Toddler: 9 to 18 months

Studies have shown that toddlers average 8-10 colds & other illnesses per year, particularly during winter months. Most are not dangerous at all. The best clue is in the eyes – a baby who looks well usually is, while a baby who is really ill will tell you with the look in his eyes.

Prevention is best. Toddlers should see the pediatrician at about 9, 12, 15, and 18 months of age. These visits are not just for shots, but are times when we screen for a variety of subtle problems and are a good opportunity for you to learn more about your baby.

At 9 months the first routine blood tests are drawn, screening for Lead Poisoning and Anemia. At 12 months the 1st Hepatitis A vaccine may be given, at 15 months the 4th Pneumococcal and the first MMR, and at 18 months the 4th doses of DTaP and Polio & HiB are given as well as the 1st Varicella; The benefits of giving these vaccines FAR outweigh the risks involved. If you want to know more about this, see our more detailed vaccine handouts or ask.

Fever is the body’s normal response to any kind of illness and actually HELPS you get better. It is not dangerous and cannot hurt your child. Furthermore, neither the presence nor the height of a fever has any correlation with how dangerous the illness causing it is. Minor viruses often cause very high fevers, while some deadly illnesses cause little fever at all. Thus, it is the OTHER symptoms of illness we are most interested in when evaluating your child.

Fever is uncomfortable, and this is why we treat it. Use Acetaminophen (Tylenol, many other brands) according to the instructions in our Acute Illness Guide. Never use aspirin in children. Sponge baths are also unwise – they actually raise the temperature deep inside the body rapidly while cooling only the surface. Getting the child with a fever to drink plenty of fluids is important for many reasons, and will help get the fever down as well.

Do not use nonprescription “over-the-counter” medications for coughs, colds, diarrhea, etc. unless directed by your provider. In general, the side effects far outweigh the minimal benefits in this age group.

Teething can start anytime from 3 – 15 months, and is somewhat painful. It can cause drooling, a runny nose, poor sleep, irritability, and even pulling at the ears. It does not cause fever, vomiting, diarrhea, or a rash however. It is best to avoid “rub on” teething medications – babies can overdose on these. Use Acetaminophen for the pain and give the baby something to chew on to speed up the process. A bagel often works better than conventional teething rings, especially beyond 6-7 months age.

Even a minor illness that doesn’t seem be getting better after 7-10 days should be seen by the doctor. Most Pediatric Dentists (and the American Academy of Pediatric Dentistry) recommend a first dental check-up by 12 months. However, The American Academy of Pediatrics recommends a first dental screening at three years of age. Anytime in between is acceptable. A list of local Pediatric Dentists, as well as some General Dentists who are quite good with young children, is available from our front desk.

Toddlers STILL need FULL TIME protection.

Continue to use your car seat at all times. The car seat should remain rear-facing until 2 years of age.

Make sure the high chair has a wide base and will not fall over if bumped by another person or if the child is squiggling. NEVER leave the baby alone in a high chair. If your toddler starts trying to learn to climb out of the high chair himself, you must discipline them not to (or else discontinue using the high chair altogether). Falls from high chairs can cause serious injury.

Similarly, while there is no developmentally “right or wrong time” to switch from a crib to a bed, safety dictates that when a child starts climbing out of the crib themselves, it’s time.

If you haven’t yet, it’s now essential to “Childproof” your home. Be sure all small choking hazards are both out of reach and out of sight (e.g. buttons, coins, bottle caps, pins, nuts, raisins, older child’s toys). Put “shock stops” in all unused electrical outlets and move all cleaning fluids, medicines, etc. to high cabinets. Don’t rely on so-called “Childproof” cabinet latches – they don’t work. Make sure your water heater is set not to exceed 120ºF.

Be prepared for poisoning emergencies (see Acute Illness Guide).

Never turn your back on a toddler in a bath, around a bucket of water, or on a changing table EVEN FOR A SECOND!Toddlers can and do drown in less than 2 inches of water, and bathtubs are the most common sites of drowning in this age group.

Second Hand Smoke is very dangerous. Even if you or a family member smokes outside- the smoke is brought in on your clothing. Please consider quitting.

Babies should always be off the bottle completely by their first birthday. There are two reasons for this.

First, developmentally this is the appropriate time. A baby between 9 and 12 months will happily take the cup and won’t miss the bottle much. If you continue to give a bottle beyond 12 months, however, the toddler becomes more and more attached to it emotionally, and it becomes harder and harder to wean.

Second, after 12 months, bottles – in any amount, even only once per day, even containing only water – have been shown to cause increased rates of 5 separate health problems:

• Ear Infections
• Dental Cavities
• Speech Delay
• Obesity (even into adulthood) Anemia

None of the above risks apply to breastfeeding or pacifiers, only bottles. From a health standpoint it is fine to continue breastfeeding and/or pacifiers as long as you like – although the 9-12m age is relatively easy time to wean most babies from these things as well (compared to earlier or later ages) if you want to.

Start by introducing whole milk at around 9 months of age. Put whole cow’s milk in the sippy cup while continuing to use formula or breastmilk in the bottle. Gradually between 9 and 12 months give the cup more and more, the bottle less and less. This means the baby will get more and more milk, less and less formula. Shortly before 12 months the bottle disappears, and the formula disappears with it. Consult with your provider regarding this process, if your child is on a hypoallergic or soy formula.

9-12 months is not just a formula and bottle transition time, it is a solid feeding transition time as well. A child in this range should be doing more and more of it himself. Feeding independence is something most emerging toddlers want and can handle, and it’s important to gradually give it to them. It is important for the toddler not to psychically connect feeding or being fed with their parents love for them (a connection only a toddler, not a baby, can make) as this will set them up later in life to use food for comfort when they are sad or stressed. After 12 months it is best for your child to think that you really don’t care much about whether or how much they eat.

Self feeding will be messy. At 9 months you feed your baby. By 12 months you mostly clean up after your toddler instead. Don’t get mad and don’t worry about how much they are getting. Kids this age are usually very good about knowing when they are hungry and when they are full, and they learn things by watching the food go “splat” on the floor, too. Think of it as their first physics lesson.

It does not matter whether the baby is self feeding table foods or baby foods, or some mixture. While most toddlers can eat most table foods by 12 months, some may not be so good at chewing & swallowing yet and for them baby foods may be more appropriate for a while longer. While messy it is still most developmentally appropriate to let them feed themselves by 12 months of age.

“Stage 3” foods are just a plot by the baby-food makers to keep you buying their products longer than you have to. If a baby can handle stage 3, he or she can handle table foods as well.

If you have not weaned the bottle before 12 months and you want to wean your 15 or 18 month old, the technique described above for 9-12 months will likely not work. The only way to wean a “full fledged” toddler (over 13 months) is to go “cold turkey”… and endure the few days of temper tantrums that will ensue when he or she doesn’t get the bottle they want. Soon enough the bottle will fade into memory and become “ancient history” and the tantrums will subside. To get you through this ordeal, remember this: if your toddler wants the bottle, you offer the cup, and they refuse it and/or throw a tantrum, it means that they weren’t thirsty – they wanted the bottle for some other reason.

Avoid foods that the toddler could choke on. These include nuts, hard candies, raw carrots, steak, and hot dogs. Babies under 1 year of age should not consume honey. Otherwise there are no restrictions to your child’s diet. There has been no evidence to show prolonging the introduction of certain foods (eggs, nuts, fish) decreases the risk of allergy, eczema or asthma & in fact may increase the risk.

At each well-child physical we will measure your child’s height, weight, and head circumference and plot them out on a
“growth curve”. This is the ultimate measure of whether your toddler is “getting enough”.

Toddlers over 11-12m should be given utensils with their meals – spoons and perhaps forks (that aren’t too sharp). Prior to 15 months expect them to use these mostly as toys, not tools for eating. They will use their hands for that. But between 15 and 18 months most toddlers start using them more and more for feeding, and by 18 months should be pretty good at it.

Check to be sure there is Fluoride in your water. Most but not all Massachusetts communities have it; bottled water, Methuen and most NH towns do not. If it’s not in the water you’re using, ask us for recommendations. By 18 months-2 years of age fluoridated toothpaste should be used to brush teeth. Use only a smear over the toothbrush.

By 9 months your baby is doing lots of exciting new things. Most babies can sit up for long periods with confidence and without support. They can get around on their own by creeping, crawling or standing holding on. A 9-month-old is getting quite good at manipulating small objects with their hands – and is just starting to use a “pincer grasp”. He holds his own bottle or cup, and she can finger feed. He or she babbles with repeated consonant-vowel sounds (ba-ba-ba, ma-ma-ma), but usually these don’t have meaning yet – on the other hand a 9 month old is starting to understand a good deal of what you say!

At or shortly after 9 months a baby reaches an important cognitive (thinking) milestone – the attainment of what psychologists call “object permanence”. This means they start to understand that things still exist even when not in their immediate senses. You can tell your baby has reached this point when they start looking for toys that roll out of sight, or when they start to think “peek-a-boo” is a really funny game. This is the first step for the rapid changes that follow…

By 12 months weight will be about triple what it was at birth! Age 9 to 12 months marks a baby’s transition into “toddlerhood”. This does not necessarily mean that they will start walking – although that is possible. Some babies walk as early as 9 months, 12-13 months is average, and as late as 16 months is perfectly normal. More important to this transition are the cognitive & psychological changes that going on around this time that define the difference between a baby and a toddler. A baby takes the world as it comes, a toddler acts on the world. A baby isn’t really aware of being a separate individual yet, while a toddler knows that he is his own person – and is both thrilled and frightened by that discovery. Unlike a baby, the toddler has a mind of her own, and can make things happen. Because of this, it is around this age that parents need to start disciplining their children. It is important for parents to become good at disciplining skills, and get the child used to a certain discipline routine/style, during the 9-18m age range. Establishing good discipline habits (or changing bad ones) at a later age is a much harder proposition.

At about 12 months a baby’s words will start to have meaning. Pronunciation doesn’t count at this age – any sound that consistently means the same thing when the baby utters it is considered a word. By this definition, the average 12 month old has 2-3 words, the average 15 month old has 5-10, and the average 18 month old has >20 (and should be just starting to string a few 2-word phrases together). Reading to the child becomes important at this age – choose simple picture books, not books with story-lines yet or too many things on a page. Gradually start to expect language from your child. Don’t respond to pointing, whining, or grunting from the child when they could be using words.

Temper Tantrums start to appear shortly after the first birthday, and usually peak in intensity around 18 months of age. Remember that tantruming per se does not break any rule. We all tantrum. What you want to teach is that tantrums are not an effective way of getting either attention or what you want. Therefore, tantrums do not need to be disciplined. They should simply be ignored.

Finally, 9-18 months is a time when you want to put in place and establish any lifelong habits you want to teach – things you expect as normal daily routines that you don’t want to have to “fight about” later – even if they may not seem important yet. Examples include such things as brushing teeth, wearing shoes, and washing hair. Toddlers in this early phase will accept and adjust to such new routines easily, while older toddlers will resist.

Very limited or no screen time is recommended for children under two years of age. Screen time refers to television, computer, video games, tablets and phones.

This is an important age for maintaining normal sleep patterns. Remember that children learn what you teach them, and it is up to you to decide what you want to teach them. Different families will have different styles on this subject. For most, it is important to stick with your bedtime “ritual” – or modify it gradually (e.g. removing the bottle from it), and be sure the baby falls asleep IN BED, not in your arms. This way, the baby can learn to go to sleep independently, without help. When brief awakenings, which are normal, occur during the night the baby will then not need you to “go back down”. Both of you will sleep better as a result. It is not uncommon for good sleep patterns established earlier to break down during illnesses or family trips or other times when routine is disrupted. It may take some effort and some times of letting the toddler “cry it out” in order to re-establish good habits.

Sunlight is a threat to healthy skin. Use a sunscreen on exposed baby’s skin – even in spring and fall when you might not think of it.

Select a PABA-free preparation with SPF 15 – 30.
Ointment is better than powder for protecting against diaper rash, but it really doesn’t matter which ointment you use. Powders (all types) can also be dangerous if accidentally inhaled. Soap is very drying even “baby soap”. Dove is the mildest and probably the best. Avoid deodorant soaps.

“As far as I can tell, we’ve done everything right. Four weeks ago my husband and I bought Andrew his own potty, explained what it was, and put it in the bathroom. He didn’t show any interest in using it—except as a hat—and we were careful not to pressure him. But this morning when he woke up, I finally gave in to temptation and asked him if he might want to use the potty today. He looked at me and then started to cry! I couldn’t understand what I’d said to upset him. I didn’t know how to react, so I just gave him a hug and said, ‘Okay, honey, you don’t have to.’ But I wish someone could tell me what’s going on.”

If you are the parent of a young child in diapers, you may share Linda’s uncertainty over how best to begin toilet training. You are probably concerned about putting too much pressure on your child by starting too early, or letting him down by starting too late. You may be confused by conflicting advice in the media and from relatives and friends—telling you that you can toilet-train your child by his first birthday, or that you should wait until he is three or four; that you can “train in a day,” or that training should take place gradually over several months to a year; that a parent-enforced routine of regular potty sessions is the best way to train a child, or that it’s better to let the child decide when, where, and how he will go. As if this weren’t enough, your child’s own evolving urges and needs can suddenly derail even the simplest, most positive training program. Your family situation—marital stress, a recent move, a new baby in the family—may affect your child’s progress in ways you hadn’t predicted, while your own feelings or memories from childhood may color your attitude toward toilet training and, indirectly, that of your child.

Most likely, what you are looking for when approaching the toilet-training process are simple answers to two basic questions: “When should I start?” and “What method should I use?” Many people you ask are willing to provide you with cut-and-dried responses to these questions. However, their advice may not be appropriate for your family or your child. Some children are ready to start toilet training at eighteen months, while others would learn more quickly and easily if they waited until age three or four. Many children respond well to a regular potty routine, but yours may resist using the potty at the same time every day and prefer to wait until he feels the need to go. The truth is that nearly any non-punitive approach to toilet training will get the job done sooner or later, but an approach specially tailored to your child’s stage of development and learning style will take you both through the process in the most positive, efficient way. By learning how to evaluate your child’s readiness for toilet training, you will be able to start the process at the best possible time for her.

You will learn to find your own answers to the questions “When should I start toilet-training my child?” and “What method should I use?” You will learn which basic skills your child must acquire before true bathroom mastery can occur. You will become familiar with a variety of verbal, physical, social, and other approaches to teaching your child about potty use, and discover ways to mix and match these techniques to suit your child’s personality, temperament, and evolving needs. If you find yourself stymied by your child’s resistance to training, you will find information about what may be causing the problem—along with encouragement to discard methods that aren’t working and try a new approach.

Above all, you will be encouraged to look at toilet training not as a grueling if necessary part of parenting a young child, but as an early opportunity to familiarize yourself with your child’s developing personality and to find out how he learns best. When you think about it, toilet use is one of the first and most significant skills your child must acquire consciously, rather than in response to the kinds of instinctive urges that prompted him to learn to walk or talk. There is nothing instinctive about using the potty. It is a practice that your child adopts for no other reason than that you want him to and that he wants to please you and to be like you. To teach him this habit, you must consistently encourage him, monitor his progress, and reward him for success.

You must observe his responses to your training techniques and adapt your approach accordingly. You must support your child in his earliest efforts to set goals for himself and consistently meet them. In the process you may discover that your child learns best through verbal interaction (talking about potty use rather than simply imitating and practicing) or that he responds to learning by doing (sitting on the potty at scheduled times so that potty use becomes a regular part of his routine). You may find that he appreciates tactful reminders or stubbornly resists them, that he is happiest when allowed to demonstrate every step of his progress or prefers practicing behind closed doors.

These discoveries, which enhance your understanding of your young child and help you to teach him how to learn, offer benefits beyond just learning to use the toilet. They lay the groundwork for you to connect with your child in positive ways—and set the tone for efficient learning in the years to come. The key to toilet training—and, yes, the fun of it—lies in choosing the time and techniques that work best in your family, teaching yourself to use them effectively and consistently, and observing your child’s amazing progress as he responds to a lesson plan designed for him alone.

For more information & tips on Toilet Training, Healthychildren.org’s Potty Training page is a great place to start.
Source: Healthy Children.org