Well Child Resources
Breastfeeding Tips

Breastfeeding your new baby should be an enjoyable experience. Getting off to a good start may be challenging, but the first two weeks are so important that using your breastfeeding resources will be paramount to being a successful nursing mother.Ask to see a Lactation Consultant during your hospital stay. The sooner you have someone assist you with positioning and latch on the better. Watch baby for sucking and swallowing at the breast and if the baby is swallowing well. The baby should nurse 10 times in 24 hours the first 2 weeks.

A good indicator of intake will also be stools which should be abundant and yellow (4-12 stool diapers a day), by the 7 th day of life. Keep a journal indicating how often baby feeds well at the breast , how many wet and stooled diapers baby has a day.

Mom’s often need help in the first few days with latch, sore nipples, and sometimes engorgement.

Please call a lactation consultant to come to your home if breastfeeding isn’t going well or contact Dr. Ramsdell.  To find a lactation consultant in your neighborhood, go to the website of the international lactation consultants at ilca.org or contact La Leche League at www.lalecheleague.org or for Wake County at 
www.lllusa.org/web/WakeCountyNC.html.

by “Sam” McDevitt, Pediatric RN, and licensed lactation consultant

Vaccine

Our goal is to administer the vaccines in a safe manner as efficiently as possible. Many parents ask us if they can hold their child during vaccine administration. We recognize that the comfort of a parent’s arms can be helpful during this time and we actually count on a parent’s help to make sure we can administer the vaccines safely. Doctor Ramsdell can offer suggestions to parents on a way to hold their child in their arms or on their laps in a comforting way that offers good visualization of the injection sites.

Children ages 3 years and up often sit in a parent’s lap with a parent holding each hand in order to expose injection sites on the upper arms. Children under the age of 3 years are given vaccines in the lateral thighs. This can be accomplished by a parent holding a child sitting in their lap with hands up and away from the injection site.

1 Month Visit

One month olds are increasingly more aware of the world around them. They response to faces, smiles, and voices, and start reaching out their hands. Your baby will go through changes during the coming months than at any other time in his/her life. Some key developments during this time will transform your baby from a totally dependent newborn into a responsive, loving human being.

Smiling: the very first image a baby can perceive in the human face. As family members smile and coo at the baby, the sense of self and connection is taking form.

Visual Tracking: at the end of the second month, baby’s vision is coordinated enough to follow an object horizontally and vertically. Once this skill is mastered, he or she will prefer moving objects over stationary ones.

Seeing Color: a baby can perceive color at birth and often are drawn to bright colors. Infants like the large swatches of color at a modern art museum. They also will be drawn to a grandmother with a vivid red blouse.

Contrasts: sharp contrasts, and black and white shapes are easier for a baby to perceive. Initially, babies often seem to be looking at their parents “eyebrows”, instead of directly in the eye. This is because of the focal point of their vision, but also because of the contrast.

Localizing Sound: infants will quiet when stimulated with sound, especially the parent’s voice. He/she can place sound and follow traveling sound with his/her eyes and body.

Grasping: hands gradually unclench and become a source of fascinations and sucking gratification. Babies also like to have their hands and feet stroked.

Discovery Play Ideas

Use play during the coming months to strengthen your relationship with your baby. He/she will spend much time practicing his/her new abilities.

Baby Massage: even the youngest newborn loves skin-to-skin contact. Holding and touching provide important cues to a new baby that he/she is protected, loved and cared for. It can stimulate or calm a baby, and provide an opportunity to share special time with your baby.

Balance:
Provide balance stimulation for the baby as follows:
  • Rock in your arm/rocking chair
  • Swing in infant chair
  • Rock in cradle
  • Ride in stroller
  • Lifting from sitting or lying position
  • Lay on stomach on a large inflatable ball and rock back and forth and side to side.
  • Do baby sit-ups and stand-ups (do smoothing and slowly, supporting the head and neck until the baby has strength to keep head in line with baby)

Reward him/her with smiles and funny expressions and talk to him/her through your joint activities.

Talk to and sing to your baby. Read a magazine or newspaper aloud. Watch TV with the baby. Babies are often soothed by the droning sounds of baseball/football and hockey games. Parents can hold the baby on their shoulders during a televised games and sing out the scores or sing along with the commercials.

Introduction to Sleep Training

At a month of age, the area of the brain involved in diurnal cycles, the supranuclear chiasm, starts to ‘light up’. Now is the time for parents to start introducing the idea of “bedtime”. Try putting the baby down in his/her bassinet with a smile and a lullaby. As the baby starts to fuss, gently pat him/her You can lay the baby on a cotton ‘burp pad’. This will have the fragrance of the mother’s milk, and will act as an olfactory cue to the baby that it’s bedtime.

Baby Safety

Carbon monoxide and smoke detectors are a must. When traveling to relatives, if you don’t have a carbon monoxide detector, sleep with the window cracked open. Be especially careful about vacation houses with erratic heating systems and insufficiently drafted wood burning stoves.

Don’t drive sleep deprived.

Don’t overheat the baby. If the baby is bundled up for the cold, and then put in a car seat – unzip the baby’s jacket as the car warms up to let out heat. A baby can not regulate his/her temperature as well. This also applies to space heaters. If an infant is dressed for 75 degrees and the room temperature rises to the 90s in the night – the baby can get overheated.

Changing tables: even though a baby doesn’t role over yet, they can sometimes ‘hop’ when they cry. Keep a hand on them at all times.
When holding a swaddled baby, keep a hold of a baby’s knee when walking around the house and up/down stairs. If you fall, your reflex will be to grab the baby against your chest.

Don’t put an infant seat on a small table…A common occurrence is a young child tilting the infant seat off the table to look at the new baby.

Carbon Dioxide Rebreathing: Don’t let a baby sleep on the tummy, or in any position where they can fall into a crevice. For example, if a baby falls sleep on a father’s chest and falls into the crevice formed between the father’s body and back of the cough – the baby can be trapped in a pocket of carbon dioxide. This can decrease respiratory drive and lead to SIDS.

Fire Safety Parents of newborns are notoriously sleep deprived. Don’t fall asleep with the dryer on or the stove on. Many parents have fallen sleep sterilizing bottles and woken up with the smell of burning plastic. When visiting relatives, rehearse in your mind how to unlatch doors/windows and get out of the bedroom in the event of a fire and you’re disoriented. Bring your own flashlight in the event of a power outage.

An impromtu fire escape for babies/young children: Get a duffel or strong laundry bag and fireproof rope. Knot the rope every foot and tie it securely through the top of the duffel bag. In the event of a fire, and you have to get out of a window without a fire escape, tie the free end of the rope to a radiator or piece of plumbing, and put young children in the duffel bag. Lower them to the ground and climb down yourself.

2 Month Visit
Development

Two month olds have had a tremendous growth in personality. They’ll smile and coo, turn to your voice, and listen intently. He/she will also start recognizing other people and voices, plus the cadences of different languages. The baby’s visual tracking is improving as well as the ability to perceive objects. The baby’s hands and mouth are its favorite toys – providing a flood of sensory input. The baby will have much more head control, and will push up on his/her arms.

Crying

Around this time, a baby’s cry becomes more focused. Parents will recognize the hungry cry, the pain cry, the frustration cry and the “I’m tired and want to be left alone……..” When babies are tired, they often have a ‘whiny’ cry. It is thought that his/her nervous system is fatigued – in much the same way two years olds will start to cry and whine after a couple of hours at a birthday party – or adults will want to retired to a quiet place after a half a day at an amusement park.

Sleep: Teaching the Baby to Self Soothe

This is the time to start sleep training. Try to develop a short go to bed ritual, complete with lullaby and gently put the baby into his/her crib/bassinet. Try to help the baby sense his/her surroundings, and teach the baby that the crib is a “warm/cozy” place. Turn on a music box, or sing a song, rub the baby’s tummy. Then slowly slow up the lullaby to a whisper and slow the tummy rub. Slowly pull your hands away and creep out of the room. The baby might toss/turn or fret. You can go back into the room and try to calm the baby again. . (See the article on Sleep Issues)

Vaccines

Two month olds will start their major infant vaccines. These are very important in that the diseases they cause are potentially serious and life threatening.
DTaP: diptheria, tetanus and acellular pertussis:
These three illnesses are among the worst known to man.

Diphtheria

Diptheria has a very high case fatality rate and can strike otherwise healthy children. Even with today’s antibiotics, diphtheria can be deadly. Besides airway obstruction, it can cause cardiac arrhythmias. In many underdeveloped countries, and war zones where public health networks break down, many people go unvaccinated. Several years ago there was a notice in the New York Times that a college age student from Scarsdale NY died of diphtheria in Florida. According to report, the person had received only one vaccine in early infancy and no others.

Tetanus

Tetanus has been a dreaded killer striking active, healthy people. At the turn of the 20th century, it was common to know someone who had died of tetanus, especially among pioneer children, manual workers and especially soldiers. Tetanus is another illness that today’s doctors have rarely seen and have never treated.

Pertussis (whooping cough)

Pertussis is a particularly horrible disease for children, especially young infants. Infants can go into respiratory failure and have to be hospitalized. At the 2005 American Academy of Pediatrics convention, there was a case presentation of a 2 month old in Pittsburgh who had recently died of pertussis despite being admitted to the pediatric ICU at Pittsburgh Children’s Hospital. The source of the whooping cough wasn’t determined. Older children with pertussis are usually not as sick, but they can have severe wracking coughs that can last for months, even with antibiotic treatment.

Haemophilus influenza

Is a commonly encountered and easily transmitted germ. It can appear as a green conjunctivitis or purulent runny nose. It can sometimes take on a virulent form, causing infection of the epiglottis (the flat at the top of the trachea) or traveling from the nasal passages to the blood stream, causing meningitis. The vaccine was released in l985 after several years of stunningly successful clinical trials. The rates of meningitis and serious forms of Haemophilus plummeted.

Polio

Before the vaccine was released about l955, polio was a well known and greatly feared disease. Even the president of the United Stated, FDR, was struck by it. Polio would give severe fever, chills and headache, i.e. summer flu like symptoms. Not everyone would develop the life threatening paralytic forms of it. Doctors who did their training in the days before polio vaccine have horror stories to tell of children in iron lungs and those who survived, paralysis. Polio used to affect pregnant women, and there were special maternity areas in some urban hospitals to accommodate the paralyzed women. Many people think that polio is a thing of the past. It’s incidence has declined because of world wide vaccination campaigns. There are some ‘anti-vaccine’ people who feel comfortable with their children being unvaccinated against polio, but there are few people with a background in medicine or biology who would want their children using a bathroom in an international airport without having had polio vaccine.

Pneumococcal pneumonia

Pneumococcus, otherwise known as strep pneumoniae, is a very common bacterial pathogen. Many children in nursery school will have it in their nostrils and not be sick at all. However, in the setting of viral infections such as influenza, which disrupt the mucosal barrier, pneumococcus can sometimes proliferate and become pathogenic. It is a cause of bacterial ear infections, sinusitis, bronchopneumonias and blood stream infections (sepsis). People with sickle cell disease, weakened immune systems and those who have had a splenectomy are especially susceptible to severe forms of the disease.

Rota virus

Rota virus is a major cause of vomiting and diarrhea. It can make infants and young children really sick and leads to thousands of hospitalizations every year for IV fluids. In third world countries, where IV fluids are not as available, Rota virus is a major cause of death.

Hepatitis B

Hepatitis B is endemic in many parts of the world. Although it often causes a mild, self-limited disease in young children, about 8% of people who acquire Hepatitis B go on to become chronic carriers and are also at risk for developing liver cancer in middle age. Hepatitis is transmitted by body secretions (blood, menstrual pads, semen). It can contaminate untreated water systems (menstrual blood), and food (an accidental cut in a restaurant worker who is a chronic carrier).
After the baby receives his/her two month vaccines, a dose of tylenol can be given 0.4mL = 40mg. The baby can experience “soreness” of the legs, and this can minimize this feeling

Other tips for parents of two month olds

Many parents start to feel housebound. They don’t go out, or get together with friends as much. They feel they have to stay home at nap time so the baby can get on a schedule. Younger babies are a lot more flexible and portable than a toddler. Babies can “bond” to a baby blanket or cloth diaper and with a theme lullaby, the parents can induce a nap at a friend’s house or in the car. Baby carriers and slings allow parents to go to museums, restaurants, even the movies (if you sit near an exit and have ear puffs for the baby). If it’s cold or rainy, the baby can go for walks up nestled up against your chest, with a rain coat, or parka wrapped around you and the baby. The baby will be heated by your body, but will need a hat. When walking with the baby in a carrier, always keep a hand free to protect the baby’s head if you were to slip and fall. If it’s sunny, the baby sling as as a sun shield.

Baby carriers also protect the baby from respiratory viruses. The baby is in your air zone, rather than in a stroller or on the floor an infant seat where people can come up and touch.

Tip: It’s easy for babies to bond to grandparents, aunts/uncles, close family friends at this age. The baby can even recognize a grandmother’s perfume. This is a good time for the grandparents and others to babysit for short periods of time. It doesn’t have to be at the baby’s home. An attachment blanket or burp pad can be used as a cue to the baby that it’s time for bed. It’s harder on the baby if the parents wait until the baby is over six months old for relatives to babysit.

4 Month Visit

This is an especially fun check up for pediatricians because the babies are so outgoing and social. They’ll giggle and chuckle and reach out to be held. Parents can see their baby’s awareness of the people around them expanding greatly. Also, the baby is usually less “fussy'” because he/she is more in touch with the environment. Babies usually enjoy outings – shopping malls, fruit stands, trips to a modern art museum are a feast for the eyes and ears.

A special note for babies of this age: When visiting relatives, a baby likes to look at the person from a distance from the vantage point of the mother or father’s lap. If a grandparent comes up too close, and tries to hold the baby, he/she might cry out of disorientation. Also, when being held by a parent, if the baby is passed to another relative without realizing it, he/she might cry if he/she turns and sees a different person.

Sleep:

If the baby is not consolidating his/her sleep into at least one long stretch of 5-7 hours, try to address it now. The longer you want, the harder it will be. Sleep difficulties worsen as the baby gets older and more opinionated. See the article on Sleep Issues.

Vaccines:

At four months, babies get a booster of the primary series of vaccines: DTaP, Haemophilus, Pneumococcal, Polio, Hepatitis B and Rota virus vaccines. A booster dose multiplies the antibody levels of the first vaccine. (see Immunizations and the 2 month visit article). The tylenol dose that can be given after the vaccine is 0.8mL = 80mg.

4 month Safety issues:

Babies start rolling over around this time. The most common injury in this age group is the child falling off the bed after being put down for a short time in the center of a large bed while visiting relatives. Even though a baby can’t crawl to the edge, while sleeping he/she might roll over once, then twice, and eventually be at the edge of the bed. It’s a good idea to make a temporary crib by boxing the baby in with a rolling barrier such as heavy books or surround the bed with chairs.

Another common scenario is the baby falling from a changing table. This usually happens with a relative who has been out of practice and forgets how quickly the baby can move.
Putting the baby in a stroller without strapping him/her in. As the baby gets bigger, if he/she starts to cry and kick, he/she can be propelled out of the stroller.
Having the baby on your lap and he/she lurches forward and gets splashed with hot coffee or tea.

This ability to “lurch” when excited makes it extremely important to keep a grip on the baby when walking up and down stairs. Don’t let frail relatives carry the baby, or siblings who aren’t tall or coordinated enough to break their fall in the event they slipped.

CO and smoke detectors are still of paramount importance. Also, have a “mental fire drill” when visiting relatives so you know how to get out of a house or hotel in the event of an emergency.

Avoidance of Illness:

The baby is still very susceptible to respiratory and other infections. Parents often become more relaxed than they were in the immediate newborn period. Still don’t pass the baby around a room of relatives and keep the baby out of the reach of toddlers and preschoolers. (See the article of Contagiousness of Nursery School Illnesses).
Continue boiling water.

If you are handling raw eggs, raw meat or other “organic substance, wash your hands before lifting the baby.
Don’t put a pacifier in a baby’s mouth without quickly rinsing it with water.

6 Month Visit
Development:

The baby will be very interactive and start babbling and vocalizing more. Babies love sitting on the parents’ lap and listening to conversations .

Motor skills:

Gross motor: Six month olds are beginning to balance themselves in a sitting a position. In the coming months, they will start crawling and getting into mischief.

Fine motor:

Babies will be able to transfer toys and play with them more intently.

Safety:

Now is the time to do serious baby-proofing. As your baby becomes more mobile, he/she will discover every little thing that drops on the floor. When sitting on someone’s lap, he/she can lean forward and grab things. Cups of hot coffee and tea are especially dangerous.
He/she will also start to crawl in the coming months. Watch out for phone cords, extension cords, and any type of hanging object. Babies at this age can often propel themselves out of the stroller if they start kicking and aren’t strapped in.

Choking:

Always check the floor for anything that looks enticing. Don’t put anything that could be a choking hazard on a coffee table. This is the time to learn how to do the Heimlich maneuver. Also, have babysitters and grandparents learn how to do the Heimlich maneuver.

Avoidance of Illness:

The baby will be reaching out to people and more exploratory. Also, he/she will always mouthing things. Don’t let the baby ‘teethe’ on anything that someone else has recently put in his/her mouth. When going to play groups, put any toy that has been mouthed, into a separate bin so it won’t be picked up by another baby. You can also bring a collection of your baby’s own toys.

Vaccines:

Most six month olds will receive their third DTaP (diptheria, haemophilus, polio, pneumococcal and rota virus vaccines, plus a hepatitiis vaccine

Diet:

Babies can start on solids around this time. See the article on “Infant Feeding Tips”. All foods should be pureed and the same consistency as commercial baby foods. Parents can introduce new foods every day or two, slowly building up the baby’s repertoire. Don’t introduce more than one food at a time, and hold off new foods if the baby is sick or has diarrhea. Parents can make baby “goulash” in which they mix together several foods the baby has already had, just as carrots, potatoes and peas. Yogurt can also be started.

Formula:

Continue iron fortified formula. The baby should have a minimum of 16 ounces a day but not more than 32. Breast fed babies usually nursing 6-8 times through the day

Sleep:

Most babies will sleep through the night at this age.

9 Month Visit

Nine month olds are increasingly aware of people and can understand segments of conversation. They will be doing more complex babbling, as they begin to master the muscles involved in language. Their motor skills are expanding – they are able to pull to stand and starting to cruise. A nine month old is like a little explorer, creeping on the floor, checking everything out, picking things up and examining them from different angles, and often putting them in the mouth for an exploratory chew.

Safety:

Now is the time to do serious baby-proofing. As your baby becomes more mobile, choking becomes more of a hazard. He/she will discover every little thing that drops on the floor. Keep checking the floor for anything that looks enticing.

Burns:

When sitting on someone’s lap, he/she can lean forward and grab things. Cups of hot coffee and tea are especially dangerous. At this age, they can actually fall into a toilet bowl or bucket of water and not be able to lift them self out.

Injuries:

At this age, the baby will reach up and pull things. Watch out for phone cords, extension cords, and any type of hanging object. At this age, babies can pull to stand next to a bookshelf or other piece of furniture and pull it down.

Avoidance of Illness:

9 month olds are very sociable and people will come up close. Also they are always putting things in their mouths. Don’t let the baby ‘teethe’ on anything that someone else has recently put in his/her mouth. When going to play groups, put any toy that has been mouthed, into a separate bin so it won’t be picked up by another baby. You can also bring a collection of your baby’s own toys.

Vaccines:

Most nine month olds will not need any vaccines, but some might need a third Hep B, or perhaps a flu vaccine.

Diet:

Continue introducing new tastes to the baby. Let him/her taste things off your finger. Just make sure that the food is smooth enough and pasteurized. Mashed/mushy (but unsalted) foods being served to the rest of the family can be put on the baby’s plate. Let the baby play with the food, and use his/her fingers to taste it.
If you go to a restaurant with the baby, you can let him/her task the various foods, however, avoid anything that is not served hot and might have been left at room temperature a long time. For example, let the baby have the mashed potatoes, but not the guacamole.

Formula:

Continue iron fortified formula. The baby should have a minimum of 16 ounces a day but not more than 32.
Breast fed babies usually nursing 6-8 times through the day

Sleep:

Most babies will sleep through the night at this age. However, babies are readjusting their sleep cycles and some infants who had been champion sleepers will wake up in the middle of the night and cry out as if asking “…where’s everyone?…” If your baby starts waking up in the middle of the night, reassure him/her that you are there but that mommy and daddy are sleeping. Don’t turn on lights or give the baby a bottle. You don’t want to stimulate the baby to wake up further. Usually the baby will slip back to sleep. If not, lean against the crib and act as if you’re going back to sleep yourself. If these measures don’t work, read one of the several excellent sleep references such as Healthy Sleep Habits, Happy Child, by Marc Weisbluth or The No-Cry Sleep Solution, by Pantley.

1 Year Visit

The baby’s first birthday is a very emotional time. Learning to walk allows the baby to become so much more autonomous – and more able to explore. One of the most important milestones is pointing. The baby will see something, wonder what it is and point as if to ask ‘what is it?”. The baby’s babbling will be more melodious and complex. As babies listen to language around them, their comprehension is greater than many people realize. Babies have an innate ability to discriminate the noun and verb of sentences, and this explains why they can learn a “foreign” language so much faster than older children and adults, who are more ‘settled in their ways’.

Singing helps babies learn language. Let the baby play with simple, sound-making toys such as a xylophone helps develop a better sense of pitch. Also letting a child initiate sounds with a simple musical instrument, such as a xylophone. If you have a piano, let the baby sit on your lap and touch the chords.
It is recommended that you rotate toys, so that there new things for the baby to analyze “figure out’.

Safety:

As the baby starts to walk, parents have to be extremely vigilant at other people’s houses. Don’t let them wander around a house without you. They can find an ungated open window, a penny on a coffee table or other choking hazard on a coffee table, or danging cord with an iron on top of an ironing board. When visiting relatives, bring your own electrical outlet covers and masking tape to cover sharp edges on coffee tables.

Burns become more of a hazard at this age. When carrying a cup of coffee or other hot food, make sure the baby is not underfoot. Keep them away from hot food being placed on a table. Years ago, a toddler got a severe hand burn by putting her hand on a pan of lasagna. Its best to keep them completely out of the kitchen when pulling things in an out of a stove or draining hot water from pasta. In the bath room, don’ t let the baby play with any faucets, and cover the bathtub faucet.

When having a party, or other large gathering, it’s a good idea to hire a professional babysitter for toddlers, and keep them cordoned off in a baby-proof area. You can also put “bells” on their shoes. As babies start to walk, they can quickly “slip out of sight” while the parents or relatives are talking and greeting guests. They also won’t answer when you call out their names.
The AAP (American Academy of Pediatrics) has an excellent safety check list. You can probably find it on its website.

Avoiding Illness:

Babies often have a high fever around the first birthday. This is because they are crawling all over the floor and putting a wide range of objects into their mouths. If you watch a baby long enough, he or she might actually chew on the sole of someone’s shoe. Babies at this age often put their hands in the garbage. Keep them far away from raw egg shells which can harbor salmonella.

As the baby masters walking, he/she is able to stand up and be in the “direct line” of a cough from a playmate or cousin with a cold. One way to minimize illness is to wash the baby’s hands frequently with an alcohol based ‘sanitizer’ after birthday parties and other gatherings.

Diet:
Making the Switch from Formula:

The baby can switch from formula to whole milk. If a baby has been on a cow milk based formula, such as Enfamil or Similac, you can make the switch over a couple of days. One year olds are supposed to have a minimum of 16 ounces of dairy products, and a maximum of 32 ounces. Yogurt and cheese are included in this dairy amount. One ounce of cheese is similar to a 8 ounce glass of milk.

Switching from Soy or Hypoallergenic formula

If the baby has been on soy or a hypo-allergenic formula like Alimentum, any transitioning has to be done very slowly. Kids who have ezcema or loose stools with milk can often, but not always, start tolerating it after the age of 15 months. It’s OK to keep the baby on the low allergy or soy formula until 15 months, while introducing small amounts of yogurt or pizza cheese. Progress slowly and look for any appearance of eczema or diarrhea after the cheese or yogurt.

Iron Intake:

Even though milk is very nutritious for toddlers and young children, too much can deplete their appetite for other foods. Also, if a baby has milk products throughout the day and bedtime, the calcium of milk with compete for absorption with iron. Iron in the diet will not be sufficiently absorbed, leading to anemia. This is a common problem with big milk drinkers who don’t like eggs, beans. iron fortified cereals, meat and other sources of iron. Good ways of increasing iron in the diet is adding some Product 19 or Special K to baby cereal or meat loaf. Many old fashioned cereals such as Corn Flakes, which were popular during the Depression (1930s), have iron fortification. This was done to counteract the abysmal diet many families had. When serving a high iron food like eggs, don’t give milk at the same time. Another way of enhancing iron intake is heating up tomato sauce (which contains Vit C) in a cast iron skillet. You can give toddlers eggs several times a week, even daily. The cholesterol is not a problem (in fact, cholesterol is a major component of the brain). Try to introduce beans at this age. They are a great source of iron,. but are one of those foods that young children might reject if not introduced early enough. Lentil soup and lima beans are popular to children in some countries while many American children consider them ‘yucky’.

Vaccines:

One year olds receive the Measles Mumps and Rubella vaccines, and Varicella. They can also receive their 4th booster of Prevnar (pneumococcal).

15 Month Visit

This is the golden age for language development. The neurons in the language areas of the brain are rapidly elaborating their branches and making connections. Toddlers have an uncanny ability to absorb language around them. Studies have shown that they can discern the noun and verb of sentences in a foreign language and pick up the gist of a conversation much more easily than older people.

If you live in a bilingual environment, the baby should be exposed to both languages at this time. Even if the language isn’t used often enough for the child to become fluent, he/she will absorb enough to acquire the cadence and accent of the language. It will make it much easier to learn the language when re-exposed to it at school, or when traveling to visit relatives.
At this age, most toddlers use about 5-7 words (outside of mama, dada). This is tremendous variability among children – some will have an extensive vocabulary of 20-50+ words, and others will still be using mama, dada consistently, and babbling. The important thing is that the child is babbling with a ‘language’ like rhythm and that he/she is responding to language. One of the most important indicators of language is pointing and going up to the parents as if asking what something is.

Diet:

Toddlers might become more “discriminating” at this age and start refusing foods they used to eat. It is thought that they are “thinking” more about what they eat, and making a conscious decision that some foods are ‘yucky’. They often have a propensity to want the same foods over and over again.

Many toddlers can easily load up on milk and dairy. This can gradually lead to iron deficiency in that the calcium of milk competes with iron for absorption within the intestinal tract. When serving a toddler a high iron meal like eggs or meat, offer something with vitamin C, such as fruit slices or vegetables. Don’t give milk at the same time.
Don’t let toddlers eat any food or juice that hasn’t been pasteurized. Avoid uncooked vegetables that could possibly be contaminated by e.coli.
Make sure all foods are small, and soft to avoid choking. Keep them away from uncut grapes and hot dogs. Also, don’t let them eat any hard such as an apple or pretzel while walking.

Safety:

This is an especially challenging age. Don’t let them out of your sight. The toddler has the ability to move much faster now, and can run into traffic. They can also wander away in a department store or airport and not answer when you call his/her name. Especially hazardous situations are parking lots (the child can walk away from you), houses with pools off the patio (the child can wander out of the house and fall in the pool unnoticed). Other special dangers are marinas and harbor walkways without railings. A toddler can run ahead of you and if he/she were to fall into the water, it’s often murky and at least 8 feet deep.

If you take a toddler to a baseball game, keep them right near you so they don’t get hit by a fly ball. They are totally unaware of swinging bats and golf clubs.
Other health hazards are manure. Dog and cat excrement can contain parasites. Cow manure can harbor the e.coli 0157 that can cause hemolytic uremic syndrome. If you are visiting a farm, or other outdoor area, don’t let the child near any manure. Also don’t let them near fallen logs where raccoons might be nesting. Raccoon excrement is especially hazardous to children.

Vaccines:

15 month olds get a boosters of their primary vaccines (Haemophilus, DTaP, Prevnar)

18 Month Visit

At this age, the child is experiencing a growth spurt of language. The sounds and gestures that have swirled around the child since birth are being synthesized into meaningful words and phrases. For example, while a nine month old can understand the word “cookie”, and a fifteen month old might say it, the eighteen month old will start combining it with other words into a short sentence. It’s an amazing process.

Many children with have a vocabulary of 20-50 words, and speak simple two word sentences. However, many other children will only have a few words. This is an age when language skills in normal children can have a tremendous spread. Within a playgroup of same age children, there will be some children who have an extensive vocabulary and full sentences, while others will have less than 10 words. There are many children who go through a language burst around 20-24 months and catch up quickly with the early talkers. There are others who will be still be late talkers at age two. It is thought that the language center of the mind develops later in some children. There are many scientists, mathematicians, architects and other “visual thinkers” who were late talkers. /p>

Children who live in a bilingual environment are expected to be about 6 months behind in language milestones. They are astutely listening to the two languages and analyzing the vocabulary and grammar. They might say some words in one language and use the other language for others; for example, the Spanish leche for milk and English for other nouns. Some parents (and day care teachers) might express concern because the child isn’t talking. Then, after the second birthday, the child often starts speaking basic sentences in both languages.

At 18 months, it is difficult to tell which child is going to have a language explosion within a few months and which is going to be a very late talker and not speak by age two. Early Intervention is a federally funded program that provides speech, as well as occupational and physical therapy for children with developmental delays. In order to participate, the child has to be evaluated by a team of experts. Because so many children have a burst of language about 20-22 months, many pediatricians will not want to make a referral to Early Intervention until a child is two. An 18 month old who is more likely to be on the verge of speaking is one who has lots of babbling with a natural cadence, as if speaking in a foreign language – with an occasional understandable word. If a child comes up to the parent, points to things, and acts as if he/she is talking to them, that is a sign of natural language progression. If a child hardly says anything, or if he/she seems “frustrated” and makes sounds that sound like ‘open’ vowels like “….aaahh….” or a frustrated “….uurr….” he/she could benefit from earlier speech therapy.
There are some ways a parent can facilitate language. One technique is constructing a sentence around one of their utterances. The parent listens to the child and tries to respond to a word he/she might use. For example, if the child says “…..paaark……” as he/she sees the playground in the distance, the parent can respond with the statement “..let’s go play in the park…..”.

Another way of facilitating language is with picture books. Children have phenomenal memories and will soon become familiar with the story line. Once they know a book, when you read it to them in the future, as you point at one of the main characters or objects, they might say the name of the character or object. Try this with books that are very simple and familiar like “Good Night Moon” . You can also try it with books that have more of a storyline like the “Little Engine That Could”.

Safety:

The child is much faster and agile now, but still doesn’t have the judgment to avoid danger. When an 18 month old is running down the street, he/she might keep running instead of stopping at the curb. In the park, he/she can run into the path of a child on a skateboard or children playing baseball. When walking on a dock, keep a grip on the child. At a swimming pool, an 18 month old will follow the lead of older children and jump into the pool. Another hazard is burns. As the toddler gets taller, he/she can grab hot liquids from a table top.

Diet:

Most children will be a little “finicky” at this age. It’s OK if they don’t eat a balanced diet on a day to day basis, but they should balance out over the week. For example, if a toddler eats a good source of protein one day and fruits/vegetables another, he/she will stay in nutritional balance. Most toddlers don’t eat three good meals a day. They might eat a good lunch, then only nibble at dinnertime. They usually don’t need as much food as parents think they do. A basic rule of thumb is that a toddler should get a minimum of 16 ounces of milk or other calcium rich food, and a source of vitamin C.

Vitamins:

It’s good to be a multi-vitamin with iron to any child who is finicky. There are many over the counter drops available, such as Poly Vi Sol with Iron. The best time to give an iron containing vitamin is just before a meal. Try not to let the vitamin touch the child’s teeth. Iron containing vitamins can cause a gray stain on the teeth.

Giving up the Pacifier:

Many children who were colicky in the newborn period were given pacifiers. If the child has continued using the pacifier after six months, he/she can be a “pacifier-addict” by 18 months. The parents might cringe at the thought of putting the child to bed without the pacifier. Sooner or later the child is going to have to bite the bullet and give it up. It’s a question of timing. Most parents will not want to take away the pacifier when the child is sick or a night when they have to assure some sleep (i.e. before a big presentation at work).
The best time to “give it up” is a Friday night (or other when the parents can stay up late and not go to work in the morning). Let the child see that the pacifier has gotten “dirty” and had to be thrown into the garbage. When the child asks for it later, tell them that the pacifier has “gone”. The child will scream/yell/holler. Maintain a calm exterior, turn on the TV, and let the child fall asleep watching a movie. The next day, keep them busy, and whenever he/she asks for the pacifier, tell them it’s “gone”. It takes about two days of being “run ragged” for a child to “give up” a pacifier.

2 Year Visit
Development:

Your 2 year old’s gross motor skills are being honed at this time. Their energy level is at the highest and they seem to always be on the go. Running becomes much more coordinated and their gait changes from the wide-based toddle gait to a more adult-like, heel-toe gait. By the end of this year, he or he will learn to kick a ball and direct the ball’s movement, pedal a tricycle, and walk backwards. Walking up and down stairs holding on becomes easier and he/she will first alternate feet walking upstairs and later alternate feet when going down. Try to give your two year old time outdoors each day to run and explore and expend some of his/he tremendous energy. Remember than his/he judgment and abilities do not quite match their excitement and you must still protect him/he from injury and teach street and park safety. In other words, protect the child from him/herself.

Fine motor skills are also being fine-tuned at this time. During this year, your child will learn how to hold a pencil in the correct position (thumb and the 1st/2nd finger opposing each other on opposite sides of the writing instrument). This gives him/her better control over the writing movement and the ability to draw lines and circles. He/she will be able to build a tow of 6 blocks. You will also notice that your child now explores objects differently. Their newly developed fine motor skills allow them to explore objects by taking them apart and putting them back together, twisting things inside and out, and dropping and banging objects. They will learn to screw and unscrew lids as well as turn handles, which means being able to open doors. Obviously, because of these advanced skills, you will need to be vigilant about keeping medicines, household cleaners and detergents out of your toddler’s way.

Expansion of language skills is the most dramatic change in your two year old’s development. They have a rapidly expanding vocabulary (and their receptive language is larger than expressive language). In the coming year, he/she will go from speaking 2-3 word sentences to sentences composed of 5-6 words. They seem to learn about 50 new words a month. Reading to your child is most important now because of the expansion of their receptive and expressive language skills. Because of your toddler’s attention span (which can be limited), try to keep to books which are shorter and therefore more enjoyable. You will begin to see the use of pronouns such as I, me, you and they. He/she will also be able to follow 2-3 step commands without difficulty (indicating receptive language). By the age of 3, your toddler will understand prepositions such as on, under, in front, or behind. He/she will be able to tell you his name, age and possibly sex. Expressing emotions becomes easier and he/she will be able to tell you he/she is angry, tired, happy or excited. He/she will also learn to communicate his/her needs and desires. This is a GREAT milestone because being able to express emotions and communicate needs and wants takes away some of the frustration toddlers have earlier in the year. This will go a long way in helping deal with tantrums and autonomy issues. The important thing to remember is that there is a huge variation in the development of language skills at this age, so try very hard not to compare your toddler to another. If you are concerned that your child’s language is not developing, please make us aware of your concerns.

Cognitively, there are two phases which reveal how your child is thinking at this time. The first is that your toddler will take everything you say literally. So if you say “if I eat another think, I will explode”, your child may become worried that this could happen to him. The second is that everything that happens in your child’s world is a result of something he/she has done. Toddlers are very egocentric and this is one of the reasons why separation, divorce, and death are difficult for your toddler (they often feel it is their fault). Other cognitive skills include learning how to complete small puzzles, sort objects by shape, color or size, match objects on hand with pictures and play make-believe. By the end of this year, your toddler will be learning cause and effect. He/she will also begin to reason things out rather than react emotionally or physically. (It is almost as if you can watch the “wheels turning” inside their head). You’ll see that much of your child’s play is through imitation and they “do as you do and not as you say”.

Diet:

A toddler’s diet is often a very frustrating issue for parents, grandparents and friends. Usually 3 meals a day with 1-2 snacks id desired. However, there may be days when your toddler eats next to nothing and other days when you think they will eaet you out of house and home. Try to look at the diet a week at a time rather than on a daily basis. Controlling what goes into his mouth is about the only control your toddler has and he will use it to a maximum. There will be days on end when he wants only pizza and then will abruptly shift to refusing pizza and only wanting apples.; Try to not make eating and feeding a control issue with your toddle.e If you are concerned that he/she doesn’t eat a balanced diet, start supplementation with a multivitamin with iron (i.e. Poly-Vi-Sol). This will ensure that your child gets the vitamins and iron she needs and can take away some of the worry about his/he diet. One thing many children do is drink to the exclusion of eating solids. If this is the case, try to cut back on the amount of milk to 16-24 ounces a day and cut back on juices. Don’t let iron containing vitamins sit against the teeth, they can cause a gray strain. Place the vitamin dropper to the back of the inside of the cheeks and then give the child something to drink or eat. Remember to brush your toddler’s teeth on a regular basis and by the end of this year, a visit to the dentist is in order.

Safety:

Important safety issues include stair gates, window guards, and protection from accidental poisonings (keeping medicine, cleaners, and detergents under lock and key). Street and park safety is also a big issue. Teaching your child to hold your hand when crossing the street and to stop at the corner is important. Show them (by example) that you only cross at crosswalks and when the light is green or says “walk”. Keep a close eye on your toddler in parks where he/she may attempt to do things which he/she is not quite capable of (i.e. climbing to the top of the monkey bars, standing in swings, etc.) Swimming pool safety must be kept in mind during the spring and summer months. Teaching your child to swim is a good idea.

Toilet Training:
A few pointers on toilet training are:
  • You may wish to wait until your toddler is past the majority of his “negativism” (often the earlier training is started, the longer the whole process takes).
  • Make sure they are developmentally ready (can verbalize the need to stool or urinate, can pull pants up and down and can sit on a potty by themselves).
  • Nap and nighttime training take a longer time.
  • Most children are trained by 3-4 years old and often going to school can be the impetus in a “very difficult to train” child.
Temper Tantrums and Discipline:

Temper tantrums usually occur when a child is frustrated so you will see more of them your child is hungry, tired, or over-stimulated. A few important points about tantrums are: allow your child to express his/he emotions, but try to redirect him/he from aggressive or violent behavior (which means letting them have the tantrum, try to remove them from potentially dangerous areas, or if they will let you, hold them in your arms). If the tantrum is occurring in a public place (restaurant, Toys-R-Us), take your child to an area where they can “have the tantrum” (parking lot, corner of the store, restroom). CONSISTENCY is most important so if you say NO, make sure you mean it. Physical punishment is not useful, especially since you are trying to prevent aggressive or violent behavior.

Try to ignore the tantrum attention – even negative, is a way of reinforcing behavior and this is not a behavior you want to continue. Remember that at the end of this year, your child will be better at expressing frustration, needs, wants and emotions, and therefore, tantrums will ease up. A good way to think about discipline is viewing it as a positive way to help your child develop self-control. Do this by encouraging and rewarding good behavior. Developing rules and limits are important, but you must give your toddler the ability to be independent. In other words, sometimes there can be too many rules/limits. Don’t change the rules (again, consistency) and if there are annoying behaviors which you want to avoid, extinction (meaning, ignore the annoying behavior) is often the most successful. During the extinction process, you will often see the annoying behavior increase at first and then slowly decrease. Try to give your toddler choices when you can (giving them choices of two, i.e. do you want to wear the red or blue pajamas?), and don’t ask questions unless you are willing to take “no” for an answer. Don’t say “do you want to take a bath?” if the bath is not negotiable, but say “in the bath, do you want to play with the boats or the fish?”

One last point is just a reminder that all children (and parents!) survive this sometimes very trying period in development and at the end you will be able to say “WE MADE IT”.

3 Year Visit

Some parents and babysitters can be much less conversational around preschoolers. While the child plays, the parent can do chores around the house and take the child shopping or for walks to the park. Hours can go by without the adult having a conversation ‘with’ the child about his/her experiences. The child is not harmed by this type of more perfunctory adult interaction, especially if the child is part of a boisterous family. If there are lively siblings and aunts/uncles around, the child gets a lot of stimulation. However, if a family with an only child hires a babysitter who is very quiet and spends hours taking the child for walks and shopping trips, the child can be missing some intellectual stimulation. A similar scenario can occur in families where the mother is overburdened with chores, shopping, running a household or volunteering at school. Even the most well meaning parents can be overwhelmed. They can set aside a “story time” for the child each evening, and talk about ‘what happened that day” at dinner.

It is not necessary for the parents to be chatterboxes and constantly direct their conversations to the child. Having time for self directed play and reflection helps a child learn to ‘think’. One of the reasons the American Academy of Pediatrics wants parents to limit television time is that playing quietly is an important part of their intellectual growth. Too much fast action and commercials can shorten children’s attention spans. Many parents turn on the TV in the morning as they’re getting ready to work, getting the kids off to school. This can be a time when the child brings some ‘story books’ or to the kitchen table to look at quietly while the parents read the morning paper.

Imagination:

A three year old has an especially vivid imagination and can get so absorbed in play that he/she can ‘tune out’ the world around them. The child can be sitting in the middle of the living room playing and overhear segments of their parents’ conversations. The child can then splice these segments together and think that something happened that didn’t. For example, parents can be talking about a hurricane at grandma’s condo in Florida and that next week the family is going to grandma’s house for dinner. The child might have only heard the segment “hurricane in grandma’s house”. Later on in the week, the child might say “……….I don’t want to go to grandma’s……..” because in his/her mind, they think that there’s going to be a hurricane there. It’s very important to be aware of what’s on television when a three year olds in the room. When they see violent images, the child can think that it’s happening down the street.