human growth.

We certainly have.

We've done the infant,

we've survived the toddler years, barely, and today we are turning the page to a really special, sometimes chaotic, but incredibly magical time in human development.

We are tackling Chapter 18, the preschool child.

And just to set the stage for everyone listening, maybe you're a nursing student on your commute cramming for finals, maybe you're a parent trying to figure out why your four -year -old just told you a very elaborate lie about a dragon living in the kitchen cabinets.

The very common scenario.

Right.

Our focus today is strictly that window between age three and age five.

Three to five.

It sounds like a short window, just two years really, but the transformation that happens here is profound.

How so?

It's the bridge between being a baby and being a student.

It's everything that gets them ready for that next big leap.

It really is.

And the mission for this deep dive is to decode what is happening biologically, cognitively, and emotionally during these years.

We aren't just reading the textbook here.

We want to give you the why and the how.

Exactly.

So that when you see these kids in a clinical setting or in your own living room, you know exactly what you're looking at.

We want to take the data from Chapter 18 of Introduction to Maternity and Pediatric Nursing and make it live and breathe.

That's the goal.

Because if you look at the toddler years, it's all about rapid explosive physical growth.

It's I'm learning to walk.

I'm learning to talk.

I'm learning to use a spoon.

It is frenetic.

Total chaos.

But when we hit the preschool years,

the narrative shifts completely.

What is the headline for the preschool?

What's the main theme?

Well, the physical growth actually slows down.

It stabilizes.

This isn't the era of tripling your size anymore.

This is the era of refinement.

Refinement.

I like that word.

It implies polishing.

It's exactly that.

It's about the mastery of motor skills they already have, the explosion of social skills, and the beginning of complex cognitive thought.

So it's like the hardware is finished being built.

And now they're frantically upgrading the software to get ready for school entry.

That's a great analogy.

So we have a lot to cover to get through this software update.

We're going to look at the physical numbers you need for your exams.

The vitals, the height, the weight, the need to nose.

Yep.

We're going to spend a good chunk of time inside the mind of the preschooler, which means we have to talk about our friend Jean Piaget.

You absolutely cannot do pediatric nursing without understanding Piaget.

His work is the foundation.

You really can't.

They will break down the specific personalities of the three, four, and five -year -olds because, spoiler alert, they are totally different people.

Night and day.

And we'll wrap up with the heavy hitters.

Clinical guidance on discipline, tricky topics like sex education and jealousy, and the specifics of caring for these kids in a hospital when they are terrified.

It's a full agenda, but it's all connected.

All right, let's dive right in.

Section one, the physical.

If I'm a student and I have a test tomorrow, or I'm doing an intake at a pediatric clinic,

what are the cheat sheet numbers I need to burn into my brain regarding growth?

Okay, let's start with weight because this is a classic exam question and a key critical indicator for tracking health.

I'm ready.

We know the infant triples their birth weight by one year.

That's the golden rule of infancy, right?

That's burned in there.

But for the preschooler, the rule of thumb is that they double their one -year weight by age five.

Okay, let's pause and do the math on that to make it stick.

Let's say I have a one -year -old who is, say, 20 pounds.

A good average weight.

Then you can expect them to be roughly 40 pounds by their fifth birthday.

Exactly.

It's a predictable trajectory.

So if you see a five -year -old who is still 25 pounds or is pushing 70 pounds, your alarm bell should be ringing.

Soap is off.

They are falling off that predictable curve and you need to ask why.

Right, so double the one -year weight by age five.

That's easy to remember.

What about height?

You're looking at an increase of about three inches or 7 .6 centimeters per year.

But here is where it gets interesting visually.

If you picture a toddler, what do you see?

Close your eyes and picture a two -year -old.

I see a cute little pot belly, a bit top heavy, legs apart to keep balance, kind of waddling.

Exactly.

They have that physiological lordosis, the sway back, little belly sticking out.

But in the preschool years, that disappears.

Really?

The abdominal muscles tighten up, the pelvis straightens out, and crucially, most of the growth happens in the legs.

So they stretch out.

They get lanky.

They stretch out.

They lose that baby fat roundness and develop a more slender, erect, athletic appearance.

Their whole profile changes.

And their gait changes completely.

Oh, totally.

They aren't toddling anymore.

They are agile.

They can jump, skip, and run with purpose.

They look like miniature adults rather than big babies.

They're becoming little athletes.

Okay.

Now, let's run through the vital signs.

This is crucial because if you put an adult blood pressure cuff on a four -year -old or expect an adult heart rate, you're going to panic unnecessarily.

You really are.

You have to know the pediatric norms.

So what is the norm for a healthy preschooler?

You want to look for a pulse rate between 90 and 110 beats per minute.

Which is fast for an adult, but normal for them.

Correct.

If an adult had a resting pulse of 110, we'd be doing an EKG and looking for tachycardia.

For a preschooler, that's just Tuesday.

Why is that?

Their metabolism is higher.

Their hearts are smaller.

So they just beat faster to get the job done.

Makes sense.

What about breathing?

Respirations should be around 20 reps per minute at rest.

And for blood pressure, you're looking at systolic roughly 85 to 90, and diastolic is about 60.

So 90 to 110 pulse,

20 respirations, 85 over 60 BP.

Got it.

And a quick clinical pearl here.

How hard is it to get these vitals on a squirmy three -year -old?

It can be a challenge.

I mean, that's an understatement.

The key is the approach.

Right.

You don't just march in and stick a cold stethoscope on their chest.

You let them see the equipment.

Maybe you let them listen to their teddy bear's heart first.

Let them play with it.

Exactly.

You have to win their trust before you touch them.

Because if they are crying and screaming, your respiratory and heart rate numbers will be garbage anyway.

They'll be sky high.

That's a theme we're going to come back to again and again today.

Trust and preparation.

It's everything with this age group.

What about their senses?

I know vision is a big deal because this is right before they start staring at blackboards or these days, tablets in school.

It is.

And we need to manage parent expectations here.

At age three, vision is typically around 2040.

Okay.

Not perfect.

No.

By age four, it sharpens to 2030.

Usually we don't see that perfect 2020 acuity until they reach school age, like six or seven.

So if a three -year -old doesn't see 2020, that's not necessarily a defect.

Not necessarily no.

But this is the critical window to catch issues like strabismus lazy eye or significant refractive errors.

You want to catch it before they start school.

Because if they can't see the board now, they're going to struggle to learn later.

We have to make sure they are visually ready for the classroom.

And teeth.

I assume the teething nightmares are over.

Mostly.

All 20 primary teeth, the deciduous teeth, should be fully erupted.

They have a full set of baby teeth.

They shouldn't be losing them yet.

Right.

Not until the very end of the stage, around five or six.

So if a four -year -old is losing teeth, that's a dental issue or trauma, not development, that needs a checkup.

There was one note in the text about handedness that I found - You're fighting their brain?

Forcing a switch causes a high level of frustration for the child.

It affects their confidence, their motor fluency, and can even lead to speech issues like stuttering because of the stress it puts on the brain.

So if they grab the crayon with the hand, let them roll with it.

Absolutely.

Being a lefty is just a variation of normal.

It's not a correction that needs to be made.

Simple as that.

Okay.

Okay.

Let's move to what I think is the most entertaining part of this age group.

The way they think.

Oh, it's fascinating.

We are entering the realm of Jean Piaget.

The preoperational phase.

Preoperational.

It sounds so technical, almost robotic, like a machine warming up.

But the reality is anything but.

It really is.

How does a preschooler actually see the world?

Well, Piaget breaks this down into two sub stages, and understanding the difference helps you talk to them.

First, from age two to four, you have the preconceptual stage.

Okay.

Then from four to seven, you have the intuitive thought stage.

They're related, but distinct.

Let's unpack the preconceptual stage first.

What's the headline here?

The hallmark is symbolic functioning.

This is the ability to create a mental image for something that isn't there.

Give me a real world example.

If a child hands you an empty cardboard box and says, this is my fort, or this is a rocket ship, that is symbolic functioning.

They're using a symbol.

Exactly.

They aren't hallucinating.

They know it's a box, but they are using it as a symbol for a rocket.

This is the engine of play.

They can pretend a block is a phone.

They can pretend a doll is a limitations.

This is where we have to talk about egocentrism.

Okay.

This word gets misused all the time.

It does.

We have to be very careful with this word.

In common language, if I call you egocentric, I'm calling you a jerk.

I'm saying you're selfish and arrogant.

Right.

I'm saying you only care about yourself.

In developmental psychology, that is not what it means.

Egocentrism in a preschooler means they physically and cognitively cannot understand that you have a different point of view than they do.

It's a hardware limitation, not a character flaw.

Precisely.

It's a developmental stage.

If a child stands in front of the TV, they assume you can see through them because they can see the TV.

Oh, that makes so much sense.

If they're hungry, they assume everyone is hungry.

If they are sad, the whole world must be sad.

They literally cannot step into your shoes.

That explains so much.

When a three -year -old is screaming for a cookie while you're on an important phone call, they aren't trying to be rude.

No.

They just can't conceive that your phone call matters because it doesn't matter to them.

Exactly.

And getting angry at them for being selfish is like getting angry at a blind person for not seeing a sunset.

They just can't do it yet.

As they get closer to five, this starts to fade.

But at three, it is the law of the land.

That is such a key distinction for parents.

And what about animism?

This one always trips people up in the hospital.

Animism is the tendency to attribute life to inanimate objects.

To a preschooler, everything is alive.

Everything has feelings.

Like in a cartoon.

Exactly.

It's a cartoon.

The clouds move because they want to.

The rock is sitting there because it's tired.

So if they bump into a table, they might say the table was bad or the table hurt me.

To them, the table hit them on purpose.

It wasn't an accident.

Which explains why they might be terrified of medical equipment.

Yes.

Think about a blood pressure cuff.

To us, it's a diagnostic tool.

To a three -year -old, it's a squeezing snake that's angry at their arm.

Or an MRI machine.

It's a growling monster with a big mouth.

When we tell a child the machine is going to take a picture, they might think the machine is going to eat them or steal something from them.

So we have to be careful with our metaphors.

Extremely careful.

We have to depersonalize the equipment.

This machine makes a loud noise like a drum rather than this machine is angry.

We have to choose our words so carefully.

And then there's artificialism.

The belief that people created the world and everything in it.

Right.

Who built the moon?

Did you make the rain, Daddy?

It's a very human -centric view of the universe.

Daddy is all powerful, so Daddy must have turned off the sun at night.

It creates a sense of security.

My parents control the world.

But also confusion when things go wrong.

How so?

If Daddy controls the rain, why did Daddy make it rain on my birthday?

It implies intent.

It can lead to them thinking they are being punished by a parent when something bad happens.

Wow.

Now as they move into that intuitive thought stage around age four, we see something called centering.

This feels like a logic puzzle.

It is.

This is best explained with the classic conservation task.

You've probably seen this.

With the glasses of water.

Exactly.

Imagine you have two identical glasses with four ounces of juice.

The child agrees they are the same.

Then right in front of their eyes, you pour one glass into a tall, thin test tube and the other into a short, wide bowl.

And you ask, which one has more?

The preschooler will point to the tall, thin glass and insist it has more juice.

Every time.

Even though they just saw you pour it?

Even though they saw it.

They are centering on one characteristic height.

They ignore the width.

They judge by appearance, not logic.

We call this logic failure or lack of conservation.

So to them, taller is more.

Taller is always more.

They literally cannot process that the volume remains the same because the shape changed.

So bringing this back to nursing, what does this mean for us?

If you are explaining a procedure to a four year old, you can't use abstract logic.

No, you can't say we need to take this blood so we can check your hemoglobin levels to make you feel better next week.

That is way too abstract.

Too many steps.

It means nothing to them because of their magical thinking and centering.

They won't follow you.

They deal in the immediate.

So what do you say?

You have to be concrete.

You deal with the immediate sensation.

You say this will pinch for a second like a mosquito bite and then we are done.

You don't explain the physiology.

You explain the sensation.

And you have to be careful with words like die, right?

Oh, absolutely.

If you say we're going to put some dye in your arm for the x -ray, they hear die, like dead.

I never even thought of that.

You have to say we're going to put some special medicine water in your arm.

You have to proofread your speech for homonyms and scary sounding words.

Communication with this age group really is an art form.

It's a specialty.

Speaking of communication, let's talk language.

This is the era of the vocabulary explosion.

It is huge.

I mean, the numbers are just staggering and language is the biggest predictor of school success.

Give us the numbers.

At age three, a child has about 300 words.

By age four, that jumps to 1500.

Wow.

That's a five -fold increase in one year.

It's incredible.

And by age five, over 2000 words, they are just sponges.

That is an exponential curve.

That's not just learning.

That's absorbing.

It is.

And for nurses and parents, there is a really handy rule called the sentence rule.

It's a rule of thumb, but it's pretty accurate.

Okay.

I love these little hacks.

The number of words in a child's typical sentence should roughly equal their age.

So a two -year -old says, want cookie.

Two words.

Right.

A three -year -old says, I want cookie now.

Three words.

A four -year -old says, I want the big cookie.

Four words.

And a five -year -old is using complex sentences with because, and, and, and all sorts of connectors.

It's a quick way to gauge if they're on track during a casual conversation.

Exactly.

You don't need a formal test.

Just talk to them for a minute.

Now, with all this rapid brain growth, speech challenges are pretty common, right?

Yeah.

I feel like I hear a lot of parents worried about stuttering.

Stuttering is very common in the preschool years.

We call it a disorder in rhythm.

And it makes sense if you think about it.

How so?

The brain is working faster than the mouth muffles can keep up.

They have the thought, but the mouth stumbles.

They are trying to say, I want to go to the park, but their brain is already thinking about the slide, the swing, and the ice cream truck.

It's a bottleneck issue.

The ideas are coming too fast.

Exactly.

It can cause social anxiety, but here is the reassurance.

It often improves by school age without any intervention.

It's a phase for many kids.

What should parents do?

I know the instinct is to help them, to finish the sentence for them.

And that is the worst thing you can do.

Really?

Absolutely.

Do not finish their sentences.

That increases the pressure.

It tells the child, you are too slow.

Let me do it.

The expert advice is to be patient.

Listen,

slow down your own speech when you talk to them.

I read a tip that said reading to pets helps.

Yes.

Stuttering often disappears when the child sings, talks to pets, or reads aloud to a toy.

Why?

Because there is no judgment.

There is no pressure from the dog.

The dog isn't waiting for them to finish.

It's a safe space to practice.

So if the stutter persists for a long time, therapy is helpful.

But often, just removing the pressure fixes it.

Now, we also need to look at the connection between language and behavior.

This is a huge aha moment for many parents.

It is.

We often see tantrums in kids with language delays.

And it's not because they're bad kids.

Right.

Because the tantrum is the language.

If I can't say I'm frustrated because I wanted the blue cup, not the red one, I might just throw the red cup across the room.

So the behavior is actually a communication breakdown.

Correct.

Encouraging language development often reduces behavioral issues.

Use your words is good advice, but you have to teach them the words first.

If they don't have the words, they will use their fists or their lungs.

Let's look at the clinical classifications quickly.

Because table 18 .3 in the text breaks down language disorders in a way that's really useful for triage.

What are the red flags?

There are three or four big buckets.

First, articulation disorder.

This is when the parent says, I'm the only one who understands what she says.

The speech is mushy or unclear to strangers.

Okay.

Then there is expressive language delay.

That's when the child understands commands.

Their receptive language is good, but they only point or use minimal words.

So you say go get your shoes and they do it.

Exactly.

But they can't say here are my shoes.

The information goes in, but it doesn't come out verbally.

Versus a global language delay.

That is more severe.

That's a child who doesn't play interactive games like show me your nose and uses maybe only one word like mama.

That indicates a delay in both receiving information and expressing it.

And then the scariest one, language loss.

Right.

If a parent says, Joey used to say bye bye and ball, but now he is silent.

That is a major, major red flag.

Not just a phase.

Regression in language always requires immediate evaluation.

We have to rule out hearing loss, but we also have to screen for autism spectrum disorders, which often present with regression around this age.

That is a crucial takeaway.

Regression is never just a phase.

Okay.

Let's shift gears to what these kids do all day.

Play.

You mentioned earlier, play is the business of children.

It is their job.

It's how they learn physics, sociology, math, and ethics.

And just like their bodies, play evolves.

You can track their social development by watching how they play.

So walk us through the progression from three to five.

At three years old, we see mostly parallel play and associative play.

Remind us what parallel play looks like.

Parallel means they are playing next to each other, maybe even with the same toys, but independently.

Two kids sitting in a sandbox.

One is digging a hole.

The other is filling a bucket.

They aren't building a castle together.

Exactly.

They are just existing in the same space.

They are aware of each other, but not collaborating.

And associative.

Associative is a bit more interactive, loosely associated groups, but no strong rules.

They might both be running around playing chase, but there's no winner or loser.

And the rules change every 10 seconds.

It's more a shared activity than a structured game.

Then comes age four and five.

By age five, we hit the holy grail.

Cooperative play.

This is playing by rules.

This is complex, imaginary scenarios.

The fun stuff.

The really fun stuff.

Trip to the moon, where everyone has a specific role.

You're the astronaut, I'm the alien, and the couch is the spaceship.

This requires a lot of cognitive skill.

You have to agree on the rules, stick to your role, and negotiate with others.

Exactly.

It's the foundation of society.

If you can't play cooperatively, you can't work in an office later in life.

It teaches compromise.

Okay, I'll be the alien this time, but next time I get to be the astronaut.

Now we can't talk about play in the modern world without talking about screens.

What are the guidelines?

Because let's be honest, the iPad is the modern babysitter.

It is.

And we have to be realistic.

The American Academy of Pediatrics, AAP, is strict here.

For children aged two to five, non -educational screen time should be limited to one hour per day.

One hour.

That is a tight budget for a lot of families.

It is.

And the nuance is important.

Ideally, it shouldn't just be parking the kid in front of a tablet alone, passive viewing.

It should be high quality programs watched with parents.

So active viewing.

You're co -viewing.

Yes, you're part of it.

What is that character doing?

What color is that?

Why is the tiger sad?

You make it interactive.

You bridge the screen to the real world.

So if they watch a show about baking.

You talk about baking.

Maybe you bake cookies later.

It stops the screen from being a hypnotic device and turns it into a tool.

One aspect of play that always fascinates me is the imaginary friend.

Is that normal?

Or is it a sign of loneliness?

It is completely common and normal.

In fact, it's often a sign of a creative, intelligent child.

Oh, that's reassuring.

It helps them adjust to independence.

It's a coping mechanism for loneliness or fear.

I'm not scared of the dark because Mr.

Nobody is with me.

It allows them to practice social interactions with a safe partner who always agrees with them.

How should parents handle it?

Do you set a place in the dinner table for Mr.

Nobody?

You acknowledge them.

You don't deny their existence.

That would be like denying their feelings.

You play along to an extent.

However, and this is a big guidance point, you do not let the imaginary friend take responsibility for bad behavior.

So if the say, well, you are responsible for Mr.

Nobody, so we have to clean this up together.

You don't let them outsource their conscience.

It keeps them grounded in reality while respecting their imagination.

That is great advice.

Okay, let's get into the specific personality profiles.

The text breaks down the three -year -old, the four -year -old, and the five -year -old as having very distinct vibes.

They really do.

And knowing these helps you not to take things personally.

Let's start with the three -year -old.

We call this stage the delight.

The delight.

That sounds promising after the terrible twos.

It is.

They are generally helpful.

They want to please.

They are less prone to the erratic tantrums of the two -year -old.

They are proud of their new skills.

They can dress themselves, use the toilet, wash their hands.

They want you to watch them do it.

All the time.

Watch me, mommy.

Watch me.

They are seeking validation and praise.

But they have specific fears, right?

Yes.

Because of that visual concrete thinking, the three -year -old is terrified of bodily harm.

And because they don't understand anatomy,

the loss of body parts is a very real, very literal fear.

Give me an example.

If a little boy sees his infant sister being changed, he might notice she looks different from him.

He might genuinely think she was injured or had something cut off.

It's terrifying to him.

Oh, wow.

Or if they scrape their knee, they might think all their blood is going to leak out.

They don't understand volume or closure.

That's why band -aids are magical.

Yes.

A band -aid doesn't just cover the wound.

To a three -year -old, it seals the body back up.

It keeps their insides in.

You will often see a three -year -old wanting a band -aid for a tiny, invisible scratch.

And you should just give it to them.

Give it to them.

It's psychological first aid.

What about their relationship with parents at three?

This is where the father's prestige increases.

And we see that romantic attachment the opposite sex parent.

The girl wants to marry daddy.

The boy is attached to mommy.

Freud would have a field day.

He did.

But practically, it means they are identifying with the same sex parent, but romancing the opposite.

It's how they learn gender roles and relationships in a safe way.

Okay, so three is the delight.

Then we hit four and things change.

The four -year -old is, let's call it the aggressive show -off.

The honeymoon is over.

It's a more difficult phase.

They are boisterous.

They are aggressive.

They are flooded with testosterone and energy, both boys and girls.

They like to show off their skills, but they are competitive.

Paddling.

Constant tattling on siblings to prove they are the good one.

And the language changes too.

Yes.

They might start swearing, not because they are mean, but because they are imitating what they hear and they realize those words have power.

It gets a reaction.

If saying a certain word makes mommy gasp or daddy angry, that's power.

They are testing boundaries.

And they are trying to prove they are better than everyone else.

Yes.

They are obsessed with age.

I'm four, you're only three.

But physically, they are very capable.

They can use scissors, lace shoes, and I love this detail.

The four -year -old runs with a purpose.

What does that mean?

They aren't just running in circles like a toggler.

They are running to get somewhere.

They are mission -oriented.

I'm running to the kitchen to get a snack.

And cognitively, their curiosity takes a darker turn.

This is often when questions about death begin.

Will I die?

Will you die?

They are very direct.

And as a nurse or parent, you have to answer honestly but gently.

You don't say, Grandma went to sleep.

Because then they will be terrified to go to sleep.

Interestingly, the text mentions that four -year -olds often prefer raw materials over fancy toys.

Yes.

A cardboard box is better than a dollhouse.

A box of sand is better than a video game.

Why?

Because the four -year -old has that explosive imagination we talked about.

The box can be anything.

A fancy toy is only one thing.

The box is a blank canvas for their brain.

Okay.

We survived the aggressive four -year -old and we arrive at five.

The five -year -old is the comfortable age.

We can breathe again.

Yes.

They are more responsible, patient, and serious.

They like to finish what they start.

They enjoy games with rules and actually try to follow them.

They look to authorities.

Parents, teachers for control and guidance.

They trust that adults have it handled.

They do.

They're less fearful, more secure.

And physically.

They are ready for the world.

They can name the days of the week.

They can print their first name.

They can ride a tricycle with speed and dexterity.

They can use a hammer.

They are really ready for kindergarten.

They're seeking knowledge, not just attention.

That's a perfect way to put it.

So we have the delightful threes, the aggressive fours, and the comfortable fives.

That's a really helpful framework.

It helps parents and nurses not to overreact.

When the four -year -old calls you a pooh -pooh head and kicks the door, you realize, okay, this is development.

This is the aggressive show -off phase.

It's not a character flaw.

It's a stage.

And it passes.

Speaking of pooh -pooh heads, let's move to section six.

Guidance and discipline.

This is probably the number one question parents ask nurses during well -child checks.

How do I handle this kid?

It is.

And the first thing to establish is the goal.

The goal isn't punishment.

The goal is self -discipline.

We want the child to eventually regulate themselves.

We aren't training dogs.

We are raising humans.

So what is the gold standard technique?

Timeouts.

But, and this is a big but, they have to be done correctly.

Most parents do them wrong.

And then they say they don't work.

Okay.

Teach us the right way.

First, the duration.

The rule is one minute per year of age.

So a three -year -old gets three minutes.

A four -year -old gets four minutes.

Not 20 minutes.

That's too long.

They forget why they are there.

And the technique.

Where do they go?

Straight chair, facing a corner, or a boring wall.

No toys.

No TV.

And critically, no eye contact.

Why no eye contact?

Because eye contact is attention.

Even angry attention is attention.

You want to remove the reinforcement.

You are essentially putting the behavior on pause.

It's about removing stimulation.

And use a timer with a buzzer.

Yes.

This is a brilliant psychological hack.

When the buzzer rings, the timer says they can get up, not the parent.

It shifts the authority to the inanimate object.

It removes the power struggle.

It's impartial.

Totally impartial.

The timer is the boss.

What if the child talks or gets up during the timeout?

The timer restarts.

That's the hard part for parents, but the child learns quickly.

If I get up, I stay longer.

And keep the explanation short.

Less than 10 words.

You hit, so timeout.

Not a lecture.

They stop listening after 10 words anyway.

Save the lecture for later when everyone is calm.

What about rewards?

Rewards are effective, but we have to distinguish them from bribes.

This is a subtle but vital difference.

Break it down.

A reward is agreed upon before the behavior occurs.

If you behave in the grocery store today, we can play at the park after.

It's a contract.

It teaches planning and consequences.

And a bribe.

A bribe happens during the bad behavior to stop it.

The kid is screaming in the cereal aisle, and the parent says, Stop screaming and I'll give you a candy bar.

That's dangerous.

It's disastrous.

It teaches the child that screaming gets candy.

It reinforces the bad behavior.

Never bribe.

It solves the problem for five minutes, but creates a monster for five years.

Let's touch on jealousy.

Sibling rivalry is huge in this age group.

It's strongest in children under five.

It's often triggered by a new baby.

You see aggression biting the baby or regression.

Right.

The potty trained kid starts wetting the bed again.

Exactly.

A four -year -old who has been potty trained for a year suddenly wets the bed or asks for a bottle.

They want the attention the baby is getting.

They're trying to become a baby again.

How do you manage the aggression if the four -year -old hits the baby?

You separate them, obviously.

But here is the counterintuitive part.

You have to give the aggressor attention to.

Wait, really?

The instinct is to comfort the victim and scold the bully.

Think about why they are hitting.

They are hitting because they feel insecure and unloved.

They feel replaced.

If you only comfort the victim and punish the aggressor, you confirm their worst fear.

Mommy loves the baby more.

You have to affirm them.

I love you, but we do not hit.

Give them a special big kid job to help with the baby so they feel included, not replaced.

Make them an ally, not an enemy.

Exactly.

That is tough to do in the moment, but it makes total sense psychologically.

Now,

moving to uncomfortable topics for some parents.

Sexual curiosity and masturbation.

It's a normal part of development.

They are discovering their bodies.

It's not sexual in the adult sense.

It's exploratory.

It's like finding your nose, but a different part.

So if a parent walks in and the child is touching themselves, what's the advice?

Don't shame them.

Do not say, that's dirty or you're bad.

You explain that it is a private activity.

We do that in our room, not in the living room.

You set boundaries, not shame.

Because the shame can cause problems later.

It creates anxiety that lasts a lifetime.

You just teach them about public versus private behavior.

And questions about where babies come from.

Be honest.

Use correct terminology.

Don't use made -up code words for body parts.

The asking of the question indicates readiness to learn.

Keep it simple, but truthful.

The baby grows in a special place inside Mommy called the uterus.

You don't need to explain the mechanics of conception yet, usually.

Let's talk about a specific clinical condition that affects a lot of families.

Anuresis.

Bedwetting.

Specifically, involuntary urination after the age where control should be established.

Usually after age five.

There are two types, right?

Yes.

A primary anuresis is a child who has never been dry at night.

Secondary anuresis is when a child has been dry for a year or more, and then starts wetting the bed again.

Secondary usually signals something is wrong, like a stressor.

Often stress, regression, like a new baby, or a urinary tract infection.

But primary anuresis is often physiological.

It's more common in boys.

There's a genetic component.

Chromosomes 12 and 13 are implicated.

It often runs in families.

So it's not just laziness?

Never.

It can be small bladder capacity or deep sleep patterns.

They just don't wake up when the bladder is full.

It's not their fault.

How do we treat it?

First, rule out organic causes like diabetes or UTI.

That's step one.

Then lifestyle changes.

Limit liquids after dinner.

Make sure they void right before bed.

And use motivational therapy reward dry nights, but never punish wet ones.

Punishment makes it worse.

It increases anxiety, which makes bed wetting worse.

It's a vicious cycle.

What about medications?

I know there are some options, but they come with warnings.

There are two main ones.

Desmopressin is a synthetic hormone that reduces urine production at night.

It works well, but is often temporary.

Once you stop it, the wetting might return.

It's good for sleepovers or camp.

And the other one.

Imipramine or Tofranil.

This is a tricyclic antidepressant.

It has a side effect of treating inner esus.

But, and this is a huge safety warning for nurses, it has serious side effects.

Such as?

Mood changes, sleep disturbances, and cardiac dysrhythmias.

That sounds heady for bed wetting.

It is.

And an overdose is life threatening.

It is not recommended for children under six usually, and must be kept locked away from siblings.

It's generally a last resort.

We try everything else first.

Moving on to daily care and safety.

These kids are heading off to preschool.

What should parents look for in a facility?

It's not just about finding a babysitter.

You want to check state licensing.

Look at the student -staff ratio.

Check their philosophy on discipline.

Does it match yours?

That's a big one.

And look for accreditation from the NAEYC National Association for the Education of Young Children.

That's the gold standard stamp of approval.

And safety.

You mentioned earlier they have good motor skills, but immature judgment.

That's a dangerous combination.

It is the peak age for certain types of accidents.

They can run fast, but they don't look for cars.

They can climb, but they can't get down.

Specific hazards.

Falls or big stairs?

Must be clear.

Shoes need good soles.

Burns?

They are tall enough to reach the coffee mug on the table now, or experiment with matches.

And poisoning?

They're curious.

They are so curious.

Pills look like candy.

They can open cabinets.

This is the age to lock the garage in the under -sink cabinets.

Stranger danger is also a concept taught here.

Yes.

But be specific.

The text advises teaching them to run to a house, you know, if a stranger approaches.

Not just run away, which is vague, run where, but run to safety.

Run to a specific place.

Give them a plan.

Finally, let's discuss hospitalization.

When a preschooler lands in the hospital, it could be traumatizing.

It can be.

Remember, they have magical thinking.

They often view illness as punishment.

I was bad, so now I'm sick.

I hit my brother, so now I have leukemia.

I stole a cookie, so now I broke my leg.

They genuinely believe this.

That is heartbreaking.

So the nurse has to actively correct that.

Yes.

You have to reassure them they aren't being punished.

You have to say you are sick because of germs, not because you were bad.

And you have to use play.

Play is vital for assessment and recovery.

We distinguish between therapeutic play and play therapy.

Unpack that.

Therapeutic play is used to retrain muscles or help with a physical issue.

For example, having a child blow bubbles or blow out a flashlight candle.

Why would we do that?

To expand their lungs after surgery.

It's deep breathing exercises disguised as fun, or having them squeeze play dough to rebuild hand strength.

It's play with a medical goal.

And play therapy.

That is a psychiatric technique.

It's used by trained therapists to help the child express fear or stress through dramatic play.

It's about emotional release.

They might beat up a doll to express anger at the doctors.

It's a way to process trauma.

And when it comes to procedures, like that shot we talked about earlier.

Preparation is key.

But keep it simple and immediate.

Demonstrate on a doll.

Look, the dolly is getting a shot.

Let them give the doll a pretend shot.

It gives them a sense of control.

Exactly.

A sense of control over the situation.

And tell them it's okay to cry.

Crying is a normal response.

And expect regression.

Yes.

A potty trained four -year -old might wet the bed in the hospital.

Parents need to be told this is normal and temporary.

Do not punish it.

Just change the sheets and move on.

They will regain the skill once they are home and safe.

This has been such a comprehensive tour of ages three to five.

It really is a unique bridge between babyhood and school age.

It is.

It's a time of stabilization physically, but massive expansion socially and cognitively.

It's a really special time.

So let's recap the big takeaways for the learner.

What do they absolutely need to remember from this?

Okay.

Number one, growth.

Weight doubles the one -year weight by age five.

Height increases about three inches per year, and they get that slender, athletic look.

Got it.

Number two.

Cognition.

PETA's preoperational phase.

Remember magical thinking, egocentrism, can't see your view, and animism.

Objects are alive.

They interpret things literally and concretely.

Trucial for communication.

Three.

Vocabulary explodes from 300 to over 2 ,000 words, and remember the sentence rule.

Sentence length equals age.

Four.

Play.

It moves from parallel, alone, but near, to associative, to cooperative roles and roles.

It's their work.

Discipline.

Consistency is key.

Timeouts are one minute per year of age, no bribes.

And finally.

The personalities.

The helpful threes, the aggressive fours, and the comfortable fives.

Knowing the stage helps you manage the behavior.

And here is a final provocative thought to leave you with.

We talked about magical thinking,

animism, and artificialism.

Consider how that impacts a child's experience of a chronic illness.

If they believe their thoughts can cause events, which is part of magical thinking,

do they believe their anger at a parent caused their leukemia, or that their broken leg is because they didn't share a toy?

That is a heavy thought.

It changes how we comfort them.

We have to explicitly absolve them of guilt they might be secretly carrying.

We have to tell them, you did not cause this.

It might be the most important thing you say to them.

It might be the most important nursing intervention you can do.

Exactly.

Understanding the development changes the care.

That's it for this chapter 18 deep dive.

A warm thank you from the Last Minute Lecture Team.

Good luck with your studies.