Peds, part 10: G&D - Toddlers - Development and Parental Guidance
by Meris Shuwarger BSN, RN, CEN, TCRN December 22, 2021 Updated: December 07, 2022 8 min read
This article discusses normal growth and development and expected milestones for toddlers (children between one and three years of age).
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
Physical growth and development milestones for toddlers
Weight, height, gross motor skills, and fine motor skills are among the most common physical growth and development milestones for toddlers.
Weight expectations for toddlers
Toddlers are expected to gain about four to six pounds per year. By age two and a half, their weight should be four times their birth weight. So if a child weighed 6 pounds as an infant, at two-and-a-half years old, they should weigh around 24 pounds.
Height expectations for toddlers
Toddlers grow about three inches per year. Caregivers will notice that at this stage in a toddler’s development, they start to grow up instead of out. Infants tend to be pudgy because they need the weight to help with all of the physical development they do in their first year. After that, they start to stretch out.
Gross motor skills in toddlers
Gross motor skills refer to big movements using big muscles. At 15 months, a toddler should be able to walk without help.
At 18 months, they should be able to jump in place with both feet (bunny hop) and throw a ball overhand. This doesn’t necessarily mean they’re going to be good at throwing the ball, but they should be able to demonstrate that skill.
By two years of age, a toddler should be able to climb stairs and kick a ball. Kicking a ball is a notably complex skill because it requires the toddler to be able to make contact with the ball and propel it forwards as well as have an understanding of where they are in space in relation to the ball.
Fine motor skills in toddlers
Fine motor skills concern little movements using little muscles.
At 15 months, a toddler should be able to successfully build a tower of two cubes.
At 18 months, they should be able to build towers of three to four cubes. They should also be able to use a spoon without rotation, that is, they are able to get the spoon up to their mouth in the correct position.
At two years of age, toddlers should be able to build a six- to seven-cube tower.
By two and a half years, they should be able to build a tower of eight cubes. They will also be able to draw a circle. Toddlers usually accomplish shape-drawing in this order: circle, square, triangle. If you want to remember this, you’ll see it’s in that alphabetical order: C, S, T. The circle comes first as it is a fairly easy thing to draw; the child simply moves their hand around and joins the line at where it started. The more complex shapes take more skill to draw.
Why are towers built from cubes so important in assessing a toddler’s fine motor skill development?
Building towers of certain numbers of cubes is a key way to assess a child’s development. Cube-tower building is part of the Denver II assessment, a formal developmental screening tool that assesses children from birth to 6 years of age, and includes gross and fine motor milestones.
Cognitive development in toddlers: the sensorimotor stage
In terms of cognitive development, toddlers are still in the sensorimotor stage, which means they are still exploring the world using their senses.
Language development in toddlers
At this stage in a toddler’s language development, they begin to use holophrases, which are one-word sentences, for example “Hungry.” This fairly obviously translates as, “I am hungry.” “No.” is another extremely common holophrase. So is “Want.” (“I want whatever it is I am looking at or thinking about.”)
By age two, a toddler should have more than 50 words and two- to three-word phrases. This is when we see explosive growth in their language, comprehension, and use. Toddlers will go from having no language to using all of language very quickly.
Normal behaviors for toddlers
The following are normal behaviors in toddlers.
Ritualization provides a sense of comfort for a toddler. For instance, having a comfort item to sleep with, like a Teddy bear. The consistency of the bear’s presence at bedtime is a ritual. If the Teddy bear is missing when it’s time to go to bed, this will present a problem because the child’s ritual has been disturbed.
Negativism is when a toddler automatically says, “No.” — to anything and everything. For example, a caregiver might ask the toddler, “Do you want to have a bite of my sandwich?” And the immediate response from the toddler is “No.” followed by, “What is it?” Their immediate reaction is negativism in action.
Temper tantrums are another expression of negativism. Parents and caregivers may have different experiences of just when temper tantrums occur in their children. For some it’s the “Terrible Twos.” For others, their children are three years old when the tantrums start.
When someone is egocentric, it means like they are thinking of themselves as if they are the center of the universe. While this may be unwelcome in an adult, egocentrism is very important for a toddler, because they need to fulfill their needs in order to continue to live (survive). Further, they have’t learned how to consider the feelings of others, another hallmark of egocentrism. In practice that means hearing a toddler say “I want” a lot. Toddlers don’t understand sharing because it hasn’t occurred to them that another person might be sad when, for example, they don’t get to play with a particular toy the toddler holds. They can’t see the situation from the other person’s point of view.
Psychosocial development in toddlers: autonomy vs. shame and doubt
A toddler’s psychosocial development at this stage is autonomy versus shame and doubt, the second of Erik Erikson’s stages of psychosocial development.
Age-appropriate play for toddlers
When the child was little, they played on their own, which we call solitary play. As the toddler develops, new modes of play emerge.
Parallel play is when a toddler plays independently next to other children. They are next to each other, but they are not playing together, hence “parallel” play. For example, one toddler might be playing with blocks while the toddler next to them is playing with cars.
The toys that interest a toddler at this stage of their development include push and pull toys, wooden puzzles, blocks, and balls.
Nutrition for toddlers — what parents should know
Parents of toddlers will discover that nutrition can get a little bit intense at this stage of the child’s development, because they are now eating more solid foods but are still at risk for choking.
What milk should a toddler drink?
Whole milk should be introduced into a child’s diet when they reach one year old. At this point, formula may be phased out and replaced with whole milk. At age two, toddlers should be transitioned to 2% milk. Whole milk has lots of fat in it, which is important for developing brains. But by age two, it’s time to cut down the fat content and go to 2% milk.
It is also important to limit milk to two to three servings per day. Too much milk, too much calcium, can decrease a child’s iron, which can lead to anemia.
If cow’s milk is contraindicated for a child, supplement their diet with calcium-rich and high-fat foods.
Limit juice, offer water to toddlers
Juice should either not be given at all or be limited to four to six ounces per day. Juice is sugar-rich, which can have an adverse effect on a child’s dental and physical health. You may have heard dentists say that each bottle of juice comes with its own cavity.
Offer water to a toddler several times a day instead.
Supervise toddlers during meal time
Toddlers are still at risk for choking, so it is important to be aware of choking hazards and supervise children when they eat. Our pevious article on safety issues covered this in more detail.
What is physiologic anorexia in toddlers?
It’s common for young children to experience physiologic anorexia. This is when the child says, “I’m too busy to eat.” They will tell a caregiver that they are running around or playing with their toys, and they don’t want to stop to sit down and eat a meal.
Encourage toddlers to eat healthy foods in small amounts
Instead of making a toddler stop what they are doing for sit-down meals, making available small, healthy finger-foods that they can snack on throughout the day is a good alternative. This is also known as grazing. Consider serving fruits and vegetables that can be cut into small sizes and that are stable at room temperature. The child can come and snack on these when they want to.
Toilet training for toddlers
A child indicates they are ready for toilet training when they start to recognize and communicate they need to use the toilet. What often happens is the child will let their parent or caregiver know that they need to use the bathroom. Note that this announcement might come before or after the child has gone (in their diaper). This is normal; the child has started to recognize that the two — knowing that they have to use the toilet, and doing it — go together.
Two more signs the child is ready for toilet training are when they wake up dry from nap or bedtime and if they are staying dry for two hours at a stretch during the day. Children normally have to go to the toilet every two hours, so when they stay dry for the duration, that indicates that they’re ready to transition to using the toilet rather than a diaper.
Sleep requirements for toddlers
A toddler should get between 11 and 12 hours of sleep each day. This is a lot of sleep, but is important for a child’s brain and physical development.
It is also important to maintain the child’s sleep structure, that is, maintaining a consistent bedtime routine.
Dental health for toddlers
Here are some of the things parents and caregivers should keep in mind when it comes to toddler dental health:
Do not give a toddler a bottle of milk or juice at bedtime.
The parent should brush and floss their child’s teeth right before bedtime as part of the child’s bedtime ritual. Having the child help will teach them to take on the responsibility of their dental care. For instance, the adult might say, “I’m going to brush your teeth first, and then you can brush them.” The child may just wiggle the brush around in their mouth, but they are learning to take care of their teeth!
Just as any adult should, toddlers should be seeing the dentist twice a year.
Toddler vaccination schedule
Note: The charts on ourPediatric Nursing Flashcards are a handy way to get to know the pediatric vaccination schedule for young and older children.
Hep. B, IPV
Between the ages of 6 and 18 months, the child should be getting their third doses for hepatitis B and IPV (the polio vaccine).
MMR, Hib, PCV, varicella
At 12 – 15 mos, the child should receive their MMR, Hib, PCV, and varicella vaccines.
MMR is the abbreviation for the combined vaccine for measles (an infectious viral disease causing fever and a red rash on the skin), mumps (a contagious disease caused by a virus whose symptoms include swollen salivary glands and a fever), andrubella.
The vaccine for Hib, haemophilus influenzae b, is very important to help prevent a certain type ofmeningitis.
PCV is thepneumonia conjugate vaccine, a pneumonia vaccine for younger children. It is administered at around 2 months of age.
Varicella is a herpesvirus that causeschickenpox and shingles (a viral infection that causes a painful rash).
MMR and varicella are given at this age because these are live virus vaccines, and children cannot get them until they are at least one year old.
A child should get their hepatitis A vaccine between 12 and 23 months of age. Hep A is used to prevent hepatitis A, a type ofliver disease.
A child should get another dose of the DTaP vaccine between 15 and 18 months of age. DTaP is a combined vaccine for diphtheria (highly contagious bacterial disease),pertussis, and tetanus (a serious disease of the nervous system caused by a toxin-producing bacterium).
Starting at one-year of age, children should be getting their seasonal influenza vaccine annually, when it is seasonally appropriate.
Hi, I'm Meris with Level Up RN. And in this video, I'm going to be talking to you about the normal growth and development and expected milestone for toddlers. That's going to be children between one and three years of age. I'm going to be following along using our pediatric flashcards. These are available on our website, leveluprn.com. If you need to get a set for yourself, I highly recommend it. But if you already have a set, I would invite you to follow along with me. All right, let's get started. So first up, we are talking about some of the physical development of a toddler. They're expected to gain about four to six pounds per year. Their weight should be four times their birth weight at age two and a half. So if we had a 6-pound infant at two and a half years old, they should be 24 pounds, right? Just a general guideline there. Now their height, they grow about three inches per year. So you will see that they really start to grow up instead of out. You know, we have those little pudgy babies, but when they hit that toddler stage, they really start to stretch out kind of. They grow up and they don't gain as much weight as they did when they were infants, because there's a lot of physical development to be done in that first year.
Now, gross motor skills. Remember, we're talking big movements, big muscles here. 15 months, they should be able to walk without help. 18 months, they should be able to jump in place with both feet, so like bunny hop, and throw a ball overhand. So it doesn't necessarily mean they're going to be good at throwing it. They're not going to be joining the MLB or anything like that, but they should be able to throw a ball overhand. By two years of age, they should be able to climb the stairs and kick a ball. Kicking a ball is actually a really interesting skill because it requires both the strength of of being able to actually make contact with that ball and propel it forwards. But it also requires an understanding of where they are in space in relation to that ball. So it's actually a pretty complex skill. Fine motor skills, we're talking little movements, little muscles, fine motor skills. 15 months, they should be able to successfully build a tower of two cubes. You will see that building towers of certain numbers of cubes is a thing. This is a thing that you have to know, and it has to do with the Denver II assessment. This is something that assesses these motor milestones. So with this, building a tower of two cubes at age 15 months. At age 18 months, we should be able to build tower of three to four cubes. We should also be able to use a spoon without rotation. Just meaning that I get it to my mouth and it is in the correct position. Two years, they should be able to build a six to seven cube tower. We love these cubes. And by two and a half years, they should be able to build a tower of eight cubes and draw a circle. I'm going to tell you what my pediatric professor told me, which is when you're talking about drawing shapes, it's circle, square, triangle. So we really go in that alphabetical order. So C, S, T. So circle, square, triangle. So in that two and a half year range, they're able to draw a circle. Circle is actually a pretty easy thing to do, right? I'm just moving my hand around. When we get into the more complex ones, that takes a lot more skill.
Okay. Moving on, we're talking about cognitive and psychosocial development. Cognitive, they're still in that sensory motor stage. So still exploring the world with their senses. When it comes to their language, they are now using hollow phrases, which is a one word sentence. So it's kind of hard to grasp, but a one word sentence would be something like hungry, right? Really what they're saying is I'm hungry. Or no is a hollow phrase, right? Or want. Really they're saying, I want that, but it's a hollow phrase. They should have more than 50 words and two to three word phrases by the age of two. So that's when we see explosive growth in their language, comprehension, and use. So you'll see them go from no language to all of the language very quickly. Now, when we talk about normal behaviors, ritualization is one. So that's like having a comfort item I sleep with, right? Every night, my son has Bear-Bear, right? He's three years old. He sleeps with Bear-Bear every night. If we don't have Bear-Bear, we've got a problem because that's his ritual. Negativism, this means-- it doesn't mean that they're pessimist, it means that they automatically say no. So when my son was two, if I said to him, "Finlay, do you want to have a bite of mommy's sandwich?" He would say, "No." And then he would kind of say like, "What is it?" But their immediate reaction is to say no, and that is negativism. They can also throw temper tantrums. You'll hear about the terrible twos, but really, I think it's the terrible threes. Three has been the bad age for both of my kids. That's been the really hard one for us. But again, it's in that toddler area of development.
And then egocentric, that means like I'm thinking about myself, I'm the center of the universe. But that's very important when you're little because you need to fulfill your own needs so that you can continue to live. And also, you haven't learned how to consider the feelings of others, right? So they're egocentric, so you're going to hear a lot of I want, right? I want that. They don't understand sharing because it hasn't occurred to them that the other person might be sad when they don't get to play with that toy. Now psychosocial development, their Erikson's stage is going to be autonomy versus shame and doubt. When we talk about play, so remember we had solitary play when they were little, and now we have parallel play. So parallel play means I'm playing next to somebody else who is also playing, but we're not playing together. So I'm playing with blocks, and my friend Henry is playing with the cars. We're next to each other, we're not playing together though, that's parallel play. Toys that they like, push and pull toys, wooden puzzles, blocks, and balls.
Moving on now to parental guidance for nutrition. All right, nutrition gets a little bit intense in these ages because they are now eating more solid foods but still at risk for choking. So whole milk should be introduced when a child reaches one year old. So we should phase out-- like formula, for instance, replace it with whole milk. And then at the age of two, they should be transitioned to 2% milk. That whole milk has lots of fat in it, which is awesome for those developing brains. But by age two, we're going to cut down the fat content and go to 2% milk. Easy to remember, two and two. Okay, additional things. We're going to limit milk to two to three servings per day, because too much milk, too much calcium can decrease the child's iron, right? So we can end up with anemia from too much milk. Juice should be either not given at all or limited to four to six ounces per day. My kids' dentist always said that each bottle of juice comes with its own cavity because juice is so sugar-rich. So we really want to limit that intake. Things we want to avoid, again, choking hazards. You can check out the previous video on that. It's common for kids to have physiologic anorexia, which would be less intense way to say that is, I'm too busy to eat. I'm running around. I'm playing with my toys. I don't want to sit down and eat a meal. I'm too busy, mom. So instead, we might have little finger foods that they can snack on while they play, something like that. We can give them like a little plate and say-- like my husband always called it charcuterie. So we would just have little fruits and vegetables and things that could be stable at room temperature, and they would just come and snack on it when they felt like they wanted to.
All right, moving on to toilet training, sleep, and dental health. Toilet training, this is how a child lets you know that they're ready to do toilet training. They're going to tell you that they need to use the bathroom. And that might be right before or right after. That's okay. We're starting to recognize that the two go together. They're going to wake up dry from nap or bedtime, and they're going to stay dry for two hours during the day. That's about how frequently they go to the bathroom. So that would be indication that they're ready to transition that into doing that in the toilet versus in a diaper. Sleep, they're going to sleep 11 to 12 hours a day. That's a lot. So we want to maintain that sleep structure for them. That they have a consistent bedtime. Sleep is so important for brain development and physical development too. Dental health, we don't give bottles of juice or milk at bedtime. We should be brushing teeth right before going to bed. And the parent should be brushing or flossing the child's teeth, and then having the child help them do it. So I always tell my son, "I'm going to brush your teeth first and then you can brush them." And then he kind of just wiggles it around, you know? [laughter] And they should be seeing the dentist twice a year, just like an adult.
Lastly, let's talk about vaccinations. We do have a nice table here for you, separated by age. So between 6 to 18 months, they can get their third dose of hepatitis B. Typically, that's just at the six-month visit, but they would also get IPV. We talked about that in the infant video, but it kind of bleeds over because it can be up to 18 months. Then we have 12 to 15 months, they should be getting MMR, Hib, PCV, and varicella. You'll note that MMR and varicella are present here now because these are live virus vaccines, and children cannot get them until they are at least one year old. 12 to 23 months, hepatitis A. 15 to 18 months DTaP. And one to three years, they should be getting their seasonal influenza vaccine every year, during that time when it is seasonally appropriate. All right. Let me ask you some quiz questions so you can test your knowledge of key facts I provided you. Okay, tell me first, at what age is a child expected to weigh four times their birth weight? At the age of two years, how many cubes should a child be able to stack on top of each other successfully? What type of play does a toddler typically engage in? At the age of two years old, what type of milk should a child be drinking? And tell me, what is the age at which a child may begin to receive live virus vaccines? All right, let me know how you did in the comments. I can't wait to hear and I'm sure you did great. If you need a little refresher, you can always go back and watch this video again. Thanks so much and happy studying.
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