Pediatrics - Milestones 18 Mos - 5 Years

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Physical developmental milestones at 18 months

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Walks alone
Eats with spoon
Can undress self

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Cognitive developmental milestones at 18 months

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Scribbles on own
Points to one body part; nose, ear

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Language developmental milestones at 18 months

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Says several single words
Points to show someone what he/she wants

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Emotional developmental milestones at 18 months

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May have temper tantrums
Shows affection to familiar people
May cling to caregivers in new situations

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Radial head subluxation

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Nursemaid's elbow

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Physical developmental milestones at 2 years

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Stands on tiptoe
Kicks a ball
Begins to run

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Cognitive developmental milestones at 2 years

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Sorts shapes and colors
Follows two step directions, “pick up your toy and put in toy box”

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Language developmental milestones at 2 years

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Says sentences with 2-4 words
Points to things in book

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Emotional developmental milestones at 2 years

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Copies other, especially older children
Shows defiant behavior

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Temper tantrum

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Common between 1-4 years
Child may throw him-herself down, kick, scream, strike out at people or objects.

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Why do children have tantrums?

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Behavioral responses to stress, frustration and loss of control.
- Child is attempting to achieve autonomy and mastery over the environment.
- Difficulty expressing frustration with experiences beyond their developmental level.

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Management of temper tantrums

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Child-proof environment (minimizes need to say no)
Use distraction with increased frustration, redirect the child then reward positive response.
Present options to the child within child’s capabilities.
Fight only the battles that NEED to be won.
Do not abandon child during tantrum.
Do not use negative terms/
Never allow child to hurt self/
Parents “don’t hold a grudge”, but don’t grant the child’s demands.

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Breath holding

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Starts from 6 months-6 years, usually during the first year of life.
Child engages in a prolonged expiration that is reflexive and may become pale or cyanotic.
Is reflexive, not volitional, in nature.
Child is surprised, starts to cry and then falls silent in the expiratory phase.

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Management of breath holding

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With frequent spells, evaluate for underlying disorder
- OSA, Orthostatic Hypotension, seizures, tumors

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Healthy techniques to handle breath holding

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Focus treatment on behavior modification
Child-proof the environment
Use distraction with increased frustration
Present options to the child within child’s capabilities
Do not abandon child during tantrum
Never allow child to hurt self
Do not submit to child’s every whim

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Child oriented approach to toilet training

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Parents avoid pushing, process begins when child is developmentally ready or shows signs of readiness.

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What are the variant forces in toilet training?

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Physiological maturation
- Ability to sit, walk, dress and undress

External feedback
- Understands and responds to instruction

Internal feedback
- Self-esteem and motivation, desire to imitate and identify with mentors, self determination and independence.

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Stages of toilet training signs

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18 months - child may show signs of readiness

24 months - step by step approach for teach the child his/her role in the process should be initiated

30-36 months - most children will have achieved daytime continence

36-48 - most children will have achieved nightime training

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Importance of potty chair in toilet training

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Assess child’s readiness and desires to train.

Introduced at home.

Convenient location for child
- Child encouraged to observe, touch and familiarize
NO PRESSURE FROM PARENT
When interest is shown, can sit, fully clothed
- Conceptualize for child- take stool from diaper to potty chair
- Imitation is a powerful way to introduce the idea of using the chair.

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Importance of reminders and reinforcements in toilet training

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Based on cues or specific times (awakening or after meals) parents can synchronize practice runs to the potty chair.
Certain elements can be frightening
- Flushing- disappearance of feces
- Flush toilet paper, join saying bye-bye
Use praise for successful toileting
- Child esteem is delicate and it is imperative that parents support the child throughout all phases.

When the parent-child relationship becomes strained, take a 3 month break.
If the child further regresses, parent need to remain supportive and discourage feelings of failure, keep confidence and self –image high.

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Toilet training regression

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Setback do occur
- Withholding stool, insistence on wearing diapers after learning to use toilet.

Normal part of training
- Is not failure
- Reassurance to parents, be accepting
- It is only temporary

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Physical developmental milestones at 3 years

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Climbs well
Pedals a tricycle
Walks up and down stairs

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Cognitive developmental milestones at 3 years

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Does puzzle with 3-4 pieces
Copies a circle with pencil or crayon
Understands what “two” means

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Language developmental milestones at 3 years

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Says first name, age and sex
Carries on conversation using 2-3 sentences
Talks well enough for strangers to understand most of the time.

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Emotional developmental milestones at 3 years

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Takes turns in games
Shows concern for crying friend
Knows what is “mine”

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Physical developmental milestones at 4 years

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Pours, cuts with supervision and mashes own food
Catches a bounced ball most of the time

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Cognitive developmental milestones at 4 years

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Starts to understand time
Plays board games or card games

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Language developmental milestones at 4 years

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Sings a song from memory
Knows some basic rules of grammar, “he”, “she”

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Emotional developmental milestones at 4 years

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Enjoys doing new things
Is more and more creative with make-believe play
Cooperates with other children

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Parasomnia

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Abnormal event that occurs during sleep; includes, night terrors, sleep-walking and sleep-talking.

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Night terrors

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Usually occur within 2 hours after falling asleep, during deepest stage of NREM sleep – may last up to ½ hour (at which time child goes back to sleep and has no recall of event)
- Child may sit up, thrash around in bed, exhibit rapid breathing, tachycardia, sweating
- Often is incoherent and inconsolable
Often associated with sleepwalking

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How often do night terrors occur?

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Occurs in 3% of children

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Management of night terrors

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#1 reassure parents
- Child is not in pain
Avoid/decrease stress
Establish regular sleep schedule
Avoid sleep deprivation
- This will prolong deep sleep when night terror occur

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Sleepwalking

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Also occurs in slow-wave sleep
Common between 4-8 years of age
Typically benign in nature, except injuries can occur while child is walking around.

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Management of sleepwalking

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Environment obstacle free
Bell on child’s door
Avoid/decrease stress
Avoid sleep deprivation
- However, scheduled awakenings may be used if child sleep walks frequently in predictable times.

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Nightmares

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Frightening dreams during REM sleep, usually followed by awakening.
- Child may have vivid recall
- Child may seek parental reassurance
Peak occurrence 3-5 years of age
Usually self-limiting, associated with
- Stress
- Anxiety
- Sleep deprivation

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Dysomnia

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Any disturbance involving the amount, quality or timing of sleep.

Includes difficulty initiating sleep and nighttime awakening.

Results in daytime fatigue for parents and child.

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Dysomnia factors

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Quantity and timing of feeds first years of life
- Most infants beyond 6 months of age can go through the night without being fed
- Night feeding is a learned behavior

Bedtime habits
- Going to sleep - positive parental behavior (rocking, sing, reading)
- Going back to sleep after awakening without these attentions may be difficult
- Set limits within child’s biologic rhythms.

Child temperament
- Low sensory threshold - more prone to waking
may start around age 9 months ~ time separation anxiety is beginning.

Changes in routine

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What is the difference between night terrors and nightmares?

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Night terrors
- NREM, 2 hours after falling asleep, lasts 1/2 hour
- don't wake up during, may sleepwalk
- don't remember event

Nightmares
- REM sleep
- vivid recall of event
- usually wake up during event

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Physical developmental milestones at 5 years

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Stands on one foot for 10 seconds
Hops, may be able to skip

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Cognitive developmental milestones at 5 years

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Counts 10 or more things
Can draw person with at least 6 body parts

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Language developmental milestones at 5 years

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Speaks very clearly
Tells a simple story
Says name and address

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Emotional developmental milestones at 5 years

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Shows independence
Likes to sing, dance and act
Is aware of gender