The 12-month-old stands proudly, somewhat bowlegged, belly protruding. Walking, one of the most exciting developmental milestones, occurs near the toddler’s first birthday, bringing with it increasing independence. During his first year of life, the infant was rarely in conflict with his environment. He might have been demanding when he cried, he required considerable care, and he changed the balance in the family. However, he spent most of his first year getting to know and trust his parents and his environment. As a toddler, he becomes increasingly competent in acting upon the world around him, all on his own. His world broadens, bringing both excitement and challenge.

Autonomy and independent mobility are developmental achievements of which the parents and toddler are justifiably proud, but the toddler constantly encounters barriers posed by his environment. He cannot go as fast as he would like without tripping, he cannot always reach desired objects, and he can fall and hurt himself. New hazards, such as access to hot liquids (eg, coffee cups left on surfaces within reach) and stairs, are now within his reach. Although they may be charmed by his exploits, a toddler’s parents and other caregivers must watch him constantly to keep him safe.

As the toddler’s autonomy, independence, and cognitive abilities increase, he begins to exert his own will. In response, his parents’ perceptions of his demands change dramatically, influenced by their own upbringing and childhood experiences. Do the parents understand their toddler’s needs and attempt to meet them? The 12-month-old’s dramatic struggle for autonomy will test his parents’ ability to let go, permit independence, and enjoy aspects of his behavior that are out of their direct control. The toddler’s messy attempts to feed himself can be difficult for his parents as they sort out their own desire for order and neatness with his need for self-care.

Fortunately, the toddler is endowed with a social feedback loop to recognize both pleasure and displeasure from significant caregivers. Adults build on this characteristic by providing appropriate responses to a toddler’s actions. Adult laughter in response to a well-played game of “peek-a-boo” holds the key to future good times in other interactive games, but laughter following a plate of food thrown on the floor sends the same positive message and invites later disruptive behavior. Turning away, ignoring, or expressing displeasure at the plate of food thrown on the floor sends a more appropriate message and helps prevent later disruptive behaviors.

Positive activities, such as cuddling, holding, praising, and firm enforcement of rules about not biting, hitting, and kicking, help the toddler develop emotional expression. Consistency is the keystone for dealing with a 12-month-old, and establishing regular routines becomes all-important.

Although the toddler’s level of activity increases significantly during this period, his rate of weight gain decreases, and struggles over eating arise for many parents. A toddler frequently eats a large amount at one meal and very little at the next. However, hunger guides him and he eats a sufficient amount over time. The key is to offer nutritious foods consistently and not worry about whether all the food is finished each time.

Responding sensitively to the 12-month-old’s behavior is a complex task. Some parents who did well with the more dependent, younger infant are less sure of their role now. Toddlers beginning their second year of life seem to thrive when parents accommodate their demands yet maintain a strong parenting presence, including a full measure of patience, enough self-confidence to set limits, the judgment to know which needs are most important, and the ability to realize that their 12-month-old’s negative behavior is not directed against them. Reading aloud is a positive way of spending time together and can be worked into the child’s daily routines (eg, at bedtime, nap time, and mealtime). By letting the child choose the book, the parent can support the child’s growing independence and, by reading aloud and naming the pictures, the parent can help the child learn language and satisfy his curiosity about the world. Parents need to be positive role models for their toddler, both physically (eg, by eating nutritiously and wearing safety belts in the car) and emotionally (eg, by being calm and consistent in setting limits and handling tantrums). Parents who enjoy their toddler’s growing independence can best provide a stable home base as the toddler’s curiosity and mobility carry him into an expanding world.

Children this age are uncomfortable about being restrained in their activity. The physical exam may be more successfully performed while the child is on a parent’s lap or standing on the floor. Speaking directly to the child and taking a playful stance about the exam will make it easier for the child to cooperate. If the child becomes upset, it is a good idea to remind the parent that this is an expected reaction at this age. As part of the complete physical exam, perform the noninvasive procedures first, with the eyes, ears, nose, mouth, and abdomen examined last.

The first priority is to attend to the concerns of the parents. In addition, the Bright Futures Early Childhood Expert Panel has given priority to the following topics for discussion in this visit:

• Family support (adjustment to the child’s developmental changes and behavior, family-work balance, parental agreement/disagreement about child issues)
• Establishing routines (family time, bedtime, teeth brushing, nap times)
• Feeding and appetite changes (self-feeding, nutritious foods, choices, “grazing”)
• Establishing a dental home (first dental checkup, dental hygiene)
• Safety (home safety, car safety seats, drowning, guns)

History

Interval history may be obtained according to the concerns of the family and the health care professional’s preference or style of practice. The following questions can encourage in-depth discussion:

• Tell me how things are going at home and how your family is adapting to your 12-month-old.
• Where are you currently living? Does anyone else care for your child other than you?
• What concerns do you still have from your last visit?
• What new concerns do you have about your child today?
• I see you are concerned about ___________________.
• What major changes or stresses have occurred in your family since your last visit?

Observation of Parent-Child Interaction

During the visit, the health care professional should observe:

• How does the parent interact with the toddler (eg, anxiously, calmly, reciprocally, in a controlling manner, or inattentively)?
• Does the child check back with the parent visually?
• When the health care professional gives the child a book, does the parent follow the child’s gaze?
• Does he bring an object of interest to show or share with the parent?
• How does the parent react when the health care professional praises the child? How does the parent react to being praised?
• If siblings are in the room, how do they interact with the toddler?
• Does the parent seem positive when speaking about the child?

Surveillance of Development

Do you have any specific concerns about your child’s development, learning, or behavior?

Social-Emotional

•   Tell me about your child’s typical play.

• Plays interactive games (eg, “peek-a-boo,” “pat-a-cake”)
• Imitates activities
• Hands you a book when he wants to hear a story

•   Does your child feel free to explore or stay very close to your side?

• Waves “bye-bye”
• Has a strong attachment with parent or significant caregiver
• Shows distress on separation from parent

Communicative

•   How does your child communicate?

• Demonstrates prodeclarative pointing (points to a desired object and watches to see whether the parent sees it)
• Imitates vocalizations and sounds
• Speaks 1 to 2 words
• Jabbers with inflections of normal speech

Cognitive

•   What do you think your child understands?

• Follows simple directions
• Identifies persons upon request (eg, “Where is ___?”)

Physical development

•   Tell me how your child uses his hands and legs.

• Bangs 2 cubes held in hands
• Stands alone

Physical Examination

A complete physical examination is included as part of every health supervision visit.

When performing a physical examination, the health care professional’s attention is directed to the following components of the examination that are important for a child this age:

Measure and plot:

• Length
• Weight
• Head circumference

Plot:

• Weight-for-length

Eyes

• Examine pupils for red reflexes
• Perform cover/uncover test for conjugate ocular mobility

Mouth

• Observe for caries, plaque, demineralization (white spots), and staining

Neurologic

• Observe gait

Genitals

• Determine whether testes are fully descended

Screening

Universal Screening	Action
Anemia	Hematocrit or hemoglobin
Lead (High prevalence area or on Medicaid)	Lead screen
Selective Screening	Risk Assessment*	Action if RA +
Oral health	Does not have a dental home	Referral to dental home or, if not available, oral health risk assessment
	Primary water source is deficient in fluoride	Oral fluoride supplementation
Blood pressure	Children with specific risk conditions or change in risk	Blood pressure
Vision	Parental concern or abnormal fundoscopic examination or cover/uncover test	Ophthalmology referral
Hearing	+ on risk screening questions	Referral for diagnostic audiologic assessment
Lead (Low prevalence area and not on Medicaid)	+ on risk screening questions	Lead screen
Tuberculosis	+ on risk screening questions	Tuberculin skin test
*See the Rationale and Evidence chapter for the criteria on which risk screening questions are based.

Immunizations

Consult the CDC/ACIP or AAP Web sites for the current immunization schedule.

CDC National Immunization Program (NIP): http://www.cdc.gov/vaccines

American Academy of Pediatrics Red Book: http://www.aapredbook.org

The following sample questions, which address the Early Childhood Expert Panel’s Anticipatory Guidance Priorities, are intended to be used selectively to invite discussion, gather information, address the needs and concerns of the family, and build partnerships. Use of the questions may vary from visit to visit and from family to family. Questions can be modified to match the health care professional's communication style. The accompanying anticipatory guidance for the family should be geared to questions, issues, or concerns for that particular child and family.

Adjustment to the child’s developmental changes and behavior, family-work balance, parental agreement/disagreement about child issues

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It is best to review plans for discipline before a need arises. Discuss plans for “time-outs” when needed to calm the situation, and “time ins” when the unwanted behavior ceases. At this age, “time-outs” may take place in a playpen or crib to protect a child from injury and should be brief (1 to 2 minutes).

Forewarn parents about possible temper tantrums in the future and the child’s tendency to be clingy sometimes and to merrily go her own way at other times. Recommend the use of praise to strengthen good behaviors and offer suggestions for how parents might deal with biting, hitting, or other possibly harmful activity.

A child this age starts to recognize what is permitted and may touch something forbidden. At the same time, she will look back at the parent to test a reaction. This is a normal and positive move toward internalizing rules. Temper tantrums are more frequent as the child tries to master new skills and struggles with her move toward independence and autonomy.

SAMPLE QUESTIONS:
When your child is troublesome, what do you do? What do you do when she doesn’t cooperate? What do the others in your family do? Do you need help in managing your child’s behavior? Sometimes raising a child can be frustrating. Does anyone ever get angry with her? What happens then? Do you ever spank her? How do you reward your child?

ANTICIPATORY GUIDANCE:

• Try not to punish your child with spanking, shouting, or long explanations. A firm “No!” is the best way to deal with minor irritations (just as “Yes!” is a great way to reward good behavior). You may want to consider a brief time-out. Put the child in her crib or playpen for 1 to 2 minutes only, until the undesirable behavior stops.
• Distracting your child with something new that gets her attention or directing the child to a new activity are excellent ways to reduce unwanted behaviors. She wants to be near you and hear your voice—reading aloud to her is a great strategy for this purpose. (It’s also a way to help her love books.)
• Time with family and special caregivers is the best treat you can give your child.

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Parents need time away from their toddler to pursue their own interests, have regular time alone to rest, and maintain other important relationships. During this time, they also may need extra help from community resources.

Parenting is difficult sometimes. If it is culturally appropriate, having someone to talk to about parenting issues can help mothers and fathers get through the rough spots and appreciate the joys of watching their young child grow and develop.

SAMPLE QUESTIONS:
Who cares for your child other than you? Have you shared your child’s health information with them?

ANTICIPATORY GUIDANCE:

• Make sure that you discuss your child’s medical needs and your feelings about healthy diet, discipline, and oral health with all of your child’s caregivers.
• Make sure that any environment where the child stays has the same, or better, safety standards as your home and that the transportation to and from sites other than home is safe.
• Share any information that we discuss with other caregivers.

SAMPLE QUESTIONS:
What activities do you enjoy doing outside of the home? How often do you get together with friends? What things do you do with friends? Do you need help in finding other community resources, such as a faith-based organization, recreational centers, or volunteer opportunities? Who do you talk to about parenting matters?

ANTICIPATORY GUIDANCE:

• Maintain or expand ties to your community through social, faith-based, cultural, volunteer, and recreational organizations or programs.
• Learn about and consider participating in parent-toddler playgroups.
• Consider joining a parent education class or parent support group.

Family time, bedtime, teeth brushing, nap times

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Establishing family traditions is extremely important for long-term self-recognition.

Establishing routines around bedtime, meals, and playing is important, even at this age. Stranger anxiety reaches a peak in the next few months.

SAMPLE QUESTIONS:
What do you all do together? What do your child’s brothers and sisters do with him? Tell me about your family’s traditions. What are some of the new things that your child is doing? How does your child react to changes in his routines or to strangers? What is your child’s routine for meals and snacks?

ANTICIPATORY GUIDANCE:

• Avoid watching TV during “family time.” Instead, play with your child and his brothers and sisters each day through games, storytelling, reading aloud, pointing and naming, listening to music, laughing, and exercising.
• At this age, your child may feel anxious around unfamiliar people. When meeting someone new, allow time for him to warm up. Try to use a consistent child care provider.
• Schedule 3 meals and 2 to 3 snacks at regular intervals during the day. This is another good way to establish a consistent daily routine. Regular meal and snack times also provide a constant supply of nutrients to fuel his many activities. Protecting your toddler against getting too hungry also will help prevent tantrums due to hunger.

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A 1-year-old should be sleeping 12 to 14 hours a day. Bedtime should be at the same time each night and should become a nightly routine. Reading and singing before bedtime are examples of sleep-promoting activities. A favorite toy or object also may help reassure and calm the child. Nightlights also may be beneficial. For both nap time and bedtime, he should be put in the crib awake so that he can make the transition from awake to asleep on his own.

Another important routine to establish during this age is daily tooth brushing as soon as teeth erupt.

SAMPLE QUESTIONS:
How are sleeping routines going? Is it difficult getting your child to go to sleep? What time is bedtime? How do you manage naps? How does your child move around? How are you and your child adjusting to his increasing mobility? How frustrated is he about getting himself where he wants to go? How often do you brush your toddler’s teeth?

ANTICIPATORY GUIDANCE:

• Establish a nightly bedtime routine that begins with quiet time for your child to relax before bed, and ends with your child soothing himself in his own crib. Reading and singing to your child will help him get to sleep. A favorite toy or a nightlight also can help. Make sure to space nap times so that your child is tired at bedtime.
• Toddlers should continue to have at least one nap during the day. It is important to establish a regular nap time routine.
• Another important daily routine is teeth brushing. Establish a regular time each day for this task, such as after breakfast and before bed.

Self-feeding, nutritious foods, choices, “grazing”

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Meals should be relaxed, safe, and enjoyable family times. Encourage fine-motor skills, such as using a cup or spoon and eating finger foods.

SAMPLE QUESTION:
Tell me about mealtime in your home.

ANTICIPATORY GUIDANCE:

• Cover your floor and don’t worry about messes—young children learn from experimenting.
• Avoid small, hard foods like peanuts or popcorn, on which your child can choke, and cut any firm, round food (eg, hot dogs, raw carrots, or grapes) into thin slices.
• Include your toddler in family meals by providing a high chair or booster seat at table height. Make mealtimes pleasant and companionable. Encourage conversation.

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The child should be developing toddler eating skills—biting off small pieces of food, feeding herself, and holding and drinking from a cup. Toddlers learn to like foods by touching, smelling, and mouthing them repeatedly.

SAMPLE QUESTION:
How is your child doing with feeding herself during meals and snacks?

ANTICIPATORY GUIDANCE:

• Give your toddler a spoon for eating and a cup for drinking. Be sure that they are easy for her small hands to hold.

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This is a good time for parents to establish positive eating patterns for their child by providing meals and snacks at regular intervals, giving appropriate amounts of foods, and emphasizing nutritious foods. Discuss the importance of providing healthy snacks rich in complex carbohydrates, and only moderate amounts of sweets and high-fat or low-nutrient snacks. Remind parents that they are responsible for providing a variety of nutritious foods and that their child is responsible for how much to eat.

SAMPLE QUESTIONS:
How has your child’s appetite been? What questions do you have about choosing healthy foods for your child?

ANTICIPATORY GUIDANCE:

• The toddler’s rate of weight gain will be slower than in the first year. She may eat less now than when she was an infant.
• Toddlers tend to “graze.” Her appetite will vary; she will eat a lot one time, and not much the next time.
• Let your toddler decide what and how much to eat from an assortment of nutritious foods you offer. Trust your child’s ability to know when she is hungry and full. If she asks for more, provide a small, additional portion. If she stops eating, accept her decision.
• Feed your toddler 3 meals and 2 or 3 planned nutritious snacks a day. Be sure that your toddler’s caregiver also provides nutritious foods.
• Have healthy snacks on hand, such as:
  • Fresh fruit (eg, apples, oranges, and bananas), cut in small pieces
  • Applesauce, cheese, or small pieces of whole-grain bread or crackers
  • Homemade popsicles that you make from 100% fruit juice
• Many fresh foods are fast and easy to prepare and cost less than prepared foods.

First dental checkup, dental hygiene

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Every child should have a dental home, which should be established soon after the first tooth erupts or by 12 months of age. The dental home must be able to meet the unique needs of each child, including accurate risk assessment for dental diseases and conditions; an individualized preventive dental health program based on risk assessment; anticipatory guidance about growth and development, including teething, digit, or pacifier habits; a plan for responding to emergency dental trauma; comprehensive dental care in accordance with accepted guidelines and periodicity schedules; and referral to other dental specialists when indicated.

SAMPLE QUESTIONS:
Tell me about how you care for your child’s teeth. Have you taken your child to a dentist?

ANTICIPATORY GUIDANCE:

• Be sure to get your child to the dentist by 12 months of age or after he gets his first tooth. A dentist will help you keep your child’s teeth healthy and will be available in case there is ever an emergency with his teeth, such as a broken tooth or severe pain.
• Brush his teeth with plain water twice each day, using a soft toothbrush.
• If he is still using a bottle, offer only water in the bottle.

Home safety, car safety seats, drowning, guns

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The toddler is becoming increasingly mobile and needs protection against common and uncommon hazards. Review all aspects of safety at this visit because safety is one of the most important aspects of care at this age.

If the family lives with other family members or friends, the family may not feel that it has the power to control the environment and may need help in advocating for a safe environment for their child. This also may be true for families who are living in homeless shelters or other types of temporary or uncertain housing.

SAMPLE QUESTIONS:
What have you done to “childproof” your home? The grandparents’ homes? The caregiver’s home? Do you have cabinet latches? Are tables free of heavy items that your child could pull down on herself?
How safe do you think your community is? How safe and comfortable do you and your family feel inside your home? Outside your home? How can we help so that your family feels safe? Who else can help your family feel safe?

ANTICIPATORY GUIDANCE:

• Lock away medications and all cleaning, automotive, laundry, and lawn products out of sight and out of reach. Climbing toddlers can reach even high shelves.
• Keep your toddler out of rooms where there are hot objects that may be touched, including hot oven doors and heaters, or put a barrier around them.
• Now that your toddler is walking, get down on the floor yourself and check for hazards.
• Keep plastic bags, latex balloons, or small objects, such as marbles, away from your toddler.
• Be sure there are no dangling telephone, electrical, blind, or drapery cords in your home.
• Make sure televisions, furniture, and other heavy items are secure so that your child can’t pull them over. If they seem unsteady, anchor bookcases, dressers, and cabinets to the wall and put floor lamps behind other furniture.
• Keep sharp objects, such as knives and scissors, out of your toddler’s reach.

SAMPLE QUESTION:
How often do you let your child’s brothers and sisters help you take care of her?

ANTICIPATORY GUIDANCE:

• Never leave young siblings in charge of their baby sister or brother. Allow them to help with daily tasks, like feeding, under the supervision of a responsible adult.

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Never underestimate the ability of a toddler to climb. Parents must be vigilant in preventing injuries from climbing.

SAMPLE QUESTIONS:
Do you have stair guards and window guards? Where is the mattress positioned in the crib?

ANTICIPATORY GUIDANCE:

• Some children can climb out of the crib at this age. Be sure that the crib mattress is on the lowest rung and that the sides are up when she is in it.
• Use gates at the top and bottom of stairs and watch your toddler closely when she is on stairs. To prevent children from falling out of windows, keep furniture away from windows and install operable window guards on second- and higher-story windows.

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Talk with parents to ensure that their child is fastened securely in a car safety seat and that they know when to switch from a rear-facing to a forward-facing seat.

Questions about proper installation should be referred to a certified Child Passenger Safety Technician in the community.

Child Safety Seat Inspection Station Locator: www.seatcheck.org

Toll-free Number: 866-SEATCHECK (866-732-8243)

SAMPLE QUESTIONS:
Is your child fastened securely in a car safety seat in the back seat every time she rides in a vehicle? Are you having any problems using your car safety seat?

ANTICIPATORY GUIDANCE:

• Never place your child’s rear-facing safety seat in the front seat of a vehicle with a passenger air bag. The back seat is the safest place for children to ride.
• The rear-facing position provides the best protection for your child’s neck and head in the event of a crash. For optimal protection, your child should remain rear facing until she reaches the highest weight or height allowed for use by the manufacturer of a convertible seat or infant-only seat that is approved for use rear facing to higher weights and heights (up to 30 pounds and 32 inches for infant only and up to 35 pounds and at least 36 inches for convertible seats). Do not switch your child to a forward-facing car safety seat before she is at least 1 year old and weighs at least 20 pounds.
• Be sure your child’s car safety seat is properly installed in the back seat according to the manufacturer’s instructions and the vehicle owner’s manual. There should be no more than a finger’s width of space between her collarbone and the harness strap.

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The child’s increased mobility, combined with a heightened curiosity, makes for an extremely dangerous situation around bodies of water. Explain to parents that children can drown in a small amount of water, even in buckets or a few inches of water in a tub.

SAMPLE QUESTION:
Are there swimming pools or other potential water dangers near or in your home?

ANTICIPATORY GUIDANCE:

• Watch your toddler constantly whenever she is near water. Your child can drown in even a few inches, including water in the bathtub, play pools, buckets, or toilets. A supervising adult should be within an arm’s reach, providing “touch supervision,” whenever young children are in or around water.
• Do not let young brothers or sisters watch over your toddler in the bathtub, house, yard, or playground.
• Empty buckets, tubs, or small pools immediately after you use them.
• Be sure that swimming pools in your community, apartment complex, or home have a 4-sided fence with a self-closing, self-latching gate.
• Children should always wear a Coast Guard-approved life jacket when on a boat or other watercraft.

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Guns should be removed from places in which children live and play, or unloaded and locked, with ammunition locked and stored separately. Many young children are killed by guns each year; most are injured by a sibling, a friend, or themselves.

SAMPLE QUESTIONS:
Does anyone in your home have a gun? Does a neighbor, family friend, or any home where your child might play have a gun? If so, is the gun unloaded and locked up? Where is the ammunition stored? Have you thought about not owning a gun because of the danger to children and other family members?

ANTICIPATORY GUIDANCE:

• The best way to keep your child safe from injury or death from guns is to never have a gun in the home.
• If it is necessary to keep a gun in your home, it should be stored unloaded and locked, with the ammunition locked separately from the gun.

Next: 15 Month Visit
Section: Early Childhood: 1 to 4 Years