Well Child Care, 18 Months

PHYSICAL DEVELOPMENT

The child at 18 months can walk quickly, is beginning to run, and can walk on steps one step at a time. The child can scribble with a crayon, build a tower of two or three blocks, throw objects, and use a spoon and cup. The child can dump an object out of a bottle or container.

EMOTIONAL DEVELOPMENT

At 18 months, children develop independence and may seem to become more negative. Children are likely to experience extreme separation anxiety.

SOCIAL DEVELOPMENT

The child demonstrates affection, gives kisses, and enjoys playing with familiar toys. Children play in the presence of others, but do not really play with other children.

MENTAL DEVELOPMENT

At 18 months, the child can follow simple directions. The child has a 15–20 word vocabulary and may make short sentences of 2 words. The child listens to a story, names some objects, and points to several body parts.

RECOMMENDED IMMUNIZATIONS

  • Hepatitis B vaccine. (The third dose of a 3-dose series should be obtained at age 6–18 months. The third dose should be obtained no earlier than age 24 weeks, and at least 16 weeks after the first dose, and 8 weeks after the second dose. A fourth dose is recommended when a combination vaccine is received after the birth dose. If needed, the fourth dose should be obtained no earlier than age 24 weeks.)

  • Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (The fourth dose of a 5-dose series should be obtained at age 15–18 months. The fourth dose may be obtained as early as 12 months if 6 months or more have passed since the third dose.)

  • Haemophilus influenzae type b (Hib) vaccine. (Children who have certain high-risk conditions or have missed doses of Hib vaccine in the past should obtain the vaccine.)

  • Pneumococcal conjugate (PCV13) vaccine. (Children who have certain conditions, missed doses in the past, or obtained the 7-valent pneumococcal vaccine should obtain the vaccine as recommended.)

  • Inactivated poliovirus vaccine. (The third dose of a 4-dose series should be obtained at age 6–18 months.)

  • Influenza vaccine. (Starting at age 6 months, all children should obtain influenza vaccine every year. Infants and children between the ages of 6 months and 8 years who are receiving influenza vaccine for the first time should receive a second dose at least 4 weeks after the first dose. Thereafter, only a single annual dose is recommended.)

  • Measles, mumps, and rubella (MMR) vaccine. (Doses should be obtained, if needed, to catch up on missed doses in the past. A second dose should be obtained at age 4–6 years. The second dose may be obtained before 4 years of age if that second dose is obtained at least 4 weeks after the first dose.)

  • Varicella vaccine. (Doses obtained if needed to catch up on missed doses in the past. A second dose of the 2-dose series should be obtained at age 4–6 years. If the second dose is obtained before 4 years of age, it is recommended that the second dose be obtained at least 3 months after the first dose.)

  • Hepatitis A virus vaccine. (The first dose of a 2-dose series should be obtained at age 12–23 months. The second dose of the 2-dose series should be obtained 6–18 months after the first dose.)

  • Meningococcal conjugate vaccine. (Children who have certain high-risk conditions, are present during an outbreak, or are traveling to a country with a high rate of meningitis should obtain the vaccine.)

TESTING

The health care provider should screen the 18-month-old for developmental problems and autism and may also screen for anemia, lead poisoning, or tuberculosis, depending upon risk factors.

NUTRITION AND ORAL HEALTH

  • Breastfeeding is encouraged.

  • Daily milk intake should be about 2–3 cups (500–750 mL) of whole-fat milk.

  • Provide all beverages in a cup and not a bottle.

  • Limit juice to 4–6 ounces (120–180 mL) each day of a vitamin C containing juice and encourage the child to drink water.

  • Provide a balanced diet, encouraging vegetables and fruits.

  • Provide 3 small meals and 2–3 nutritious snacks each day.

  • Cut all objects into small pieces to minimize risk of choking.

  • Provide a high chair at table level and engage the child in social interaction at meal time.

  • Do not force the child to eat or to finish everything on the plate.

  • Avoid nuts, hard candies, popcorn, and chewing gum.

  • Allow your child to feed himself or herself with a cup and spoon.

  • Your child's teeth should be brushed after meals and before bedtime.

  • Give fluoride supplements as directed by your child's health care provider.

  • Allow fluoride varnish applications to your child's teeth as directed by your child's health care provider.

DEVELOPMENT

  • Read books daily and encourage your child to point to objects when named.

  • Recite nursery rhymes and sing songs to your child.

  • Name objects consistently and describe what you are doing while bathing, eating, dressing, and playing.

  • Use imaginative play with dolls, blocks, or common household objects.

  • Some of your child's speech may be difficult to understand.

  • Avoid using "baby talk."

  • Introduce your child to a second language, if used in the household.

TOILET TRAINING

While children may have longer intervals with a dry diaper, they generally are not developmentally ready for toilet training until about 24 months.

SLEEP

  • Most children still take 2 naps each day.

  • Use consistent nap and bedtime routines.

  • Your child should sleep in his or her own bed.

PARENTING TIPS

  • Spend some one-on-one time with your child daily.

  • Avoid situations that may cause the child to develop a "temper tantrum," such as shopping trips.

  • Recognize that the child has limited ability to understand consequences at this age. All adults should be consistent about setting limits. Consider time-out as a method of discipline.

  • Offer limited choices when possible.

  • Minimize television time. Children at this age need active play and social interaction. Any television should be viewed jointly with parents and should be less than one hour each day.

SAFETY

  • Make sure that your home is a safe environment for your child. Keep home water heater set at 120° F (49° C).

  • Avoid dangling electrical cords, window blind cords, or phone cords.

  • Provide a tobacco-free and drug-free environment for your child.

  • Use gates at the top of stairs to help prevent falls.

  • Use fences with self-latching gates around pools.

  • Your child should always be restrained in an appropriate child safety seat in the middle of the back seat of the vehicle and never in the front seat of a vehicle with front-seat air bags. Rear-facing car seats should be used until your child is 2 years old or your child has outgrown the height and weight limits of the rear-facing seat.

  • Equip your home with smoke detectors.

  • Keep medications and poisons capped and out of reach. Keep all chemicals and cleaning products out of the reach of your child.

  • If firearms are kept in the home, both guns and ammunition should be locked separately.

  • Be careful with hot liquids. Make sure that handles on the stove are turned inward rather than out over the edge of the stove to prevent little hands from pulling on them. Knives, heavy objects, and all cleaning supplies should be kept out of reach of children.

  • Always provide direct supervision of your child at all times, including bath time.

  • Make sure that furniture, bookshelves, and televisions are securely mounted so that they cannot fall over on a toddler.

  • Assure that windows are always locked so that a toddler cannot fall out of the window.

  • Children should be protected from sun exposure. You can protect them by dressing them in clothing, hats, and other coverings. Avoid taking your child outdoors during peak sun hours. Sunburns can lead to more serious skin trouble later in life. Make sure that your child always wears sunscreen which protects against UVA and UVB when out in the sun to minimize early sunburning.

  • Know the number for poison control in your area and keep it by the phone or on your refrigerator.

WHAT'S NEXT?

Your next visit should be when your child is 24 months old.