Well Child Care, 24 Months

PHYSICAL DEVELOPMENT

The child at 24 months can walk, run, and hold or pull toys while walking. The child can climb on and off furniture and can walk up and down stairs, one at a time. The child scribbles, builds a tower of five or more blocks, and turns the pages of a book. He or she may begin to show a preference for using one hand over the other.

EMOTIONAL DEVELOPMENT

The child demonstrates increasing independence and may continue to show separation anxiety. The child frequently displays preferences through use of the word "no." Temper tantrums are common.

SOCIAL DEVELOPMENT

The child likes to imitate the behavior of adults and older children and may begin to play together with other children. Children show an interest in participating in common household activities. Children show possessiveness for toys and understand the concept of "mine." Sharing is not common.

MENTAL DEVELOPMENT

At 24 months, the child can point to objects or pictures when named and recognize the names of familiar people, pets, and body parts. The child has a 50 word vocabulary and can make short sentences of at least 2 words. The child can follow two-step simple commands and will repeat words. The child can sort objects by shape and color and find objects, even when hidden from sight.

ROUTINE IMMUNIZATIONS

  • Hepatitis B vaccine. (Doses only obtained, if needed, to catch up on missed doses in the past.)

  • Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Doses only obtained, if needed, to catch up on missed doses in the past.)

  • 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.)

  • Pneumococcal polysaccharide (PPSV23) vaccine. (Children who have certain high-risk conditions should obtain the vaccine as recommended.)

  • Inactivated poliovirus vaccine. (Doses obtained, if needed, to catch up on missed doses in the past.)

  • 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 of a 2-dose series 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 a 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. (Children who obtained 1 dose before age 24 months should obtain a second dose 6–18 months after the first dose. A child who has not obtained the vaccine before 2 years of age should obtain the vaccine if he or she is at risk for infection or if hepatitis A protection is desired.)

  • 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 may screen the 24-month-old for anemia, lead poisoning, tuberculosis, high cholesterol, and autism, depending upon risk factors.

NUTRITION AND ORAL HEALTH

  • Change from whole milk to reduced fat milk, 2%, 1%, or skim (non-fat).

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

  • 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, with healthy meals and snacks. Encourage vegetables and fruits.

  • 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 utensils.

  • 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. Stuttering is also common.

  • Avoid using "baby talk."

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

  • Consider preschool for your child at this time.

  • Make sure that child caregivers are consistent with your discipline routines.

TOILET TRAINING

When a child becomes aware of wet or soiled diapers, the child may be ready for toilet training. Let your child see adults using the toilet. Introduce a child's potty chair, and use lots of praise for successful efforts. Talk to your physician if you need help. Boys usually train later than girls.

SLEEP

  • Use consistent nap-time and bed-time routines.

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

PARENTING TIPS

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

  • Be consistent about setting limits. Try to use a lot of praise.

  • Offer limited choices when possible.

  • Avoid situations when may cause the child to develop a "temper tantrum," such as trips to the grocery store.

  • Discipline should be consistent and fair. Recognize that your 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.

  • 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).

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

  • Always put a helmet on your child when he or she is riding a tricycle.

  • Use gates at the top of stairs to help prevent falls. Use fences with self-latching gates around pools.

  • All children 2 years or older should ride in a forward-facing safety seat with a harness. Forward-facing safety seats should be placed in the rear seat. At a minimum, a child will need a forward-facing safety seat until the age of 4 years.

  • Equip your home with smoke detectors and change batteries regularly.

  • Keep medications and poisons capped and out of reach.

  • 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.

  • 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 30 months old.