Growth & Development: 24 Months

Development

Your child will display certain physical and mental developmental skills, also known as developmental milestones. Please keep in mind, development is slightly different for every child. If you have concerns about your child’s development, please talk to his or her healthcare provider.

At 24 months, most children are able to:

• Run well
• Walk up and down stairs without help
• Jump in place and kick a ball
• Build a tower of four cubes
• Make a scribble mark on a piece of paper and turn pages of a book one at a time
• Remove shoes and pants
• Feed himself or herself and give a kiss
• Say 10 to 50 words but understand many more. The number of words at this age can be extremely variable. It should also be rapidly expanding during the next few months. Talk to your pediatrician if you have any concerns about your child’s speech. Stuttering is common
• Identify multiple body parts
• Understand two step directions
• Play alongside other children and tolerate separation from parents
• Put two to three words together

At this age, the wheels are turning in children’s little brains. They are starting to figure out things such as where to find and get the things they want, and how to influence their parents to meet their wishes.

Toddlers model their behaviors after their parents. Teach your child good habits by setting a good example and modeling behaviors such as treating others kindly, cleaning up without complaining and reading.

Although your child is becoming more independent he or she may still be very clingy. Separation, such as bedtime, may be difficult.

Dental Development

By age 2 1/2, most children have all 20 of their baby or primary teeth. The second molars are the last to appear usually coming in between 20 and 30 months.

Your child’s primary teeth are important for chewing, speaking, and his or her smile. Primary teeth are also important for jaw growth. They hold a place for permanent teeth.

Sixty percent of 3-year-olds have one or more cavities. One of the most important things you can do for your child’s smile is to take good care of your baby’s teeth – regular tooth brushing, a healthy diet, a minimum of sticky, sugary foods (especially at night) and regular visits to the dentist beginning at age 12-18 months.

Emotional Development

Toddlers can seem “self-centered”. You may observe a few of these behaviors: refusing to share, temper tantrums, biting or hitting.

Most toddlers can seem “intense” at least part of the time. They can be extremely happy, extremely sad, and extremely angry all within 15 minutes. If your child’s temperament is intense, you are likely to see temper tantrums. If your child is quiet, you may see clinginess or whining. It is all part of the same developmental process. Your child is trying to work out how to behave around others. Your help with soothing ruffled feelings and calming angry tantrums is a huge plus for your child’s development.

By the time your child reaches 3 years, he or she is usually able to take turns in games, show affection for playmates, understand “mine” and “his” and “hers,” and show more self-control. Your child also begins to show concern for others.

Your child becomes more aware of pleasing or displeasing you during the toddler years. Somewhere around 3, toddlers can begin to show emotions such as shame, embarrassment, pride, guilt, and even envy. Self-awareness is a major emotional milestone. Now your child knows that you have expectations and knows whether he or she is living up to them. This is the first step toward the development of conscience.

Diet & Feeding

By 24 months of age, it is recommended for children to eat three meals a day. Their growth has slowed down so their appetite may have decreased. Offer healthy foods such as:

• Bread, Cereal, Rice & Pasta. Three to four servings are recommended per day. A serving size is considered ½ - 1 slice of bread (whole-grain preferred), cooked cereal ¼ - ½ cup, dry cereal ½ - 1 cup or ½ cup of rice or pasta.
• Fruits & Vegetables. Four to five servings are recommended each day. To prevent choking, cook hard vegetables until they are soft. Serve them in bite-sized pieces so your child can feed himself or herself. Fruit juices are not recommended as a substitute for fruits. However, if you do choose to offer fruit juice, limit it to one 4 ounce serving per day.
• Milk & Dairy. Two to three servings or 16 - 24 ounces of whole milk are recommended per day. Whole milk is recommended until age 2 to 3. Your child should no longer be using a bottle. Serve milk in a “sippy cup” with meals. For a child who will not drink milk, supply needed calcium by giving calcium-fortified orange juice, yogurt or cheese. Calcium supplements are available, such as Flintstones® or Tums®. Your child should be receiving 800 mg of calcium per day.
• Protein. Two to three serving of protein are recommended per day. At this age, 1 - 2 ounce(s) per serving is suggested. Lean deli meats cut into small pieces are a good option. Unfortunately, many children at this age are not very fond of meat. Two to four tablespoons meets the dietary recommendations. If your child does not have allergies, peanut butter, eggs, beans and tofu are also good sources of protein.

Supplemental vitamins are not routinely recommended. If you are concerned that your child is not eating a balanced diet, you may give one children’s multivitamin with iron per day. If you give a chewable vitamin, be sure your child can chew it properly. Keep multivitamins out of reach as an overdose could occur and cause serious harm.

Feeding Tips

Offer Nutritious Foods. Try to avoid fast foods, fried foods and excessive sweets. Do not make “junk food” available to your toddler. Resist giving soft drinks or Kool-Aid® on a daily basis. The best way to teach your child to eat healthy foods is by your good example.

Expect Appetite Changes. Expect your toddler’s appetite to vary. It is common to go through periods of wanting only one type of food. Sometimes toddlers do not seem to eat enough. However, if the growth curve that we plotted in your child’s medical record is normal, he or she is getting the necessary calories. If your child refuses to eat a specific food (e.g., broccoli) one day, offer it again another day.

Be Cautious of Choking. Certain foods may cause choking. Wait until age 4 to introduce peanuts, popcorn and hard candies. Hot dogs, grapes and firm vegetables such as string beans need to be cut up into tiny pieces, not chunks that could get caught in your child’s windpipe.

Eat Together. Family meal times are important. Your child should be sitting, not walking, running or speaking while chewing. Let your toddler feed herself or himself. Let your child help choose what foods to eat, but be sure to give only nutritious options. These should be the same foods that the rest of the family is eating, with a few exceptions.

Toilet Training

This is not a developmental milestone but a task to be mastered by your child. The following signs will let you know that your child is ready for toilet training.

• Your child remains dry for at least several hours at a time during the day or is dry after naps
• Bowel movements become regular and predictable
• Facial expressions, posture or words reveal that a bowel movement or urination is about to occur
• Your child can follow simple verbal instructions
• Your child can walk to and from the bathroom, undress and then dress again
• Your child seems uncomfortable with soiled diapers and wants to be changed
• Your child asks to use the toilet or potty chair
• Your child asks to wear grown-up underwear

Most children are potty trained between 2 to 3 ½ years. If you have any concerns please discuss them with your child’s physician.

Playtime

Toddlers are usually active and on the go. They need a safe place to explore and constant supervision.  At this age, children often imitate behaviors. They may sweep, dust, play with dishes and dolls and copy other things that they see their parents do. Play is generally solitary. The concept of sharing is not established.

Fun toys at this age include blackboard and chalk, blocks, housekeeping toys and books. Read to your child daily. Suggested activities include teaching body parts, drawing and imitating strokes with crayons, chasing and “rough house” play.

Do not leave your television on all the time. One hour of supervised TV per day is enough. Do not allow your child to have a TV or a computer in their room at this age or any age. Research has shown that this increases their risk for obesity, less than optimal school performance and other high risk behaviors.

Discipline

Discipline means “to teach” and is essential for your child to learn self-control, to respect the rights of others and to become a productive member of society. Unfortunately, it is not always easy. Each child has his or her own temperament/personality, and some may present more of a challenge than others. This is the time to conscientiously decide how you are going to discipline your child and stick to it. Toddlers need reasonable limits set to teach them what to expect and to protect them from harm.

Be Consistent. If unacceptable behavior is corrected one time, but not another, it will continue and likely worsen. Teach that “no” means “no” for the same thing every time. He or she may say “no” in return. To avoid having to say “no” all the time, plan ahead. For example, put breakable objects out of reach. Use distractions to attract your child’s attention to more acceptable activities.  Avoid constantly correcting and saying ‘no’—choose your battles and use attention for the most important priorities.

Also, expectations and discipline should be similar amongst all caregivers (i.e. parents). Doing otherwise may confuse the child and perhaps worsen existing bad behaviors.

Keep Things Simple. Rules should be short and simple and pertain to safety and respect for authority figures. Two-year olds really begin to challenge the limits. Reinforcing the rules actually gives your child a sense of security and will prevent further behavior problems. If your child breaks a rule, remove him or her from the problem area and encourage some other activity. A “time- out” might be appropriate as well. Avoid lengthy explanations, as studies have shown this to be counterproductive. A simple two word phrase such as “no biting” is enough. If parents show loss of control by hitting and yelling, children will learn to do the same and feel more frustrated.

Use Verbal Commands. Using verbal commands to initiate a behavior is generally more effective than trying to stop a behavior. For example, rather than trying to physically make your child stop throwing a ball inside the house try telling him or her that they need to stop throwing the ball inside because something could break and that throwing a ball is an outdoors activity.

Use Time Outs. Time outs should be around 1-2 minutes at this age. Start the timer after the tantrum or crying has ceased. While in time out, your child should not be able to see you or play with toys. Time out should be in a place where your child is safe. It works because it is a time out from getting your attention. The less emotion exhibited by you at the onset of the time out, the better. After the time out is over, hug and lovingly reassure your child. Let your toddler know that the specific behavior is not to be repeated.  

Praise Correct Behavior. Whenever you catch your child behaving well, show him or her you approve with a kind word, eye contact and touch. Say something like, “I like it when you pick up your toys.” Praising good behavior may prevent your child from learning to misbehave to get your attention.

Play and Interact with your Child. Spend a lot of time playing and interacting with your child. You are very important to your child, and he or she needs plenty of interaction with you. This also prevents your child from acting out to get attention.  Think of it as positive “time in”.

Rules. As children realize there are rules to follow, they sometimes respond at this age with acts of frustration and anger. Examples are breath holding spells and temper tantrums. Try to ignore these behaviors.

Respect for Authority. The next year is critical in teaching your child respect for authority. If it is not learned in these early formative years, more serious behavior problems will occur. Remember, children need unconditional love from their parents but equally important, they need limits, routines, and loving, consistent disciple as well.

Safety

Did you know that injuries are the leading cause of death of children younger than 4 years old in the United States? Most of them can be prevented. Here are a few tips:

Prevent Falls. A closed door is not a barrier to a two-year old, who can reach most door handles easily. Be sure doors and stairs, driveways and storage areas are locked or blocked by a gate or guard. Also install operable window guards above the first floor. Remove sharp-edged furniture from rooms where your child plays and sleeps. Your child is able to climb. Teach him or her not to climb on furniture or cabinets. Avoid placing furniture (on which children may climb) near windows and balconies. At this time, your child is safer in a bed instead of a crib. Consider a “toddler bed” or start with simply a mattress on the floor. Jumping on a trampoline should be limited to those which are enclosed with safety netting since serious injuries may occur even with parental supervision. If your child has a serious fall that causes a loss of consciousness, vomiting, or changes in behavior, have him or her evaluated by a healthcare provider immediately. If the fall was more than six feet or a neck injury is possible, do not move him or her and call 911.

Prevent Burns. Set your hot water heater to a maximum of 120°F. Do not leave liquids or hot foods on edges of counters or tabletops. Children will reach for anything. It is best to not have your toddler in the kitchen while you are cooking since hot liquid, food or grease can cause serious burns. Teach the meaning of “hot.” Also, keep hot appliances and cords out of reach. If your child does get burned, immediately put only cold water on the burned area. Then cover the burn loosely with a bandage or clean cloth. Call the doctor for all burns.

Prevent Fires. Check your smoke detector batteries frequently and change them one to two times per year on a date you will remember. This device can save the life of your family in the event of a fire. Practice a fire escape plan. Do not allow smoking in your home. Many house fires are caused by improperly extinguished cigarettes and cigars.

Practice Sun Safety. Avoid sunburns, which increase the risk of skin cancer later in life. Protect your child with a sunscreen, 30 SPF or better, applied 30 minutes before sun exposure and reapply at least every two hours.  Hats and protective clothing may also help, but the best practice is to avoid the hottest part of the day, or play in shade when possible.

Practice Poison Safety. Keep all medicines, vitamins, cleaning fluids, etc. locked in a safe location. Purchase all medicines in containers with safety caps. Do not store toxic substances in drink bottles, glasses or jars.  Take care with coins, button batteries, magnets, and other small toys.  If poisoning should occur, call the American Association of Poison Control Centers at 800.222.1222. Explain what your child ingested and how much. Follow the instructions given. Do not give syrup of ipecac unless specifically advised to do so. Medicines and detergent pods look like candy to a two-year-old. Be especially careful at the homes of family members and friends where your child may visit. They may have medicines that are within your child’s reach.

Car Safety. Because motor vehicle accidents are the number one killer of children ages 1 - 14, it is important to transport children in the safest way possible. This sobering statistic reminds us that even if you are a careful driver, you cannot eliminate the possibility of an auto accident. Child safety seats are made to properly restrain a child in the safest way possible. Here are some of the most common tips:

• Select a car seat based on your child’s age and size, and choose a seat that fits in your vehicle and use it every time.
• Always refer to your specific car seat manufacturer’s instructions (check height and weight limits) and read the vehicle owner’s manual on how to install the car seat using the seat belt or lower anchors and a tether, if available.
• To maximize safety, keep your child in the car seat for as long as the child fits within the manufacturer’s height and weight requirements.
• Keep your child in the back seat at least through age 12.
• Never leave your child alone in the car.

Practicing Water Safety. Kids this age love to play in water. Never leave your child alone in the bathtub or near a pool of water. Children can drown in less than two inches of water so empty all buckets after use and keep the bathroom doors closed. Most children do not learn how to swim adequately until 5 - 6 years of age. Stay within an arm’s length of your child around water. If you already have a swimming pool, fence it in on all four sides with a fence that is 4-feet high, and be sure the gates are self-latching. If you do not have a pool, wait until your child is 5 - 6 years old and can swim well. Most children drown when they wander out of a house and fall into a pool that is not fenced off from the house.

Prevent Pedestrian Injuries. If your child plays outside, a fenced yard and constant supervision are necessary. Streets and driveways are very dangerous. Hold on to your child when you are near traffic.

Avoid Farm and Yard Equipment. Never let your child travel on a riding lawn mower or on farm vehicles. This includes utility vehicles and ATVs.  Also, be sure you know where your child is when you are mowing the lawn or operating equipment.

Sleeping

For many parents bedtime and naptime are the most contentious periods of the day with their child. Topics related to sleeping and young children are some of the most highly researched and talked about aspects of parenting. The guidelines below may help you improve this experience for you and your child.

• Set a regular bedtime and morning wake time and stick to them.
• Establish a routine such that your child is calmed down before bed. No rough play or television.
• Rapidly set your child in the bed and quickly withdraw to avoid lengthy conflict.
• Ignore your child thereafter, despite any protests (unless your child is sick).
• Return your child to bed quietly and promptly if he or she wanders out. Initially, this may have to be repeated several times.
• Reward your child with praise or stickers immediately in the morning if he or she was well-behaved the night before.
• Children this age require on average 13 hours of sleep per day with one two-hour nap.  Some children have different sleep patterns and may vary.

Immunizations

By now your child should have completed his or her first immunization series. Additional immunizations are not required until age 4 or 5. The flu vaccine is recommended annually for everyone at least 6 months of age, especially those with asthma or any underlying medical condition. Many small children can develop complications from the flu that require hospitalization.

The flu vaccine protects only from influenza, which causes severe respiratory symptoms along with high fever for 4 - 5 days. Getting the flu vaccine does not protect from other cold viruses or the stomach flu (i.e., vomiting and diarrhea illnesses). The flu vaccine does not cause the flu.

Call your doctor during office hours if you have any questions.

Next Visit

Your child’s next wellness visit should be at 2 ½ years of age.