"Parenting 101"

The following comments are designed to help you enjoy your new baby and develop confidence in yourself as a parent. This information is not intended as a substitute for well-baby visits with your newborn's pediatrician. Remember, no two babies have exactly the same makeup or the same needs. Your baby is an individual with his or her own special growth pattern. Comparing your infant's growth and development with other children is not a good idea and usually causes needless worry. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular well-baby checkups! Sleep

Never give an infant honey to prevent infant botulism.

Parenting and Behavioral

Hold, cuddle, talk to, sing to and rock your baby as much as you can. A lot of your infant's development depends on his or her interaction with you. Every touch stimulates the baby's brain. Recognize the fact that parents can not always console their baby. Expect this. Of course, always check your baby when he or she seems uncomfortable, to make sure the infant is not too hot, too cold, hungry, wet or needs to burp. Give your child the benefit of the doubt and do not worry about "spoiling." Try to spend time nurturing your baby when the infant is quiet, happy and alert, instead of waiting for him or her to cry and fuss for attention. Parents should make sure they get adequate rest. Take the phone off the hook and nap when the baby naps. Encourage dad and other family members to help care for the infant. Keep in contact with friends and relatives. Go for a daily walk with the baby for fresh air.

Always put your baby to sleep on his or her back. Infants sleep most of the day but a child's sleep patterns vary from baby to baby. It is not unusual for a baby to have a "fussy" period during the late afternoon or early evening. This is how the infant's immature nervous system handles all of the day's stimuli so ... prepare yourself for it. Most babies will sleep through the night by 3 months old. "Lucky" parents get a good night sleep sooner. To achieve this, many babies need encouragement. Put the infant to bed when he or she is drowsy, but awake. Avoid rocking your baby to sleep or holding him or her until he or she falls asleep. Your baby needs to learn to fall asleep on his or her own. Try to ignore the baby if he or she is just squirming or whimpering. Your infant may go back to sleep on his or her own!

Immunizations Since immunization schedules vary from doctor to doctor, and new vaccines may have been introduced,it is always best to seek the advice of your child's health care provider concerning the child's vaccine schedule. Most physicians give the first of three Hepatitis B vaccines at the 2 week or one-month checkup, unless it was given in the hospital.

Development

Safety

Begins to recognize family voices and makes small "throaty" noises. Recognizes sounds by blinking, crying or showing the startle reflex (arms and legs move away from the body equally). Blinks at bright light and may begin to follow, but eyes often do not focus together. Watch for the first smile ... truly a milestone. It is the earliest sign of mental growth ... the first thing your baby can do on his or her own! (Usually not seen until 2-3 months). Lifts head briefly when lying on his or her stomach.

Always use a rear-facing infant car seat placed in the center of the back seat. Never leave a baby alone with a young sibling or a pet. Never leave your baby alone in a tub or on a high place, such as a changing table, bed or sofa. Set hot water thermostat at less than 120 degrees F. Insist on a smoke-free environment for your baby. If there is a smoker in the family, do not permit any smoking in the house or in the car. Make sure smoke detectors are in place and working. If your home uses gas appliances, install and maintain carbon monoxide detectors. Avoid sun exposure to baby's tender skin.

Feeding

Eliminations Make feeding a pleasant time for the entire family. Remember, your baby's first love for his or her parents arises from the bonding obtained during feeding time. The affection and touching the baby gets during the feeding period is an important part of the diet. Babies need only breast milk or iron-fortified formula at this time unless otherwise directed by your baby's doctor. Your baby's feeding habits will vary from day to day just like you. This is just another way your baby is letting you know he or she is a unique individual. If prescribed by your child's doctor, remember to give vitamins and/or fluoride. Call the doctor if you feel the baby is not gaining enough weight. Do not use a microwave oven to heat formula. Delay the introduction of solid foods until they are suggested by your infant's doctor. Do not put your baby to bed with a bottle or prop it in his or her mouth.

Every baby has his or her own unique pattern to the frequency of their bowel movements. Some go after every feeding, some once a day and others every two or three days. Most babies strain, grunt and fuss even when they have a loose bowel movement. Stool color and consistency varies from yellow in breast fed babies to brown and green in formula fed babies. Consistency can be anywhere from thin to a thick paste.

When to Call the Doctor

Anything that bothers you is important to your child's pediatrician. That's our job! Fever (over 100.2 degrees F rectally). Not gaining weight. Excessive vomiting, especially if it is forceful and goes across the room. Uninterested in eating.

Irritability or lethargy. Unusual skin rashes.

Sleep

Growth Milestones - 2 Months "The Big Smile" The following comments are designed to help you enjoy your new baby and develop confidence in yourself as a parent. They are not intended as a substitute for well-baby visits by your newborn's pediatrician. Remember no two babies have exactly the same makeup or the same needs. Your baby is an individual with his or her own special growth pattern. Comparing the growth and development of your baby with other children is not a good idea and usually causes needless worry. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular well-baby checkups. Parenting and Behavioral

foods depends on the preference of your child's pediatrician. Remember to give vitamins and/or fluoride if prescribed by your child's doctor.

The next few months are perhaps the easiest age during a baby's life. Your baby still has relative immunity to most infections. He or she is happy to see people, yet does not demand a lot of attention nor can they get up and crawl around to get into things. Your child will become responsive when you talk to him or her and is beginning to blossom into a "real" person. Continue to hold, cuddle, talk to, sing to and rock your baby as much as you can. Every interaction with your child stimulates brain development. Encourage your baby to "speak" by talking to him or her during dressing, bathing, feeding, playing, walking and driving. Stimulate your child with age- appropriate toys. Hang a rattle, mobile or some other bright object across the crib so that your infant can begin watching and reaching for it. Parents should continue to make sure they get adequate rest. A lot of moms still need a nap, so take one when baby naps. Go for a daily walk with the baby for fresh air. Mothers should have had their postpartum checkup by now.

Always put your baby to sleep on his or her back. Alternate the end of the crib where you place his or her head so he or she does not always sleep with his or her head on one side. Begin to establish a bedtime routine and other habits to discourage night awakening. Infants sleep most of the day but a child's sleep patterns vary from baby to baby. Many babies still have that "fussy" period during the late afternoon or early evening. It is OK for moms and dads to give themselves a break from that time by getting assistance from relatives and friends. Most babies will sleep through the night by 3 months old. "Lucky" parents get a good nights sleep sooner. To achieve this, many babies need encouragement. Put the infant to bed when they are drowsy but awake. Avoid rocking your baby to sleep or holding him or her until he or she falls asleep. You baby needs to learn to fall asleep on his or her own. Try to ignore the baby is he or she is just squirming or whimpering. Your infant may go back to sleep on his or her own!

At this Checkup

Development

An important part of each well-child visit is the evaluation of the baby's growth. In the vast majority of children, growth falls within normal ranges on the standard growth curves for weight, height or head size. The smooth curves of a growth chart might create the impression that a baby grows in a continuous, smooth manner. Instead, growth usually occurs in spurts. Therefore, single growth (height , weight, head size) measurement at any particular month in a child's life is of limited value - more important is the child's rate of growth over time.

Have you noticed that your baby's smile has improved, especially when he or she sees you? Infants at this age begin to show pleasure in their interactions with their parents. Before long, the neck muscles will begin to develop, allowing your baby to gain more head control. He or she will be able to hold his or her head steady and it will not bob around when you pick up your child. Until this happens, however, be prepared to give your baby extra head support. Your baby will begin to grasp a rattle or tightly hold on to your finger Between now and the 4-month checkup, most babies will start to lift their head, neck and upper chest on their forearms, craning their necks like a turtle to see what is going on. They will also straighten out their legs when you let them sit on your lap and try to stand with support. And no, this will not cause them to become bow-legged.

Immunizations Hepatitis B Inactivated Polio DTaP Rotavirus Pneumococcal Haemophilus Influnzae Safety 2nd dose 1st dose 1st dose 1st dose 1st dose 1st dose

Feeding

Discuss with your baby's doctor any problems you are having with breast or bottle feeding. Remember, "spitting up" is common and as long as your baby is thriving, the spitting is a "nuisance" rather than a "problem." Infant feeding demands will continue to vary from day to day. By 10 weeks of age, some babies are feeding only four to five times a day (breast or bottle) while others require more feeding times. This is normal. Hopefully, the interval between feedings is not at least every three to four hours during the day with lengthened intervals at night. Do not put cereal in a bottle unless instructed to do so by your baby's doctor. The introduction of solid

Continue to use an infant car seat that is properly secured at all times. Continue to put the baby to sleep on his or her back or side. Continue to test the water temperature with your wrist to make sure it is not hot before bathing the baby. Never leave the baby alone or with a young sibling or pet. Do not leave your baby alone in a tub of water or on high places such as changing tables, beds, sofas or chairs. Always keep one hand on the baby. Continue to insist that the baby's environment is free of smoke. Never shake or jiggle the baby's head vigorously. Never leave the infant alone in the house or car, even for a minute. Do not place strings or necklaces about a baby's neck or use a sting to attach a pacifier. Never hold your baby while drinking a hot liquid. If your home uses gas appliances, install and maintain carbon monoxide detectors.

Eliminations

Most babies strain, grunt and fuss when they have bowel movements. This does not mean they are constipated.

Growth Milestones - FOUR MONTHS "Emerging Personality" The 4-month-old infant is beginning to settle in by establishing regular sleeping and feeding cycles. He or she is also showing endless interest in his or her environment. The following comments are designed to help you and your partner enjoy your 4-month-old while continuing to gain confidence in yourselves as parents. This information is not intended as a substitute for wellbaby visits by your newborn's pediatrician. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular well-baby checkups. Parenting and Behavioral This is an enjoyable time for you and your baby. He or she is more fun and less work. He or she is exploring more and trying to make contact with his or her surroundings Continue to hold, cuddle, talk to, sing to and rock your baby as much as you can. Every interaction stimulates brain development. He or she needs an interested audience and a chance to use his or her laughing skills Now is the time to think about getting your baby a playpen and some suitable toys to keep him or her entertained Read brightly colored books to your baby. Reading is important to succeed as an adult and you can not start early enough. Since the 4-month-old infant is more active, spitting up is common at this age, so have a good supply of absorbent bibs to protect your baby's skin and clothing from being constantly wet If the mother has returned to a second job outside the home, she needs to feel comfortable with the child care arrangements she has made for her baby Parents need to keep in contact with friends and family to avoid social isolation

of his or her environment. Frequently, the baby may become so interested in his or her world that he or she may refuse to settle down to eat. He or she will take a few swallows of formula or breast milk and then stop to see what is going on in the room. Most pediatricians start solid foods sometime between ages 4 and 6 months. If your baby sits well when supported, holds his or her head up and seems to be hungry, it may be time to being cereal. Begin with infant rice cereal. Mix a couple of teaspoons with breast milk or formula until it becomes a thin soup. Place the spoon about half way back on the baby's tongue to teach swallowing. As your baby gets the hang of it, increase the thickness and amount of the cereal. If your baby pushes the solid food out of his or her mouth, it does not necessarily mean he or she does not like what your giving him or her. Babies have a tongue reflex that causes them to push anything out of their mouth. Remember to give vitamins and/or fluoride if prescribed by your child's doctor. Never put your baby to bed with a bottle or prop it in his or her mouth. Ask your pediatrician about giving diluted juices. Between now and the next checkup, many babies begin to drool. This is quite common and does not necessarily indicate early teething. It is probably due to a lot of saliva that the baby has not yet learned to swallow.

Sleep Always put your baby to sleep on his or her back. Alternate the end of the crib where you place his or her head so he or she does not always sleep with his or her head on one side. Encourage your baby to console himself or herself by putting your child to bed awake. Teach your 4month-old self-soothing techniques by providing him or her with a transition object, such as a stuffed animal, blanket or favorite toy. Keep to your establish a bedtime routine and other habits to discourage night awakening assistance from relatives and friends. Most babies will sleep through the night by 3 months old. "Lucky" parents get a good nights sleep sooner. To achieve this, many babies need encouragement. Put the infant to bed when they are drowsy but awake. Avoid rocking your baby to sleep or holding him or her until he or she falls asleep. You baby needs to learn to fall asleep on his or her own. Try to ignore the baby is he or she is just squirming or whimpering. Your infant may go back to sleep on his or her own!

Development A baby's development proceeds in a head to foot direction. At this age the typical child can hold his or her head high and raise the body on his or her hands while lying on his or her stomach. The 4-month-old baby keeps his or her hands open while at rest. He or she will play with his or her hands, bat at mobiles and reach for rattles. Any object he or she holds goes directly into his or her mouth. Most babies this age will show a clear preference for parents and other caregivers. They will turn toward a sound and recognize their parent's voices. Four-month-old infants babble, smile, laugh and squeal. The 4-month-old baby also begins to learn cause and effect. He or she shakes a rattle and it makes noise, you wind the mobile and it begins to move.

At this Checkup An important part of each well-child visit is the evaluation of the baby's growth. In the vast majority of children, growth falls within normal ranges on the standard growth curves for weight, height or head size. The smooth curves of a growth chart might create the impression that a baby grows in a continuous, smooth manner. Instead, growth usually occurs in spurts. Therefore, single growth (height , weight, head size) measurement at any particular month in a child's life is of limited value - more important is the child's rate of growth over time. The 4-month old will also be checked thoroughly both physically and developmentally

Feeding Feeding times may become interesting! Your baby will begin responding to all the sights and sounds

You have not seen any developmental changes since the last checkup

Immunizations Since immunization schedules vary from doctor to doctor, and new vaccines may have been introduced, it is always best to seek the advice of your child's health care provider concerning your child's vaccine schedule. Hepatitis B Inactivated Polio DTaP Rotavirus Pneumococcal Haemophilus Influnzae Safety Now that your baby is more active, parents need to be more careful than ever not to leave the child anyplace from which he of she can fall. Always keep one hand on the baby and never turn your back, for even a second, when you put your infant on a sofa, bed, changing table or any other high place. Your baby demands your full attention Continue to use an infant car seat that is properly secured in the back seat at all times If your home uses gas appliances, install and maintain carbon monoxide detectors Do not leave your baby alone in a tub of water or on high places such as changing tables, beds, sofas or chairs. Always keep one hand on the baby. Continue to keep the baby's environment free of smoke. Keep the home and car nonsmoking zones Never shake or jiggle the baby's head vigorously. Never leave the infant alone in the house or car, even for a minute. Do not place strings or necklaces about a baby's neck or use a sting to attach a pacifier. Never hold your baby while drinking a hot liquid. Remember, everything a 4-month holds goes in his or her mouth, so keep toys with small parts out of reach. Warn siblings to keep these objects away from their little baby brother or sister Do not use an infant walker at any age. The walkers are dangerous and do not help your baby's motor development 2nd dose 2nddose 2nd dose 2nd dose 2nd dose 2nd dose

Growth Milestones - SIX MONTHS The Social Butterfly The 6-month-old infant likes to be with people and there is a sudden burst in awareness of his or her surroundings. The baby loves to play face to face with parents and begins to develop a sense of trust and the beginning elements of learning (through games like peekaboo). The following comments are designed to help you and your partner enjoy your 6-month-old while continuing to gain confidence in yourselves as parents. This information is not intended as a substitute for well-baby visits by your newborn's pediatrician. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular well-baby checkups. Parenting and Behavioral

Encourage speech development by talking to your 6month-old while dressing, bathing, feeding, playing, walking and driving. Begin playing social games such as pat-a-cake, peek-aboo, so-big, etc. Begin to set some limits for future discipline by using distraction, reducing stimulation and establishing routines. Establish a bedtime routine and other habits to discourage night awakening. Make sure your baby has learned self-soothing techniques by providing your child with the same transitional object, such as a stuffed animal, "special" blanket or favorite toy. Encourage play with age-appropriate toys. Babies like to bounce, swing, reach for you, pick up and drop objects, and bang things together. Unbreakable household objects such as plastic measuring cups, large wooden spoons, pots, pans and plastic containers make great toys. Shoes are not necessary at this age except for show and to keep their feet warm.

Development

Eliminations Your baby will have his or her own frequency of bowel movements. Most babies strain, grunt and fuss when they have bowel movements. This does not mean they are constipated.

When to Call the Doctor Anything that bothers you! Fever. Not gaining weight. Excessive vomiting, especially if it is forceful and goes across the room. Uninterested in eating. Irritability or lethargy. Unusual skin rashes. Eyes are crossed most of the time Your baby seems very stiff or very floppy.

Begins to speak single (hard) consonants, like "dada" (sorry mom!). Rolls over both ways (front to back and back to front). The baby will begin to look for a toy dropped out of sight. Has no head lag when pulled to a sitting position. Begins to "tripod" (sits with one hand on the ground for support) and soon will begin to sit without support. Continues to grasp and mouth objects, but now can transfer small objects from one hand to another. Six-month-old babies begin to rake at small objects but cannot pick them up yet because their finger coordination is not yet precise enough. Shows displeasure with loss of a toy. Is able to recognize each parent and may even begin to show some stranger anxiety. Makes attempts to feed himself or herself. Smiles, laughs, squeals and begins to imitate sounds. Can be content in a playpen for a while playing with one or two toys. Can bear weight on his or her legs when held in a standing position (no, it will not make him or her bowlegged). May develop one or more teeth by the 9-month checkup. Don't worry if teething is delayed, as every child has his or her own timetable for teething. The process of getting teeth can be difficult or easy and there is no reason why one baby frets and drools during tooth eruption and another sails through it without a

whimper. Ask your baby's doctor what you can do if teething gives your little one a problem.

Feeding

Most babies double their birth weight in the first 5 to 6 months. They will not double their weight in the next six months as growth rate slows a little. Therefore, expect your baby's appetite to diminish a little in the next six months. Continue to breast feed or use iron-fortified formula for the first year of the infant's life. Feeding should be on a routine mealtime schedule which hopefully coincides with the family mealtimes. Continue introducing new solid foods, starting with fruits, yellow vegetables, green vegetables and then meats. Your baby will let you know when and how much he or she wants to eat. Your baby will begin to show preferences for some food and dislike for others as new solids are introduced. Now is the time to begin introducing a cup since it is important to eliminate all bottles by the baby's first birthday. The easiest way to do this is by taking advantage of the infant's natural curiosity and desire to imitate adults. Parents should buy two or three brightly colored plastic cups and begin drinking their coffee or tea out of these new cups. Since the child will want the same thing the parents have, start giving your child his or her milk or juice in an identical cup. The child will not be able to hold the cup by himself or herself for some time. An alternate way of introducing the cup is to use one with a top and "feeding spout." While your child will not be using this type of cup when he or she gets older, there is less of a mess when he or she tips it over! Don't lose patience! If your 6-month-old shows little interest, try again in a day or two. Don't worry if it seems your baby is taking less liquid from the cup. This is normal since the growth rate slows down for a while. Avoid giving foods that can cause choking. The most common foods babies' aspirate are peanuts, popcorn, hot dogs or sausages, carrot sticks, celery sticks, whole grapes, raisins, corn, whole beans, hard candy, large pieces of raw vegetables or fruit and tough meat. Always supervise your baby when he or she is eating and learn the proper emergency procedures for choking. If there is a strong family history of a food allergy, you might want to limit or avoid highly allergic foods such as eggs, strawberries, chocolate and seafood until your baby is older. Continue to give the breast-feeding infant supplemental Vitamin D if recommended by your baby's doctor and fluoride supplements if your water supply is not fluoridated. If your baby is being fed by a care giver, go over the schedule with him or her to make sure he or she is feeding your infant the way you want. Because your baby is getting ready to cut teeth, he or she may be "gnawing" on everything.

Safety

Your adorable newborn is about to become "mobile" so child-proofing your home should take priority at this age. Now that your baby is more active, be more careful than ever not to leave him or her anyplace from which he or she can fall. Always keep one hand on your child and never turn your back, for even a second, when you put him or her on a sofa, bed, changing table or any other high place. Your baby always needs your full attention. Never leave your baby alone with a young sibling or pet. Continue to use an infant car seat that is properly secured at all times. Avoid using baby walkers. There is considerable risk of major and minor injury and even death from the use of walkers and there is no clear benefit from their use. If your home uses gas appliances, install and maintain carbon monoxide detectors. Continue to keep the baby's environment free of smoke. Keep the home and car nonsmoking zones. Get down on the floor and check for safety hazards at your baby's eye level. Empty buckets, tubs or small pools immediately after use. Ensure that swimming pools have a four-sided fence with a self-closing, self-latching gate. Avoid overexposure to the sun. Do not leave heavy objects or containers of hot liquids on tables with tablecloths that your baby may pull down. Place plastic plugs in electrical sockets. Keep toys with small parts or other small or sharp objects out of reach. It is especially important to remind older siblings that they should always play with small objects out of reach of their baby brother or sister. Keep all poisonous substances, medicines, cleaning agents, health and beauty aids, and paints and paint solvents locked in a safe place out of your baby's sight and reach. Never store poisonous substances in empty jars or soda bottles. Install safety devices on drawers and cabinets where the infant may play. Install gates at the top and bottom of stairs, and place safety devices on windows. Lower the crib mattress. Avoid dangling electrical and drapery cords. If you have a pet, keep his or her food and dishes out of your baby's reach. Also, never allow your child to approach a dog while the dog is eating. Use the playpen as an "island of safety." Learn first aid and infant cardiopulmonary resuscitation (CPR).

Immunizations Since immunization schedules vary from doctor to doctor, and new vaccines may have been introduced, it is always best to seek the advice of your child's health care provider concerning your child's vaccine schedule. DTaP Rotavirus Pneumococcal Haemophilus Influnzae Hepatitis B 3rd dose 3rd dose 3rd dose 3rd dose 3rd dose

Eliminations

Your baby will have his or her own frequency of bowel movements. Most babies strain, grunt and fuss when they have bowel movements. This does not mean they are constipated.

When to Call the Doctor

Anything that bothers you! Appears not to be gaining weight. Your baby shows little interest in social interaction, avoids eye contact, and smiles infrequently.

Your baby seems stiff or floppy. Your baby's head lags when pulled to a sitting position. Your baby only uses one hand to reach. Your baby makes no attempt to roll over. There is no infant squealing or laughing. Eyes are crossed most of the time. You have not seen any developmental changes since the last checkup.

Growth Milestones - NINE MONTHS "The Creepy-Crawler" The 9-month-old child continues making major gains in development and begins displaying a little independence. The youngster of this age is always on the move and will begin to get opinionated about such things as what foods to eat and when to go to sleep. Occasionally, these opinions turn into protests, so now is the time to begin setting some limits and saying "no." The following comments are designed to help you and your partner enjoy your 9-month-old while continuing to gain confidence in yourselves as parents. The information is not intended as a substitute for well-baby visits by your newborn's pediatrician. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular wellbaby checkups. Parenting and Behavioral Illness

Bangs two toys together. Plays interactive games well such as peek-a-boo and pat-a-cake. Perhaps the most striking developmental achievement is the use of fingers and thumb to poke, pry, probe and pick up smaller and smaller objects. Sleeps through the night except for an occasional night wakening. The 9-month-old has now learned to be "cool" or even a little afraid of certain strangers - even family members he or she does not see very often. The baby of this age also begins to take a dim view of being examined by their doctor. Often has one or both bottom front teeth.

Feeding

Nine months is the age when a child becomes increasing susceptible to infections, probably due to loss of maternal antibodies the youngster received during pregnancy. In addition, everything goes into his or her mouth, including germs! Do not be discouraged if your child has a cold or two between now and his or her first birthday.

Keep up a constant chatter with your 9-month-old child. Talking to your child while dressing, bathing, feeding, playing, walking and driving encourages speech development. Encourage play with age-appropriate toys. Babies like to bounce, swing, reach for you, pick up and drop objects, and bang things together. Unbreakable household objects such as plastic measuring cups, large wooden spoons, pots, pans and plastic containers make great toys. A foam rubber ball helps the child develop his or her small motor skills. Provide opportunities for safe exploration. Begin to set limits by using verbal "no's," distraction, removing the object from the baby's sight or removing the baby from the object. Never use spanking as a form of discipline, even a "little" tap on the hand. If you become angry with your baby, put the child in his or her crib or playpen for one or two minutes. This will allow you to calm down and allows your baby to realize he or she has done something wrong. Consistence of discipline is very important - adhering to the limits you set keeps your child safe. Stranger anxiety may limit some parent's ability to leave their 9-month-old with grandparents or a baby sitter. It is important for parents to get out from time to time without their little one. You get a breather, and your son or daughter learns that sometimes you do go away, but you always come back.

Give your baby soft table foods if approved by your doctor to increase the texture and variety of foods in his or her diet. Give your child the opportunity to use his or her newly developed skill of plucking things by offering small bits of soft table foods. (You may need to give your child a bath after every meal!) The 9-month-old is a great imitator. The food on your plate is much more appetizing to him or her, so take advantage of this to introduce new table foods. Never give a 9-month-old food that may cause choking and aspiration, such as peanuts, popcorn, hot dogs or sausages, carrot or celery sticks, whole grapes, raisins, corn, whole beans, hard candy, large pieces of raw vegetables or fruit, or tough meat. Always supervise your child while he or she is eating. Continue teaching the infant how to drink from a cup so he or she is off any bottles by 1 year. Continue using breast milk or iron-fortified formula for the first year of your infant's life. Continue giving extra Vitamin D to the breast-feeding infant and supplemental fluoride to all children who are not exposed to fluorinated wate

At this Checkup

Development

Sleep

An important part of each well-child visit is the evaluation of the baby's growth. In the vast majority of children, growth falls within normal ranges on the standard growth curves for weight, height or head size. The smooth curves of a growth chart might create the impression that a baby grows in a continuous, smooth manner. Instead, growth usually occurs in spurts. Therefore, single growth (height, weight, head size) measurement at any particular month in a child's life is of limited value - more important is the child's rate of growth over time. The 9-month-old will also be checked thoroughly both physically and developmentally.

During this period your baby will probably learn to creep, crawl and otherwise get around the room. He or she may even pull up in the bed or on furniture and begin "cruising" around the room. Responds to his or her own name. Understands a few words such as "no-no" and "byebye." Begins developing certain concepts - for example, your child will retrieve a toy after he or she watched you put it under a blanket. May say "dada" or "mama" but not specifically. Sits well independently.

Encourage your baby to console himself or herself by putting your child to bed awake. Due to the emergence of stranger anxiety, the 9-monthold baby may show resistance to going to sleep for naps and at night. Some 9-month-old babies begin night awakenings for short periods of time. Should this happen, check your baby, but keep the visit brief, avoid stimulating your infant, and leave the room quickly once you feel

everything is OK. Do not give extra bottles, take the infant into bed with you or rock him or her back to sleep. This will only reinforce the night awakenings and it will become a habit. Sleep is also occasionally disturbed when the infant pulls up in his or her crib and can not get back down. Never put the baby to bed with a bottle.

When to call the Doctor

Anything that bothers you! Your baby shows little interest in social interaction, avoids eye contact and smiles infrequently. Your baby seems stiff or floppy. Will not bear weight on legs. No babbling, infant squealing or laughing. Does not turn when name is called. Eyes are always crossed. You have not seen any developmental changes since the last checkup.

Safety

Remember, there is no such thing as a "child proof" cap. Your adorable newborn is now "mobile" so childproofing, if not done at 6 months, is a priority. Get down on the floor at your baby's eye level and see what the infant can get in to. Continue to use a rear facing infant car seat in the back seat. Do not leave your child alone in a tub of water or on high places such as changing tables, beds, sofas or chairs. Always keep one hand on your baby. Avoid using baby walkers. There is considerable risk of major and minor injury and even death from the use of walkers. There is no clear benefit from the walker's use. If your home uses gas appliances, install and maintain carbon monoxide detectors. Always empty buckets, tubs or small pools immediately after use. Ensure that swimming pools have a four-sided fence with a self-closing, self-latching gate. Swimming pools are deadly to children at this age. Continue to keep the baby's environment free of smoke. Keep the home and car nonsmoking zones. Avoid overexposure to the sun. A waterproof sun screen with an SPF more than 15 is OK. Even with sun screen, avoid the hours between 10 a.m. and 3 p.m., when the sun is most dangerous. Do not leave heavy objects or containers of hot liquids on tables with tablecloths that the baby may pull down. Place plastic plugs in electrical sockets. Keep all poisonous substances, medicines, cleaning agents, health and beauty aids, and paints and paint solvents locked in a safe place out of the baby's sight and reach. Never store poisonous substances in empty jars or soda bottles. Install gates at the top and bottom of stairs, and place safety devices on windows. Lower the crib mattress. Learn child cardiopulmonary resuscitation (CPR)

Growth Milestones - TWELVE MONTHS "Happy Birthday" A year ago, did you wonder if you would ever make it to this day? Well, you have! And along the way you have taken a tiny helpless newborn and watched him or her become a constantly moving and exploring person. Get ready! Your baby is about to enter the toddler stage of child development. Some 1-year-old children are cruising around furniture while others are walking. All 1-year-olds get into everything and become more vocal . . . and more assertive! Your child's world is enlarging, bringing new excitement and new challenges to you as a parent. The following comments are designed to help you and your partner enjoy your 12-month-old son or daughter while continuing to gain confidence in yourselves as parents. They are not intended as a substitute for well-baby visits by your newborn's pediatrician. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular well-baby checkups. Parenting and Behavioral Because your one-year-old is mobile, whether crawling, cruising, or walking, it is important to begin putting limits on their behavior. They learn by exploration but need safe limits. Praise the one year old for good behavior. It is important to teach the child the word "no." Saying "no" in a stern voice with good eye contact is almost always effective in this age group. Some parents have a fear of the word "no." They do not want their child to feel restricted, so they bend the other way and let their youngster run wild without any limits. A child needs guidance for his or her own protection and to learn that others have rights. "No" at the appropriate time is as important for the child's development as is nutrition and love. Discipline should be consistent to be effective. To discipline a one year old, use distraction, loving restraint, removal of the object from the toddler or the toddler from the object. Discipline does not mean punishment or spanking. If you become angry with your baby, put your little one in his or her crib or playpen for one or two minutes of "time out." This will allow you to calm down and it also allows your baby to realize that he or she has done something wrong. During "time out" the child should not be able to see you or any other family member.

Immunizations Since immunization schedules vary from doctor to doctor, and new vaccines may have been introduced. It is always best to seek the advice of your child's health care provider concerning your child's vaccine schedule.

Many physicians apply a painless skin test for tuberculosis which needs checking by the parents in three days. A positive reaction does not mean the child has tuberculosis - only that he or she has been exposed to the disease. Ask your baby's doctor about possible side effects (fever, irritability, tenderness over the injection site). Some physicians at 9 months, others at 12 months, perform a hemoglobin or hematocrit determination to check for anemia ("low blood"). This requires a small poke on the finger to obtain a drop of blood.

Encourage play with age-appropriate toys. Children this age love push and pull toys. Develop motor coordination by clapping and dancing to children's music. Encourage your toddler to play alone as well as with playmates, siblings and parents. Encourage your child to play alone with supervision and with other toddlers. Remember that aggressive behaviors - hitting and biting - are common at this age. How parents respond to this behavior determines if it will continue. Despite your child's desire to become independent, you will find the 1- year-old often clinging to a parent more than before. In addition, stranger anxiety may cause some parent's not to be able to leave their child with grandparents or a baby sitter. It is important for parents to get out from time to time without their little one. You get a breather, and your son or daughter learns that sometimes you do go away, but you always come back. A demon explorer who wants to learn all about the size, shape and movability of everything in sight. Opens cabinets, pulls tablecloths, usually examines an object before putting it into mouth

Development Pulls to stand, crawls rapidly, seats self on floor , cruises on furniture or walks alone with an unsteady gait. Plays social games such as pat-a-cake, peek-aboo and so-big. Bangs two blocks together. Has vocabulary of one to three words in addition to "mama" and "dada." Drinks from a cup - not bottles. Waves "bye-bye." Feeds himself or herself Points with a finger and displays a precise pincher grasp when picking up small objects. May say one to three meaningful sounds besides using "mama" and "dada" correctly. Shows definite understanding of a few simple words; Loves music, rhythms, and rhymes Will begin to cooperate a little in getting dressed by holding still.

the plate. If your son or daughter wants more, he or she may have it. One of our problems as adults is over eating, and many of us learned this in childhood. Most babies at this age are eating mostly table foods but it is okay if your youngster still prefers "baby food." Milk intake decreases considerably and your child will either want to feed himself or herself or will still want you to do it. Give your 12 month old child a spoon to hold and get used to, although most cannot master utensils until 18 months. As much as possible, let your toddler feed himself or herself (most will want to anyway). Feed your youngster three meals a day eaten with the family, and a midmorning and mid-afternoon snack. Discuss milk feedings with your doctor. If you are formula feeding, your doctor might suggest weaning to whole milk ( note: some babies have harder bowel movements at first with whole milk) and limit the amount of milk to 24 ounces or less. It is important to eliminate all bottles by one year of age. After one year, the bottle is more of a comfort item and can cause damage to the teeth. If you are breast feeding, discuss with your child's pediatrician your feelings about weaning to a cup. Avoid foods that can cause choking, such as peanuts, popcorn, hot dogs or sausages, carrot sticks, celery sticks, whole grapes, raisins, corn, whole beans, hard candy, large pieces of raw vegetables or fruit, or tough meat. Always supervise your child when he or she is eating.

Oral Health Begin brushing your child's teeth with a tiny, peasize amount of toothpaste. To protect the toddler's teeth, do not put him or her to bed with a bottle or prop it in his or her mouth. Give your child fluoride supplements as recommended by the pediatrician based on the level of fluoride on the level of fluoride in the toddler's drinking water. Ask your pediatrician when your child should see the dentist for the first time.

Illness The 12-month-old child will continue to experience upper respiratory infections (colds) and might even have an occasional ear infection. Children who are in day care will experience more infections than those who are at home with a parent or grandparent. Feeding Your baby's appetite is going to take a nose dive in the next six months. Your child has been experiencing very rapid growth for a while doubling their birth weight at 5-6 months and tripling it at a year. Now their rate of growth is slower than in the first year and their appetite cuts back. Do not misinterpret this normal decrease in eating as a sign of illness or disease. Never, under any circumstances, force a child to eat. Develop a "take it or leave it" attitude and do not get into the habit of substituting, bribing or begging your child to eat. Your child will determine the amount of food he or she needs. Therefore, never overload

Sleep Encourage your baby to console himself or herself by putting your child to bed awake. Children this age frequently resist going to sleep because they do not want to be separated from people and their new activities. Your child may start to give up one of his or her naps, although most 1-year-olds still take two naps. Some 1-year-old children continue to experience night awakenings for short periods of time. Should this happen, check your baby, but keep the visit brief, avoid stimulating your infant, and leave the room quickly once you feel everything is okay. Do not give extra bottles, take the infant into bed with you, or rock him or her back to sleep. This will only reinforce the night awakenings it will become a habit. Never put your baby to bed with a bottle.

Immunizations and Medical Tests seek the advice of your child's health care provider

concerning your child's vaccine schedule. It is recommended that the one-year old child receive: Measles, Mumps, and Rubella (MMR) Vaccine #1 (Can be administered at either 12 or 15 months) Varicella (chicken pox) vaccine (Can be administered at either 12 or 15 months) Hepatitis B (HepB) #3 may be given at this time if not previously administered. Prevnar (Pneumococcal) Vaccine #4 (this may also be given at 15 months instead) 3rd Inactivated Polio Vaccine 4th HIB vaccine (can be administered at 15 months instead) Lead screening is done at 12 months of age for children at risk. Hematocrit or hemoglobin (for anemia) screening if not done at nine months or if needed for WIC (Women-Infants-Children).

If your home uses gas appliances, install and maintain carbon monoxide detectors. Avoid overexposure to the sun and use sunscreen. Do not leave heavy objects or containers of hot liquids on tables with tablecloths that the baby may pull down. Keep all poisonous substances, medicines, cleaning agents, health and beauty aids, and paints and paint solvents locked in a safe place out of your baby's sight and reach. Never store poisonous substances in empty jars or soda bottles. Install gates at the top and bottom of stairs, and place safety devices on windows. Lower the crib mattress.

Safety
Growth Milestones - FIFTEEN MONTHS

You must take safety to the "next level!" Your adorable newborn is now more "mobile" than ever, so child-proofing, if not done previously, is a priority. Accidents kill more children than all other diseases combined. Get down on the floor at your baby's eye level and see what your toddler can get in to. Remember, there is no such thing as a "child proof" cap. Keep the number of the poison control center near the telephone. One year is the minimum age for riding in a forward-facing car seat. If guns are in the house, safety precautions are crucial. Do not leave your 1-year-old alone in a tub of water or on high places such as changing tables, beds, sofas or chairs. Always empty buckets, tubs or small pools immediately after use. Ensure swimming pools have a four-sided fence with a self-closing, selflatching gate. Swimming pools are deadly to children this age. The cupboard under the kitchen sink is very attractive to a baby of this age, so have a lock put on all doors that have cleansers, detergents, bleaches, furniture polish and insecticides behind them. As soon as you use medicine of any kind, replace the cap and put the bottle out of reach, preferably locked up. Be particularly vigilant when you have visiting grandparents who are not used to watching the medicines that closely. Continue to keep the baby's environment free of smoke. Keep the home and car nonsmoking zones. Avoid using baby walkers. There is considerable risk of major and minor injury and even death from the use of walkers and there is no clear benefit from their use. Prevent fires and burns by: Turning your water heater down to 120 degrees F (50 degrees C), use the back burners on the stove with the pan handles out of reach, do not cook with your child at your feet, keep all electrical appliances out of the bathroom, keep hot appliances and cords out of reach, place plastic plugs in electrical sockets.check your smoke detectors and replace batters if necessary, and practice a fire escape plan.

"Whirlwind of Activity" It is easy to expect too much of the 15-month-old child. They look so much different from the crawling infant of a few months ago that many parents think their child "is no longer a baby." And while the 15-month-old child is indeed a whirlwind of activity and curiosity, he or she may lack a sense of danger or fear. Your child will try to climb up furniture or put his or her fingers in electrical sockets. Your youngster will touch everything in sight. As a parent, you may not realize what all this means until your child has his or her first temper tantrum, ruins the carpeting or nearly breaks a precious heirloom. Parenting this age is indeed a balancing act, between giving your child freedom to explore while keeping him or her sage. The following comments are designed to help you and your partner enjoy your 15-month-old while continuing to gain confidence in yourselves as parents. This information is not intended as a substitute for well-baby visits by your child's pediatrician. Never hesitate to ask your doctor for guidance concerning specific problems. This is the reason for regular well-baby checkups. Parenting and Behavioral

Show affection and praise to your toddler for good behavior and accomplishments. Talk to your child about what he or she is doing and seeing. Singing to your child is another way to encourage vocabulary development. Use picture books to enrich his or her vocabulary. Reading books to your youngster will help with language development. It is best to keep rules at a minimum - remove things when possible rather than make issues about them. Long speeches of explanation or argument with a 15month-old are useless. When something has to be done, do it in a pleasant manner. Discipline should be consistent, but done in a loving, understanding manner. Use the two "I's" of discipline. Ignore and isolate. Temper tantrums, for example, are best handled by ignoring them. If this is not possible, isolate the child by placing him or her in his or her crib, playpen or room for a "time-out." Never use the two "S's" of discipline -shouting and spanking. Positive reinforcement should be encouraged for acceptable behavior. Praise the child for good behavior and build up the child's self-esteem and self-confidence. Your child will begin to experience some frustration. Your youngster will get upset when he or she cannot do something, or when he or she can not do what he or she wants. A child at this age will try crying and screaming to get his or her way, and such protests may become full-blown temper tantrums and breath-holding spells. Trying to reason with or punish your child may actually make the tantrum last longer. It is best to make sure

your toddler is in a safe place and then ignore the tantrum You can best do this by not looking directly at her and not speaking to her or about her to others when she can hear what you are saying. Keep family outings with a 15-month-old short and simple. A child this age has a very short attention span and lengthy activities will cause him or her to become irritable and tired. The best toys are stuffed animals, dolls, books and small toys that can be pulled and pushed, filled and emptied, opened and closed. Household items such as plastic measuring cups and empty boxes are other toys your 15-month-old will enjoy. Limit television viewing and do not use the TV as a "baby sitter." Although hitting and biting are common behaviors at this age, the behavior should never be permitted. Don't worry if your child becomes curious about body parts. This is normal at this age. It is best to use the correct terms for genitals. Toddlers may want to imitate what you are doing. Sweeping, dusting, or washing play dishes can be fun for children at this age.

Sleep

If your child still has a bottle, it should be phased out in the next month.

The afternoon nap is still required by most toddlers. Bedtime problems can occur at this age because of the toddler's desire for independence. Try to be consistent and follow routines.

Immunizations By this age, most children have received the following immunizations (*depending on the doctor's schedule):

3 doses of Hepatitis B vaccine 3 or 4 doses of DTaP vaccine * 3 or 4 doses of HIB vaccine * 1 dose of the MMR vaccine 1 dose of the Chickenpox vaccine 3-4 doses of the Pneumococcal vaccine * 2-3 doses of the Inactivated Polio Vaccine *

Development

The vocabulary for a 15-month-old is usually three to six words that parents can understand and an entire language that they cannot! Will be able to point to one or more body parts. Understands simple commands ("bring me the ball"). Walking has improved and will begin to crawl up stairs. Can feed himself or herself with the use of his or her fingers. Drinks only from a cup, but still may need help in holding it. Recognizes himself or herself in a mirror. Indicates what they want by pulling, pointing, grunting and other methods of communicating Finds an object placed out of sight Points to one or two body parts Scribbles spontaneously

Toilet Training

The development of readiness for toilet training does not appear until somewhere between 18 and 24 months. Starting toilet training at an early age, even though grandparents will indicate that you were "trained at this age," will only cause the child to rebel and still be in diapers at 3 and 4 years of age. Wait for the signs of readiness: dry periods for at least two hours, knows the difference between wet and dry, can pull pants up and down, wants to learn, and can signal when he or she is about to have a bowel movement.

Oral Health

Safety

Feeding

Brush your toddler's teeth with a small amount of fluoridated toothpaste. The 15-month-old can not clean his or her teeth by alone. A child this age should be off the bottle and at the very least no bottles to bed. To avoid dental decay, do not give any juice or other sugary substances in bottles. If snacks are given, non-sugary and unsalted foods such as fresh fruits are preferable to candy and chips. Discontinue pacifier use except, perhaps, at nap time and bedtime.

Have your child eat with the family and encourage your child to do most of the feeding, even though he or she will be clumsy with the spoon and cup. Parents should not focus on table manners at this age. They will use their fingers and maybe start using a spoon. This will be messy!! Make sure food is cut into small pieces so your baby will not choke (the size of a pencil eraser) Babies still need nutritious snacks like cheese, fruit and vegetables. Some nutritious desserts are baked apples or fresh fruit. Never use food as a reward. The child's weight may stay the same for several months, so appetite will diminish. All you can expect is one fair meal a day. Try not to get into the habit of between meal carbohydrates, cookies and sweets, that will take away his or her appetite for more nourishing foods.

Continue to use a toddler car seat and make sure it is properly secured in the back seat. Use locked doors or secure gates at stairwells. Continue to keep the toddler's environment free of smoke. Avoid foods such as nuts, bacon, popcorn, hot dogs, carrot and celery sticks, whole grapes, tough meat raw vegetables and hard candy which can be aspirated by children. For the same reason, never give a child plastic bags, marbles and balloons. Keep syrup of ipecac in the home to be used to induce vomiting only after instructions from the child's physician or the poison control center. Be careful of plastic bags and balloons Guard against falls. Do not leave a chair in such a position that it enables the child to climb to a dangerously high place Prevent burns and scalds. Hot water thermostats should be set at 120 degrees so that scalding will not occur if the child turns on the hot water. Place the child in a safe place such as the playpen during meal preparation. The kitchen is a dangerous place for a child at this time. Keep hot liquids out of reach. Be careful about ironing. Keep the child away from hot stoves, space heaters, wall heaters and fireplaces. There is no such thing as a childproof cap. Poisons, medications and toxic household products should either be excluded from the home or kept in a locked cabinet. Do not store lye drain cleaners in the home. Never

underestimate the ability of the 15-month-old to climb. Ensure the crib mattress is on the lowest rung. Guard against electrical injuries from cords and outlets. Always use sunscreen when the your child goes outside to play. Avoid, when possible, going outside between 10 a.m. and 3 p.m. when the sun's ultraviolet rays are most dangerous. Never leave the 15-month-old unsupervised in or near a swimming pool, bathtub, bucket of water, ditch, well or bathroom. Knowing how to "swim" at this age does not make a child water-safe. Choose caregivers carefully and prohibit spanking. Watch your child carefully around dogs, especially if the dog is unknown or is eating. Keep your toddler away from moving machinery, lawn mowers, overhead garage doors, driveways and streets. Hold your child's hand when you are around traffic

Illnesses The 15-month-old will experience respiratory infections, such as colds, ear infections and sinus infections, especially if he or she is in day care or "preschool." Respiratory infections of this type are a normal part of growing up.
Growth Milestones - EIGHTEEN MONTHS "Mr. No!" Your sweet little baby has grown up into a toddler, entering a world of boundless energy, curiosity, independence and negativism. Having a toddler brings new challenges to you and your partner as parents. The following comments are designed to help you enjoy your 18-month-old son or daughter. This information not intended as a substitute for wellbaby visits by your newborn's pediatrician. Never hesitate to ask your child's physician for guidance concerning specific problems. This is the reason for regular well-baby checkups. Parenting and Behavioral

Show affection in the family. Be a good role model by using seat belts, avoiding tobacco and showing respect for others. The toddler is a great imitator. Do not expect the toddler to share toys, wait for his or her food in a restaurant, or be patient while you try on clothes at the store or go food shopping. Early toilet training does not mean your child is super smart. Pushing the toddler will only make him or her rebel and be in diapers even longer. Signs that a child might be ready are dry for periods of about two hours, knows the difference between wet and dry, can pull his or her pants up and down, wants to learn, and can give a signal when he or she is about to have a bowel movement. If you insist on toilet training when your child is not ready, a battle will develop ... and it is a battle you cannot win! Discuss toilet training with your child's pediatrician to get his or her views. Remember that aggressive behaviors - hitting and biting - are common at this age. They are, of course, not acceptable behaviors. How parents respond to them determines if the behavior will continue. Do not discourage your child from using a security object - a stuffed animal, favorite blanket, etc. These are important for a toddler and the child will give it up when he or she is ready. (They usually do not take them to high school!) Despite your child's desire to become independent, you will find the 18-month-old will still cling to a parent. Read simple stories to the child regularly, especially at bedtime, to enrich his verbal expression and increase his interest in the spoken language and his listening skills. Limit television viewing and do not use it as a substitute for interaction with the child. Watch children's programs with the child when possible. The principal caregiver should be encouraged to arrange time for himself/herself. Raising a toddler can often be demanding. Praise the child when they are behaving well, and always show affection

Development

Walks fast, walks up stairs with one hand held, kicks a ball. Uses a vocabulary of four to 10 words and may combine twoword phrases. Understands simple directions. Points to some body parts correctly. Shows affection by kissing parents. Feeds himself or herself, drinks from a cup adequately and uses a spoon. Imitates a crayon stroke on paper. Holds and "loves" a doll or stuffed animal; may use a household-type toy (for example, a toy telephone) appropriately. Will sit for a short time and look at pictures in a book. Turns single pages in book or magazine

The 18-month-old child gets around easier and will soon be running. It is easy to except too much of our toddler. He or she looks so different from the crawling baby of a few months ago, and many parents think their youngster is no longer a baby. Keep rules to a minimum. Long speeches of explanation are completely useless. "Because I said so!" should be enough. Be firm and consistent, but loving and understanding with discipline. Praise your toddler for his or her good behavior and accomplishments. Encourage your toddler to make choices whenever possible, but the choices should be limited to those you can live with ("red shirt or green shirt.") Never ask a toddler an open question ("Do you want to take a bath?") unless you are willing to accept the answer. Use the two "I's" of discipline (ignore or isolate) rather than the two "S's" (shouting or spanking). Keep time-out to no more than two minutes per child's age, and be consistent. When disciplining, try to make a verbal separation between the child and his or her behavior ("I love you, but I do not like it when you touch the VCR." Pick-up your toddler, hold him or her, or remove her from dangerous situations. Reassure the toddler once the negative behavior has stopped. Provide alternatives. "No, you cannot play with the telephone, but you can play with these blocks." Avoid power struggles with your toddler. No one wins! The toddler uses a powerful weapon against the parents: the temper tantrum! These occur when the toddler is angry, tired, frustrated, or does not get his or her way. Most of the time, what happens during the tantrum is fairly predictable. Occasionally a child this age my get so angry he or she will hold his or her breath and pass out. Not to worry - once they do, the body's reflexes take over and your child will start breathing again on his or her own. Again, handle temper tantrums with the two I's of discipline - ignore or isolate (time out!). Reinforce self-care and self-expression. Praise what the child does for himself (putting his hand in a sleeve, putting meat on a fork, washing his hands, etc.) Parents should say "...and you did that all by yourself!" The 18-month old child is highly pleased by parental approval.

Oral Health

Feeding

Begin brushing your child's teeth with a tiny, pea-size amount of toothpaste. To protect your toddler's teeth, do not put him or her to bed with a bottle or prop it in his or her mouth. Continue to give your child fluoride supplements as recommended by the pediatrician based on the level of fluoride in the toddler's drinking water. Discontinue pacifier use except, perhaps, at nap time and bedtime. Ask your child's doctor when you should make the youngster's first dental appointment.

Your baby's appetite is going to continue decreasing during the toddler years. Don't make a "big deal" out of it if your child refuses to eat. No one ever starved with a refrigerator full of food. The toddler's caloric needs are down and he or she is trying to show independence. Develop a "take it or leave it" attitude and do not engage in battles over eating. You cannot win, so why fight? Children this age will determine the amount of food they need. Mealtime should not be a battle. Your toddler probably did not grow much since his or her last checkup. Maybe two inches and a few pounds, but that's all.

Sleep

Share meals as a family whenever possible. This helps your baby learn Make mealtimes pleasant and encourage conversation. Avoid using snacks between meals because the toddler has "not eaten all day." The toddler should be drinking only from a cup and using utensils pretty well to feed himself or herself.

Illnesses

Store toys in a chest without a dropping lid

Encourage your child to console himself or herself by putting them to bed awake. Prepare strategies to deal with night awakening, night fears, nightmares and night terrors. Children this age frequently resist going to sleep. They will usually give you a "test" cry to see if you will return. While it is important to let the toddler know you are there, it is also important to let him or her know that the day is over. Your toddler may start to give up at least one nap. This is sometimes an awkward stage when one nap is not enough and two naps are too many. Never put your child to bed with a bottle. He or she should be off all bottles at this age!

Your toddler might have many colds and other respiratory infections during this time. Children who are in day care will experience more infections than those home with a parent or grandparent. There will be times when you will think you "live" at your pediatricians office, since many viral infections at this age come one after the other.

Toilet Training

Some children show readiness for toilet training between 18 and 24 months. When toddlers report to their parents that they have wet or soiled their diaper, they are beginning to be aware that they prefer dryness. This is a good sign and parents should praise their child. Other signs of readiness include long periods of dryness, ability to pull pants up and down, can signal when he or she is about to have a bowel movement and knows the difference between wet and dry. Toddlers are naturally curious about the use of the bathroom by other people, so let them watch you or other family members use the toilet. Starting toilet training before the child is ready will only cause the toddler to rebel and still be in diapers at 3 and 4 years of age. It is important not to put too many demands of a child or shame them during toilet training.

Growth Milestones - TWO YEARS "Miss Independent" By age 2, your child is no longer a baby. He or she can run, has given up drinking from a bottle, and can feed himself or herself pretty well. Every day your 2-year-old says new words and does more things. In spite of these achievements, the two-year-old is still a baby in many ways. The 2-year-old is difficult, if not impossible, to reason with, but still extremely lovable. He or she will assert independence at mealtime, bedtime and during attempts at toilet training. Two-year-olds typically do not know what they want, except they are sure they do not want to do what you want them to do. The 2-year-old will struggle with his or her parents before going into the bathtub, then once in the tub, will struggle with the parents when it's time to get out of the tub. At times, the toddler will be a "handful." Sometimes it is tough to parent a 2-year-old. Yet these years do not have to be "terrible," and can be "terrific." Your child is simply moving from babyhood to childhood. The following comments are designed to help you and your parents enjoy your 2-year-old while continuing to gain confidence in yourselves as parents. This information is not intended as a substitute for well-baby visits by your child's pediatrician. Never hesitate to ask your doctor for guidance concerning specific problems. This is the reason for regular wellbaby checkups. Parenting and Behavioral

Safety

Use car restraints consistently. Ensure stair and window safety. All play outside should be supervised. Toddlers do not understand danger and cannot remember "no." Knowing how to "swim" does not make a child water-safe at this age. Supervise the toddler constantly whenever he or she is in or around water, buckets, the toilet or the bathtub. Continue to empty buckets, tubs or small pools immediately after use. Ensure that swimming pools have a four-sided fence with a self-closing, self-latching gate. If your home uses gas appliances, install and maintain carbon monoxide detectors. Put sun screen on the toddler before going outside to play or swim. Be particularly careful during the hours between 10 a.m. and 3 p.m. when the sun is most dangerous. Continue to keep your toddler's environment free of smoke. Keep the home and car nonsmoking zones. Ensure electric wires, outlets and appliances are inaccessible or protected. Keep medicines, cigarettes, lighters, matches, alcohol, firearms and electrical tools locked up and/or out of the toddler's sight and reach. Always walk behind your car before you back out the driveway. Remember, almost anything in your home can be poisonous. Keep Syrup of Ipecac in the home to be used as directed by the poison control center or the health professional. Keep the number of the poison control center near the telephone. Do not expect your older children to supervise the toddler (e.g., in the house, apartment, playground, or yard). Keep the toddler away from moving machinery, lawn mowers, overhead garage doors, driveways and streets. Ensure that a toddler riding in a seat on an adult's bicycle is wearing a helmet and wear a helmet yourself. Teach the child to use caution when approaching dogs, especially if the dogs are unknown or eating. Keep plastic bags and balloons, and small hard objects out of reach. Cut food into small pieces. Know how to save a choking child.

Use picture books to enrich your child's vocabulary. Reading books to your child will help with language development. Arrange times for safe running and exploring outdoors. Playmates are important, so allow your child to experience playing with peers. This can be accomplished in a preschool, play group or just having another 2-year-olds over for a few hours. Do not expect sharing at this age. Limit television viewing. Do not use the TV as a baby sitter or as a substitute for interaction with your child. Watch children's programs with the child when possible. Turn the TV off during meals. Do not worry if your child becomes curious about body parts. This is normal at this age. It is best to use the correct terms for genitals.

Spend time teaching your child how to play. Encourage imaginative play and sharing of toys (but do not be surprised if the 2-year-old does not want to share his or her toys with anyone else). The 2-year-old may adopt a security object (such as a blanket, favorite stuffed toy, etc.) that he or she keeps with him or her most of the time. This is normal and the youngster will give it up when he or she is ready. Parents should continue to take some time for themselves. Show affection in the family. Keep family outings with a 2-year-old short and simple. The child this age has a short attention span and lengthy activities will cause the child to become irritable and tired. Allow any older siblings to have things he or she does not have to share with the 2-year-old. Many parents are beginning to plan for another child around this time. If you are, discuss with your pediatrician the best way to discuss the expected baby and the changes that will occur in the family.

siblings (who will speak for him or her) or if two languages are spoken in the house. Oral Health

Feeding

Check with your child's pediatrician concerning when and how often to see the dentist. The child will imitate a sibling or parent in the use of a toothbrush so take advantage of this to teach brushing. It is OK to use a small amount of fluoridated toothpaste. Second molars usually appear.

Discipline

Discipline is very important at this age. Do not waste your time and breath arguing or reasoning with a 2-yearold. Long speeches of explanation are completely useless. "Because I said so!" should be enough for now, but as they get older more explanations will be needed. Discipline should be firm and consistent, but loving and understanding. Praise your child for his or her good behavior and accomplishments. Encourage your 2-year-old to make choices whenever possible, but the choices should be limited to those you can live with ("red shirt or green shirt.") Never ask a 2year old an open question ("Do you want to take a bath") unless you are willing to accept the answer. Use the two "I's" of discipline (ignore or isolate) rather than the two "S's" (shouting or spanking). When disciplining, try to make a verbal separation between the child and the behavior ("I love you, but I do not like it when you touch the VCR.") Provide alternatives. If your 2-year old is playing with something you do not want him or her to have, replace it with another object or toy that your child enjoys. "No, you cannot play with the telephone, but you can play with these blocks." This avoids a fight and does not place children in a situation where they'll say "no." Avoid power struggles. No one wins! The 2-year-old still uses the temper tantrum as a weapon against parents. These occur when the child is angry, tired, frustrated or does not get his or her way. Again, handle temper tantrums with the two I's of discipline - ignore or isolate (time out!). Teach. Decide on a few rules (most of which have to do with the child's safety) and enforce them. Use time out immediately when rules are broken by placing the child alone for 2 minutes.

Sleep

The 2-year-old will eat barely enough to keep a bird alive. Appetite is finicky and will vary from meal to meal and day to day. The child is not doing much growing at this stage so he or she does not need much food to survive. Your child will only gain three or four pounds during this year. Do not expect three good meals a day. Family meals are important so let your 2-year-old eat with you to make him or her feel part of the family. Do not make mealtime a battle over food. Let you child's appetite be your guide and let him or her (within reason) choose what foods to eat. Never use food as a reward (for example, avoid saying "eat your meal and you will get dessert") The child can name foods and tell parents his or her likes and dislikes. The 2-year-old frequently wants the same thing day in and day out. No bottles! May change to 2% milk if approved by your pediatrician. Discuss a vitamin/fluoride supplement with your child's doctor. Continue to give fluoride supplementation if the water is lacking in fluoride. Make sure your child's caregiver is following your feeding instructions.

In general, an afternoon nap is still required by most 2year-olds. The child should sleep in his or her own bed if feasible. (Discuss the move from a crib to a regular bed with your child's doctor.) A 2-year-old's bedtime is usually between 7 p.m. and 8 p.m. Certain sleep problems are common during this time, including refusing to go to bed, getting out of bed and wandering around the house at night, and night terrors and nightmares. "Stalling techniques" are common at bed and nap time, such as "I have to go potty" to "I want a drink of water." A series of rituals works well to help your 2-year-old go to sleep. This is an excellent time to read a book to your youngster.

Development Toilet Training

Climbs up steps alone, one step at a time holding the stair rail or the parent's hand. Jumps off the floor with both feet. Opens doors. Kicks a ball. Can wash and dry hands. Climbs on furniture. Uses a spoon and cup well. Asks frequent questions: "What is that?" Enjoys imitating adult activities. Two year olds often go through a short period of mild speech abnormalities (like stuttering). Selects and uses a toy appropriately (feeds a doll, hammers pegs in a cobbler's bench). Most 2-year-olds have a vocabulary of 50 or more words, although this number varies with the sex of the child (girls speak more than boys), if the child has older

The term "toilet training" should be discarded since we do not actually "train" the child. The 2-year-old simply learns to control his or her urine and bowel movements when he or she is developmentally ready, just as the child learned to sit, walk and talk. Regardless of how hard you try, you cannot speed up your child's schedule and teach the youngster before he or she is ready. In fact, by over-training, you may delay the process by making your child tense and nervous, resulting in a rebellion. The last thing parents want to do is to make toilet training become a battle ground. Pick your battles, and this should not be one of them! If your child has a bowel movement at the same time every day, you may sit him or her on a little potty chair and "catch it." A favorable response from you sends a message to your child. If on the other hand, his or her bowel movement occur at irregular times during the day, watch for a characteristic expression and posture that

indicates a bowel movement. When this occurs, pick up your child and put him or her on the potty. If nothing happens in a few minutes, or if your child is alarmed in any way, take him or her off the potty. Your child's incentive to control bladder and bowel movements is to please you, the person he or she looks to for love. Therefore, praise your child's accomplishments and let him or her know you are pleased. When your child has an "accident," stay calm and don't punish. If you act distressed or angry when the child fails, training may be delayed. Signs of toilet learning readiness include awakening from a nap with a dry diaper, having bowel movements at the same time each day, being able to say "wee-wee" or "poopee", etc., knowing when he or she has to go, and being able to take off his or her own clothes. Remember, by pushing your child, scolding or being impatient, you will only delay the development of voluntary control, and possibly lay the groundwork for a real "toilet problem" in years to come.

The 2-year-old may continue to experience respiratory infections, such as colds, ear infections and sinus infections. Respiratory infections of this type are a normal part of growing up.

Safety

Continue to use proper car safety restraints in the back seat of every car trip. The greatest risk to your child's health is a motor vehicle accident. Remember, it is impossible for you to protect your child during an accident by just holding him or her. Always walk behind your car before backing out of the driveway. Beware of chewing or picking at old painted surfaces. Keep firearms out of the home or in a locked, out of sight container, unloaded. Pools must be gated. Knowing how to "swim" does not make a child water- safe at this age. Never leave a child unattended in a bathtub, even for a few seconds. Ensure the child wears a life vest if boating. Falls from kitchen cabinets and down stairs occur frequently at this age. Never leave a chair in such a position that your child can use it to climb to a dangerously high place. Be careful of items that can be left at counter level elsewhere, such as knives, scissors, cleaning agents, nail polish remover, household repair items, weed killers, insecticides, gasoline, oil, kerosene, lighter fluid and all medicines. Always keep potentially poisonous things in the items' original containers. Never put poisons in food containers or bottles. Be careful what you put in the waste basket ... 2-yearolds love to stick there hands in the trash. There is no such thing as a "child proof cap." Ingestion of toxic substances is common at this age. Never buy toys or other objects that can cut or be ingested. Suffocation by plastic bags and balloons occurs at this age. Always supervise when your child is playing near a street. Remember, a child at this age does not understand danger or remember "no"; they cannot count on being aware of the outside hazards. Be especially careful when using power lawn mowers and other power tools. Never leave a child unattended in a car or a house. Keep Syrup of Ipecac in the home to be used only as directed by your child's doctor or the poison control center. Keep the phone number of the poison control center near the telephone. Test smoke detectors to ensure they are working properly. If your home uses gas appliances, install and maintain carbon monoxide detectors. Continue to use a water proof sunscreen on your child before going outside. Avoid the hours between 10 a.m. and 3 p.m., when the sun is the most dangerous.

Growth Milestones - THREE YEARS "Goodbye Babyhood, Hello Childhood" While rearing a child at any age is no snap, things should get easier during the third year. Most 3-year-olds can be reasoned with. They will take turns and may even share toys. A child in this age group will help the parents get him or her dressed. Most are toilet trained during the day, although it is common for an occasional "accident" while busy playing. In previous generations, moms and dads learned what to expect of their child from their mother, grandmother or another family member. Today, most families are so scattered that parents do not have this help available. Therefore, do not hesitante to ask any questions you might have about your child's growth and development during the three year checkup. This is the reason for regular well-child exams. Parenting and Behavioral

The 3-year-old will ask more questions than a district attorney. Nothing is sacred and some questions will throw you for a loop! Continue reading books to your child. Arrange times for safe running and exploring outdoors. Playmates are important. Allow your child to experience interaction with peers. Three-year-olds are usually quite social and enjoy being with other 3-year-olds. This can be accomplished in a preschool, play group or just having another child over for a few hours. It is normal for children this age to have imaginary friends. Parents can sometimes use the youngster's imaginary "playmate" to their advantage (like getting your 3-year-old to do something you want them to do.) Limit television viewing. Do not use the TV as a baby sitter or as a substitute for interaction with your child. Watch children's programs with your child when possible. Do not worry if the child becomes curious about body parts. This is normal at this age. Always use the correct terms for genitals. Children this age begin to recognize gender differences and will correctly say "I am a girl" or "I am a boy."

Illnesses

Discipline should be firm and consistent, but loving and understanding. Praise your child for his or her good behavior and accomplishments. Three-year-olds like to do things for themselves. The 3-year-old does not understand "tongue-in-cheek" comments and can not always tell when a parent is joking. For example, never threaten to leave a child at the store when he or she misbehaves. Your child may continue to use a security object (such as a blanket, favorite stuffed toy, etc.). This is normal and the youngster will give up the item when he or she is ready. Keep family outings short and simple. Children have a short attention span at this age and lengthy activities will cause them to become irritable and tired. The question of preschool usually comes up now. Daycare has already been established for a family when both parents work outside the home. Even for moms who stay at home with their child, preschool a few mornings a week can be helpful. It gives mom a welcome break and provides the child an opportunity to meet new friends.The success or failure of preschool will depend upon the child's maturity and the quality of the preschool. For example, if your child seems anxious and dependent away from home, perhaps he or she is not ready for preschool. If you are expecting another baby, discuss with your child's physician how to prepare your 3-year-old.

Sleep

Appetite is perhaps a shade better than it was a few months ago, but it is still not what most parents (or grandparents) think it should be. "My child will not eat," is a familiar complaint heard at the three year checkup. Remember, feeding problems may arise if parents make their child eat more than the child needs to, or shows too much concern in what the youngster eats. The 3-year-old should pretty much be able to feed himself or herself. During meal time, the 3-year-old is sometimes very demanding of parent's attention and may also dawdle! Avoid nuts, hard candy, uncut grapes, hot dogs or raw vegetables. Control sweets and avoid junk food. Eat dinner together as a family whenever possible. Begin to teach proper table manners and encourage conversation during family meals. Turn the TV off during meals. Make sure your child's caregiver is following your feeding instructions.

An afternoon nap is usually still needed by the 3-year-old. Fears of the dark, thunder, lightning, etc. are quite common at this age. Maintain a consistent bedtime and bedtime routine. Using a night light, security blanket or toy are all ways to help lessen nighttime fears. Read to your child when possible before "lights out." Nightmares can wake a child up from sleep. The nightmares can be triggered by changes or stress. Reassure your child and put him or her back to bed.

Discipline

Encourage your 3-year-old to make choices whenever possible, but the choices should be limited to those you can live with ("red shirt or green shirt.") Never ask a toddler an open question ("Do you want to take a bath") unless you are willing to accept the answer. Use the two "I's" of discipline (ignore or isolate) rather than the two "S's" (shouting or spanking). When disciplining, try to separate the child and his or her behavior ("I love you, but I do not like it when you touch the VCR."). Provide alternatives. "No, you cannot play with the telephone, but you can play with these blocks." Avoid power struggles. No one wins! The 3-year-old still uses temper tantrums as a weapon. Respond to this behavior with the two I's of discipline - ignore or isolate (time out!). Discipline should be consistent. Do not make threats that you can not carry out. If you say you are going to do something, do it!

Toilet Training

Many 3-year-olds are trained during the day but still do not stay dry at night. Others are completely trained. Remember, the age a child uses the bathroom by himself or herself varies and it is based only on a child's readiness to be trained and the positive attitude of the parents. Avoid putting too many demands on the child or shaming him about wearing diapers. Instead, let your child no how proud and happy you are about any potty successes. Some children may postpone having a bowel movement as a way to manipulate their parents or because they are busy doing something else. Try not to make an issue of this.

Development

Can name pictures in a book. Names at least one color. Knows his or her own name, age and sex. Begins to use pronouns. Able to put on his or her own shirt, but will need help with shoes and buttons. May be able to ride a tricycle. Can jump in place and stand briefly on one foot. Can (unfortunately!) open doors. More than 50 percent of the child's speech is intelligible. There may be temporary episodes of stuttering during this time. Understands such words as "cold," "tired," "hungry." Comprehends the meaning of "on or under", and "bigger or smaller." Safety

Responsibility for accident prevention will gradually shift to your child as he or she grows older. It is still necessary for parents to keep dangerous and poisonous items out of their 3-yearold's reach and protect him or her from other indoor and outdoor hazards. Insist that your home and car be smoke free. Begin to teach your child his or her full name, address and phone number If bicycling, teach safety rules and insist on helmet use. Continue to use proper car safety restraints in the back seat of every car trip. A 3-4 year old child (once 40 lbs. or over) is safest using a belt-positioning booster seat. The greatest risk to your child's health continues to be motor vehicle accidents. Remember, it is impossible for you to protect your child during an accident by just holding him or her. Always walk behind your car before backing out of the driveway. If your home uses gas appliances, install and maintain carbon monoxide detectors. The purchase of a trampoline is not recommended because of the risk of serious injury. Keep firearms out of the home or in a locked, out of sight container, unloaded Pools must be gated. Knowing how to "swim" does not make a child water- safe at this age. Never leave a child unattended in a bathtub, even for a few seconds. Ensure your child wears a life vest if boating. Be careful of items that can be left a counter level elsewhere, such as knives, scissors, cleaning agents, nail polish remover, household repair items, weed killers, insecticides, gasoline, oil, kerosene, lighter fluid and all medicines. Always keep

Oral Health

Supervise brushing twice a day with a small amount of fluoridated toothpaste. Take your 3-year-old to the dentist, if you have not already done so. Limit juice and sweets. Continue giving a fluoride supplement if your drinking water is not fluoridated. Some dentists recommend fluoride be continued through age 8; others recommend continuing through age 12 or 16. Check with your pediatrician and dentist. Stop pacifier use

Feeding

Illnesses

potentially poisonous things in the original containers. Never put poisons in food containers or bottles. There is no such thing as a "child proof cap." Ingestion of toxic substances is common at this age. Keep syrup of Ipecac in the home to be used only as directed by your child's doctor or the poison control center. Never buy toys or other objects that can cut or ingested. Suffocation by plastic bags and balloons still occurs at this age. Always supervise when your child is playing near a street. Remember, a 3-year-old child does not understand danger or remembers "no"; your child cannot be counted on to be aware of outside hazards. Be especially careful when using power lawn mowers and other power tools. Never leave a child unattended in a car or a house. Test smoke detectors to ensure they are working properly. Continue to use a water proof sunscreen on your child before going outside. Avoid the hours between 10 a.m. and 3 p.m. when the sun is the most dangerous. Advise your 3-year-old to be careful around strange dogs, especially ones that are eating. Begin to teach your child not to talk to strangers.

Do not worry if your child becomes curious about body parts. This is normal at this age. Always use the correct terms for genitals. Modesty and a desire for privacy begin to emerge at this age. When your child starts to want privacy of his or her own, let your child know that you think this is good. Your child may continue to use a security object (such as a blanket, favorite stuffed toy, night light, etc.). This is normal and your youngster will give up the item when he or she is ready. If you are expecting another baby, discuss with your child's physician how to prepare your 4-year-old. Allow your child to participate in setting and cleaning up the table. Always praise him or her for a job well done. Provide some type of structured learning environment in preparation for kindergarten next year. Examples include preschool, Head Start or Sunday School. Show an interest in your child's preschool activities.

Discipline

Your 3-year-old may continue to experience respiratory infections, such as colds, ear infections and sinus infections. These frequent ailments often become frustrating for parents. Unfortunately, most illnesses are unavoidable, especially if your child is in preschool or has older siblings who bring the colds home from school. When your child is ill, the pediatrician will determine whether antibiotics are needed. Remember, most illnesses at this age are viral, which means antibiotics will not shorten the course of the illness

Discipline should be firm and consistent, but loving and understanding. Praise your child for his or her good behavior and accomplishments. Continue to allow your 4-year-old to make choices whenever possible but the choices should be limited to those you can live with ("red shirt or green shirt"). Never ask a 4-year-old an open question ("Do you want to take a bath") unless you are willing to accept the answer. Use the two "I's" of discipline (ignore or isolate) rather than the two "S's" (shouting or spanking). When disciplining, try to separate your child and his or her behavior ("I love you, but I do not like it when you touch the VCR.") Provide your 4-year-old with clearly stated limits along with an explanation of the consequences if rules are broken. Making children stand in the corner ("time out" by themselves for four minutes is usually an effective punishment. If you have any questions about your child's behavior, discuss them with the doctor. Meaningless threats are ineffective. Follow through with the previously stated consequences when rules are broken. Whenever possible, give reprimands privately. Always bear in mind the positive effects of praise.

Development

Growth Milestones - FOUR YEARS "Growing self-reliance" Can you believe that four years ago your child was born? Boy, "does time fly when you are having fun." Now you know why your parents used to say that you were growing up too fast. Ties to your apron strings will begin to loosen as the 4-year-old develops more independence and self-confidence. Before you know it, it will be time to start kindergarten. In previous generations, moms and dads learned what to expect of their child from their mother, grandmother or another family member. Today, most families are so scattered that parents do not have this help available. Therefore, do not hesitate to ask any questions you might have about your child's growth and development during the four year checkup. This is the reason for regular well-child exams. Parenting and Behavioral

Speech is almost always understandable. Can usually count from 1 to 10. Can walk on tiptoes, climb a ladder and ride a tricycle. May name and match three or four primary colors. Knows his or her own name. Correctly uses the pronoun "I." Children this age recognize gender differences and will correctly say "I am a girl" or "I am a boy." Can dress and undress with supervision but still has trouble with laces and buttons. Children this age also begin to be selective about what they wear. Holds and uses a pencil with good control. Can copy a cross, circle and possibly a square. Can to draw a person with a face, arms and legs. Engages in conversational "give-and-take." Can sing a song. Talks about his or her day's activities and experiences. Can identify emotions such as sadness, anger, anxiety and fear. Enjoys the companionship of other children; plays cooperatively and shows interest in other children's bodies.

The 4-year-old really enjoys playmates. At this stage the toddler will begin to play cooperatively with others. It is normal for children this age to have imaginary friends. Parents can sometimes use the youngster's imaginary "playmate" to their advantage (like getting your 4-year-old to do something you want him or her to do.) Limit television viewing to one hour per day. Do not use the TV as a baby sitter or it as a substitute for interaction with your child. Watch children's programs with your child when possible.

Oral Health

Supervise brushing twice a day with a small amount of fluoridated toothpaste. Take your 4-year-old to the dentist again this year and schedule re-checks as recommended by the dentist. If the child sucks his or her fingers or thumb, ask the dentist how to discourage these habits. Stop pacifier use.

Continue giving a fluoride supplement if your drinking water is not fluoridated. Some dentists recommend fluoride be continued through age 8; others recommend continuing through age 12 or 16. Check with your pediatrician and dentist. Learn how to prevent dental injuries and what to do in case of a dental emergency, especially the loss or fracture of a tooth.

Feeding

Sleep

The 4-year-old continues in a period of relatively slow growth. Average weight gain per year is only three to four pounds. Therefore, the appetite still is not what most parents (or grandparents) think it should be. Remember, feeding problems may arise if parents make their child eat more than he or she needs to, or show too much concern in what their child eats. Provide snacks rich in carbohydrates and limit high-fat, low nutrient foods. The 4-year-old can and usually insists on feeding himself or herself. Mealtime should be pleasant and food should never be forced. Provide nutritious foods and let your child decide what and how much to eat. Offer small portions with the availability of a second helping. The 4-year-old will often imitate peers in food likes and dislikes. Avoid nuts, hard candy, uncut grapes, hot dogs or raw vegetables. Control sweets and avoid junk food. Eat dinner together as a family whenever possible. Insist on good table manners and encourage pleasant conversation during meals. Turn the TV off during meals.

Illnesses

is higher than the back of the rear seat. The greatest risk to your child's health continues to be motor vehicle accidents. Remember, it is impossible for you to protect your child during an accident by just holding him or her. Set a good example by always using a seat belt when driving. Always walk behind your car before backing out of the driveway. Many 4-year-olds are fairly good "swimmers," but knowing how to "swim" does not make the youngster water safe. Never leave a child unattended in a bathtub, even for a few seconds. Ensure that your child wears a life vest if boating. There is no such thing as a "child proof cap." Ingestion of toxic substances is common at this age. Keep syrup of Ipecac in the home to be used only as directed by your child's doctor or the poison control center. Never buy toys or other objects that can be cut or ingested. Suffocation by plastic bags and balloons still occurs at this age. Be especially careful when using power lawn mowers and other power tools. Test smoke detectors to ensure they are working properly. Continue to use a water proof sunscreen on your child before he or she goes outside. If possible, avoid the hours between 10 a.m. and 3 p.m. when the sun is the most dangerous. Advise your 4-year-old to be careful around strange dogs, especially ones that are eating. Begin to teach your child not to talk to strangers or accept food from strangers. Teach your child the first and last names of family members. Teach your child pedestrian safety ("look both ways before crossing the street").

An afternoon nap may still be necessary. Fears of the dark, thunder, lightning, etc. are quite common at this age. Maintain a consistent bedtime and bedtime routine, using a night light, security blanket or toy are all ways to help lessen nighttime fears. Nightmares can wake a child up from sleep. They can be triggered by changes or stress. Reassure your child and put him or her back to bed.

The 4-year-old experiences less respiratory infections, such as colds, ear infections and sinus infections than the previous year. Begin to teach good habits: washing his or her hands after using the toilet, putting his or her hands in front of his or her mouth before coughing or sneezing, and washing his or her hands after coughing or sneezing. Remember, most illnesses at this age are viral, which means antibiotics will not shorten the course of the illness.

Toilet Training

Safety

By age 4, 95 percent of children are bowel trained. By age 4, 90 percent of children are dry in the daytime and 75 percent at night.

Your child continues to require close supervision. Accidents continue to be the principal cause of death in children in this age group. Know where your child is at all times. A 4-year-old is too young to be roaming the neighborhood alone. If your home uses gas appliances, install and maintain carbon monoxide detectors. The purchase of a trampoline is not recommended because of the risk of serious injury. Insist that your home and car be smoke free. Select toys that are safe. Electrical tools, firearms, matches and poisons should be locked up, out of reach. The child should not have unsupervised access to, or ride a bike in, the street. Some 4-year-olds can be taught their full name, address and phone number. If bicycling, teach safety rules and insist on helmet use. It is too ealy to expect your child to look both ways before crossing the street. Supervise all street crossings. Continue to use a car seat or booster seat secured properly until the child weighs at least 60 pounds or his or her head

Growth Milestones - FIVE YEARS "Leaving the Nest" Your 5-year-old is about to begin "real" school for the first time. Your child changes from a little one, protected by home, to a kindergartner, with the demands of a new school and new expectations. Children this age need approval, praise and encouragement. They want to please and are proud of their work. School Readiness Is my child ready for kindergarten? Should you send your child with a late summer or fall birthday to kindergarten, or should you wait another year? These are some of the questions parents of 5-yearolds ask themselves. Ideally, kindergarten should be ready for the child rather than getting the child ready for kindergarten. Use the following to see how well your child is doing in acquiring the skills found on most kindergarten checklists.

Good physical health, can see and hear well and visits the doctor and dentist regularly.

Has self-care skills (dressing, feeding, washing, manages bathroom needs). Follows directions and rules. Pays attention for short periods of time to adult-directed tasks. Able to work independently for short periods. Tolerates frustration and failure. Knows his or her full name as well as the name of his or her parents. Easily makes changes and accepts adult supervision and help. Able to play in small groups with other children. Begins to share with others. Listens to stories without interrupting. Recognizes rhyming sounds. Speaks clearly with age-appropriate language skills;Talks in complete sentences of five to six words. Understands that actions have both causes and effects. Shows understanding of general times of the day. Cuts with scissors. Holds crayon or marker; has a collection of paper, pencils, crayons. Separates from parents without being upset. Looks at pictures and then tells stories. Is able to recognize authority. Identifies some alphabet letters and most colors. Buttons shirts, pants, coats and zips up zippers. Begins to control himself or herself. Recognizes groups of one, two, three, four and five objects. Sorts similar objects by color, size and shape. Recognizes some common sight words like "stop." Counts to 10. Uses words like bigger, smaller or heaviest to show comparison. Rides a tricycle. Draws a picture of herself or himself including head, body, arms and legs. Knows her or his body parts. Understands concepts such as: in, out, under, on, off, front and back. Follows through when you give him or her one or two directions. Attempts to write his or her name.

Learn how to prevent dental injuries and what to do in case of a dental emergency, especially the loss or fracture of a tooth.

Feeding

Sleep

Appetite is usually much better at 5 as the child begins the second of three growth spurts. Continue to offer your child a selection from the basic food groups. Make meal time pleasant, turn off the TV and encourage conversation. Limit carbohydrate snacks like soft drinks, chips, candy and cookies. Instead, encourage healthy snacks, such as fruit and vegetables. Ensure your child eats a balanced breakfast and a nutritious lunch at school. Your child may enjoy helping to choose and prepare meals with supervision.

At this age expect an occasional nightmare or night terror. If the behavior become frequent, speak to your child's doctor about it. Sexuality

Safety

Now is the time to begin to teach your child the names of all body parts including genitals. Give your youngster a vocabulary to avoid unwanted touching. If this is a difficult subject for you to discuss, ask the help of your doctor or the child's teacher. Recognize that a child's sexual curiosity and exploration are normal.

Development

Skips, can walk on tiptoes and jumps forward. Throws a ball overhand. Washes and dries hands and brushes teeth unassisted. Can cut and paste. Can name four or five colors. Can state his or her age. Has a vocabulary of six to eight word sentences. Can tell a simple story. Can dress and undress without supervision. Knows his or her own phone number, address and several nursery rhymes. Can copy a triangle from a picture. Draws a person with a head, body, arms and legs. Understands right and wrong, fair and unfair. Understands games that have rules. Engages in make-believe and dress-up play, in which your child may assume a specific role ("mommy or daddy").

Continue to use a seat belt in the back seat of the car at all times. Teach your 5-year-old how to swim. Make sure all swimming pools in your area are secure. Always use sun screen when your child is outside playing or swimming. Keep your child's environment free of smoke. Conduct fire drills and make sure all smoke alarms are operating properly. Make sure any guns in the home are locked up and the ammunition is stored separately. A trigger lock is an additional precaution. And make sure these same safety precautions are followed at friends' homes. Never allow your child to handle firearms. Teach bicycle safety and make sure your child always wears an approved helmet as well as shoes while riding a bicycle. If your home uses gas appliances, install and maintain carbon monoxide detectors. The purchase of a trampoline is not recommended because of the risk of serious injury. Begin to teach your child rules for interacting with strangers, either on the phone or at the door. Never let your child play unsupervised outside.

Growth Milestones - 6 Years "The Big First Grader" Your child has changed from a little one, protected by home, to a first-grader who now must meet the demands and competition of school life. A 6-year-old is eager, active and likes to be on the go. A youngster this age is eager to act independently, but he or she is not yet able to consistently make wise decisions. A 6-year-old needs parental approval, understanding, praise and encouragement. When parents or school push too hard or expect too much, the child may become tense and nervous and develop physical symptoms such as stomach-ache, headache, fatigue and irritability.

Oral Health

Encourage teeth brushing twice a day with small amount of fluoride toothpaste. Continue to give fluoride supplements if not in the water supply. Continue seeing a dentist at least twice a year. Consider the use of dental sealants.

Parenting and Behavioral Parenting and Behavioral Adults play important roles in the life of children at age 6. Children will develop close relationships with teachers. It can be upsetting to a child when adults they love (including teachers) go through difficult times or changes. Establish rules to be followed at home with respect to: bedtime, TV watching, helping with chores such as setting the table, keeping their room neat. The TV can become a major pastime for the 6year-old. Don't let it. Television can be a positive resource if watched in small and controlled doses. Always watch TV with your child and explain the differences between reality and fantasy. Spend active time with your child on a daily basis if possible. Especially show interest in your child's daily school activities. At this age, an adult should be present at home (or other arrangements made for adult supervision) when the parents are absent. Praise and encourage the child's activities. Build the child's self-esteem. Show affection. If there are siblings, promote the individual strengths of each child. Promote activities outside the home. Remember that the goal of these activities is to have fun and develop oneself to the greatest capacity. Winning and losing should receive limited attention. Encourage reading. Read to your 6-year-old. Let him or her read to you. Read together. Your example will help reinforce that reading gives pleasure. If you haven't already done so, get a library card and use it.

As the child's permanent molars erupt, ensure that the dentist evaluates them for application of dental sealants.

Nutrition Your child may develop strong food preferences. A 6-year-old may refuse to eat some foods. This will gradually change as the youngster is exposed to different foods outside your home. Try not to use food as a reward for good behavior. Praise is better. Ensure that your child eats three regular meals and two nutritious snacks per day. Make mealtimes pleasant and companionable. Encourage conversation. Provide nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods. Model and encourage good eating habits. Serve a variety of healthy foods and avoid excessive junk food, especially those with "empty" calories such as soft drinks, chips, candy and cookies. Help your child learn to choose appropriate foods, including five servings of fruits and vegetables daily. Encourage your child to eat a balanced breakfast or ensure that the school provides one. Ensure that your child eats a nutritious lunch at school, either through the school lunch program or by packing a lunch. Good table manners take a long time to develop. Model good table manners for your child.

Sleep Ensure that your 6-year-old child gets adequate sleep. For children 6-10 years of age, the suggested bedtime is 8-9 p.m. Health Promotion Be a role model for your child by having a healthy lifestyle. Encourage regular physical activity. Limit television watching to an average of one hour per day of appropriate programs. Watch the programs together and discuss them. Reinforce with your child's personal care and hygiene. Discourage interest in tobacco products. Parents are very influential in teaching children to avoid tobacco. If a parent smokes, the parent should set a quit date and stop smoking. Modeling nonsmoking is a powerful example with important health consequences. Tell your child that smoking is related to the cause of death for 1 in every 5 people in the U.S.

Development Can bounce a ball 4-6 times; throws and catches. Skates. Can ride a bicycle. Can tie shoelaces. Can count up to 100, print first name, print numbers up to 10 and print a few letters. Knows right from left. Can draw a person with six body parts. Begins to learn some specific sports skills like batting a ball or kicking a soccer ball.

Oral Health Ensure that your child brushes his or her teeth twice a day with a pea-size amount of fluoridated toothpaste. Regularly supervise tooth brushing. Give your child fluoride supplements as recommended by the your youngster's physician based on the level of fluoride in your drinking water. Learn how to prevent dental injuries and handle dental emergencies, especially the loss or fracture of a tooth. Flossing the teeth before bedtime is recommended. If your child regularly sucks his or her fingers or thumb, begin to intervene gently to encourage discontinuation. Schedule a dental appointment for your child every six months, unless the dentist determines otherwise based on your child's individual needs/susceptibility to disease.

Safety Enforce consistent, explicit and firm rules for safe behavior. Continue to ensure that he or she wears a seat belt in the car at all times. Reinforce with your child the safety rules for swimming pools. Teach your child how to swim. Ensure that swimming pools in the child's community, in your apartment complex or at your home, have a four-sided fence with a self-closing, self-latching gate. Children should be supervised by an adult whenever they are in or near water.

Teach your child how to put on sunscreen before he or she goes outside to play or swim. Continue to keep your child's environment free of smoke. Test smoke detectors to ensure they work properly. Change batteries yearly. Reinforce with your child the safety rules for the home. Conduct fire drills at home. Lock up poisons, matches and electrical tools. Ensure that guns, if in the home, are locked up and ammunition is stored separately. A trigger lock is an additional important precaution. Reinforce with your child the safety rules for getting to and from school. Reinforce with your child pedestrian and neighborhood safety skills. Reinforce with your child the safety rules for bicycles, including use of proper traffic signals. Ensure that he or she always wears a helmet when riding a bicycle. Reinforce the importance of playground safety. Ensure that your child is supervised before and after school in a safe environment. Reinforce with your child the safety rules for interacting with strangers (e.g., answering the telephone or the door, never getting into a stranger's car). Ensure that your child's school curriculum includes information on how to deal with strangers. Teach him or her about sports safety, including the need to wear protective sports gear such as a mouth guard or a face protector.

accomplishment. Just remember to fit the job to the child's age. Examples of jobs for this age might be: empty the dishwasher, set the table and clean up after dinner, fold clothes and put them away, vacuum the car and dust furniture. The 8-year-old is looking outside the family for new ideas and activities. Peer groups become important and the child will identify with other youngsters of the same sex and with similar interests and activities. The child will often have a "best" friend - an important milestone in development. The growing influence of peers often presents a challenge to parents. As a parent, you must realize that your 8-year-old is beginning to value his or her peers' opinions as well as yours. But, at this age, parent opinion and values are still the strongest. Keep lines of communication open by not talking down to them, offering reasonable explanations and continuing to give praise and encouragement. Parenting and Behavioral

Sexuality Answer questions at a level appropriate to the child's understanding. Have age-appropriate sexual education books in the home that will answer some questions and encourage your child to ask others.

Tell your child every day that you love him or her. Always find words of praise that encourage schoolwork and friendship. Use more encouraging than discouraging words when speaking to your child. He or she needs to feel valued in the family and with friends. Provide personal space for your child at home, even if it's limited. Encourage your child to talk with you about school, friends or feelings. Answer his or her questions. Spend individual time with your child, doing something you both enjoy. Enhance your child's experiences through family trips. Help your child develop an ability to deal constructively with conflict and anger in the family, at school and in the neighborhood. Find good friends for your child. Promote interaction and allegiance with peers through participation in social activities, community groups and team sports. Help your child learn how to get along with his or her peers. Talk to your child about the enjoyable and difficult aspects of friendships. While parents should establish fair rules with respect to chores, TV watching, outside activities, homework, bedtime, etc., the number of rules should be kept to a minimum. The role of peers in the life of an 8-year-old increases, and children may resist adult authority at times. The TV can become a major pastime for the 8-year-old. Don't let it. Television can be a positive resource if watched in small and controlled doses. Always watch TV with your child and explain the differences between reality and fantasy. Ensure that an adult is present with your child (or make another appropriate arrangement) when you are not at home. Spend active time with your child on a daily basis, if possible. Especially show interest in your child's daily school activities. Understand the importance of serving as a parental role model. Praise and encourage your child's activities. Build his or her self-esteem. Show affection. If there are siblings, promote the individual strengths of each child. Encourage age-appropriate independence and selfresponsibility. Encourage reading. Read together. Your example will help reinforce that reading gives pleasure. If you haven't already done so, get a library card and use it.

Growth Milestones - 8 Years "Half-way Up the Stairs " The 8-year-old is growing slowly and steadily. You might say they are "half-way up the stairs." Eager, very active and friendly, an 8-year-old is quite mature in many ways; They know right from wrong. They are able to accept moderate responsibilities. They like to be a member of a group. They want a best friend. They want to do well. Around age 8, your child will enjoy helping with household chores. Having some simple jobs for your child to do is important. It helps to organize his or her time. It also lets the youngster feel a part of the family and gives him or her a sense of importance and

Development

Able to tell time. Can read for pleasure. Has a sense of humor ("do you know any good jokes? What's your favorite joke?"). Is concerned about rules - good (fair) vs. bad (unfair). Cares for herself, her room, and her belongings; can take responsibility for home chores. Has more control over small muscles, and therefore writes and draws with more skill. Likes to belong to informal "clubs" formed by children themselves.

Performs at grade level in all subjects (e.g., scores at the 40th percentile or better on school achievement tests)

Oral Health

smokes, the parent should set a quit date and stop smoking. Modeling nonsmoking is a powerful example with important health consequences. Tell your child that smoking is related to the cause of death for 1 in every 5 people in the U.S. Safety

Nutrition

Ensure that your child brushes his or her teeth twice a day with a pea-size amount of fluoridated toothpaste. Teach him or her how to floss. Give your child fluoride supplements as recommended by the health professional based on the level of fluoride in your drinking water. Schedule a dental appointment for him or her every six months, unless the dentist determines otherwise based on your child's individual needs/susceptibility to disease. As your child's permanent molars erupt, ensure that his or her dentist evaluates them for application of dental sealants. Teach your child how to handle dental emergencies, especially the loss or fracture of a tooth. Teach your child not to smoke or use smokeless tobacco.

Sleep

Growth in weight and height should remain steady. Report to your physician any rapid weight gain or if there has been no weight gain at all. Allow your child, with supervision, to choose and prepare family meals. This will help teach good food habits. Encourage your child to eat three regular meals per day and nutritious snacks. Share meals as a family on a regular basis. Make mealtimes pleasant and companionable. Encourage conversation. Model and encourage good eating habits. Serve a variety of healthy foods. Teach your child how to choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Teach your child how to eat a balanced diet. Teach her to choose plenty of fruits and vegetables; breads, cereals and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Teach your child how to eat a nutritious lunch at school, either through the school lunch program or by packing a balanced lunch. Children watch what their parents eat, so set a good example.

Ensure that your 6-year-old child gets adequate sleep. For children 6-10 years of age, the suggested bedtime is 8-9 p.m.

Exploring, experimenting and curiosity lead to accidents and injuries from firearms, falls, automobile accidents and drowning. Anticipate that your child may make errors in judgment because he or she is trying to imitate peers. Educate and reinforce the principles of safety especially since the 8-year-old is usually under less adult supervision. Continue to ensure that your child wears a seat belt in the car at all times. Make sure everyone in the car wears a seat belt. Reinforce safety rules for swimming pools. Teach your child how to swim. Ensure that swimming pools in your child's community, in the apartment complex or at home, have a four-sided fence with a self-closing, self-latching gate. Children should always be supervised by an adult whenever they are in or around water. Ensure that your child puts on sunscreen before he or she goes outside for long periods of time. Continue to keep the child's environment free of smoke. Test smoke detectors to ensure they work properly. Change batteries yearly. Reinforce with your child the safety rules for the home, including what to do when home alone. Discuss visitors, not tying up the telephone for long periods of time, and what to do in case of fire or other emergencies. Conduct fire drills at home. Lock up poisons, matches and electrical tools. Ensure that guns, if in the home, are locked up and ammunition is stored separately. Reinforce your child's knowledge of the neighborhood safety rules. Reinforce with your child the safety rules for bicycles, including use of proper traffic signals. Ensure your child always wears a helmet when riding a bicycle. Ensure that your child is supervised before and after school in a safe environment. Reinforce with your child the safety rules for interacting with strangers (e.g., answering the telephone or the door, never getting into a stranger's car). Ensure that your child's school curriculum includes information on how to deal with strangers. Reinforce sports safety with your child, including the need to wear protective sports gear such as a mouth guard or a face protector. Make sure windows are closed or have screens that can not be pushed out. Do not allow your child to play on a trampoline unsupervised.

Sexuality

Health Promotion

Have age-appropriate sexual education books in the home that will answer some questions and encourage your child to ask other questions. If your child receives family life education at school or in the community, discuss it with him or her. Answer questions at a level appropriate to your child's understanding. For parents of girls: Prepare your daughter for menstruation.

Be a role model for your child by having a healthy lifestyle. Supervise your children's play with their peers. Encourage regular physical activity. Limit television watching to an average of one hour per day of appropriate programs. Watch the programs together and discuss them. Reinforce with your child personal care and hygiene. Discourage interest in tobacco products. Parents are very influential in teaching children to avoid tobacco. If a parent

Growth Milestones - 10 Years "The Pre-Adolescent" This age has been called the beginning of pre-adolescence. Children begin to "spread out" as their rate of development accelerates. Some begin to grow rapidly and mature early. In every fifth grade room there will be one or two girls who are already menstruating. By the age of 10, children have informally

chosen the leader of their peer group, whether it is the child who plays baseball well, the one who can run fast or the one with new ideas for games. At the same time, those who fail to fit in are often reminded of their faults and pushed aside. 10 year olds have primarily same-sex friends. Friends assume greater importance, and the child's independence from the family is now obvious. This may be a relatively calm period for your child. Preadolescents are fairly easy to get along with. They are affectionate with both Mom and Dad. But, at the end of this age, you may begin to notice a change in mood. Get ready! You are about to enter adolescence. Parenting and Behavioral

Give your child fluoride supplements as recommended by the health professional based on the level of fluoride in your drinking water. Schedule a dental appointment for the child every six months, unless his dentist determines otherwise based on his individual needs/susceptibility to disease. As your child's permanent molars erupt, ensure that the dentist evaluates them for application of dental sealants. Reinforce with your child how to handle dental emergencies, especially the loss or fracture of a tooth. Reinforce with your child the dangers of smoking and smokeless tobacco.

The 10-year-old is very social. Even though family is important, your child will value his or her friends and their opinions very highly. Supporting and enhancing your child's self-esteem and self-confidence is critical during this period. Children who feel good about themselves are better equipped to withstand negative peer pressure. Parents need to spend time with their child, talk to him or her, and praise him or her for achievements made. Identify your child's strengths and always keep the lines of communication open. A possible conflict arises for parents when they misinterpret the child's alignment with peers. Parents can acknowledge their child's desire for independence by offering increasing responsibility. For example, parents may identify certain tasks as appropriate chores, while allowing the child to decide himself when to complete them. An allowance may also promote your child's growing sense of independence. No one likes to be different. If your 10-year-old is small and skinny and or does not come up to the shoulder of some of his or her classmates, reassure your child that there is nothing wrong and he or she soon will begin to grow. Children this age are usually industrious, helping with household tasks, pet responsibilities and small domestic projects. The 10-year-old enjoys being together. They play board games and cards or watch TV. Your child may want to join a club in your neighborhood or at school. He or she may enjoy an organized group such as scouts or a religious group. As a parent, you should support these kinds of activities in your child's community. School is very important in the life of a 10-year-old and school progress, achievements or problems can become a major issue. Learning problems may not become evident until the later elementary school years, as classroom expectations for performance increase. Some children are apprehensive about the transition into middle school. It is therefore important that parents monitor their child's school progress and keep in touch with teachers and school administrators.

Nutrition

Poor appetite is rarely a problem in this age period. In fact, the reverse is true, especially in girls. Encourage your child to eat three regular meals per day and nutritious snacks. It is especially important during this age period to evaluate your child's food consumption, along with the amount of exercise he or she is doing. Obesity is worrisome in this age. Studies have shown that children who weigh too much at this time are more likely to be overweight as adults. Share meals as a family on a regular basis. Make mealtimes pleasant and companionable. Encourage conversation. Model and encourage good eating habits. Serve a variety of healthy foods. Teach your child how to choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Teach your child how to eat a balanced diet. Teach him or her to choose plenty of fruits and vegetables; breads, cereals and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Teach your child how to eat a nutritious lunch at school, either through the school lunch program or by packing a balanced lunch.

Sleep Sleep problems are rare at this age, except for an occasional nightmare. With homework, TV and extra activities, many children are sleep-deficit. Children this age need nine to 10 hours of sleep per night. Sexuality

Development

Able to tell time. Can read for pleasure. Has a sense of humor ("do you know any good jokes? What's your favorite joke?"). Is concerned about rules - good (fair) vs. bad (unfair). Cares for himself/herself, his/her room and his/her belongings; can take responsibility for home chores. Has more control over small muscles, and therefore writes and draws with more skill. Likes to belong to informal "clubs" formed by children

Oral Health

Do not wait until your child is mature to let him or her in on some of the changes taking place in their classmates. You are wrong if you think a 10-year-old is still too young to talk about such things. An open dialogue with your child about puberty and sex can help ensure he or she learns facts within a framework of values that your family feels is important. If this is uncomfortable for you, ask the child's doctor for help and/or references. If the child receives family life education at school or in the community, discuss it with him or her. Provide additional information as needed. For parents of girls: Prepare your daughter for menstruation. For parents of boys: Prepare your son for wet dreams. Begin to teach the child that delaying sexual behavior is the surest form of protection against disease and pregnancy. Explore the child's understanding of sexually transmitted diseases, including AIDS.

Ensure that your child brushes his or her teeth twice a day with a pea-size amount of fluoridated toothpaste and flosses.

Safety Injury prevention should be stressed with the 10-year-old. Preadolescents may engage in dangerous risk-taking behaviors (e.g., dares, drinking, smoking) as a result of peer pressure. Some children are able to influence their peers to engage in

dangerous or illegal activities against their better judgment. If the peer group includes older children, the child may encounter pressure to perform acts and take risks for which he or she is not developmentally competent. Recognizing this possibility may help parents teach their children about dealing with negative peer pressure.

"Declaration of Independence" Nothing in life can prepare parents for the experiences they are about to have with their 12-year-old. What a roller-coaster life it will be for everyone. Your adolescent bounces between childhood and adulthood, being irresponsible and responsible, testing parental authority and then depending on it. Parents often do not know what to expect and many adults find it difficult to understand the adolescent's growing need for independent action, and even for rebellion. Most parents and their children get through it intact and much of what you hear and see in the media is greatly exaggerated. May parents look back and can chuckle. Parenting and Behavioral

Continue to teach your child that all firearms are unsafe and should be presumed loaded. Store all weapons unloaded in locked cabinets. Ammunition should be similarly locked but in a different location. Most firearm injuries occur in and about the home. Ask friends if they have a gun in the home. Teach your children the NEW rules of gun safety: Never touch a gun; Every Gun is Loaded; When in doubt, get out. Exploring, experimenting and curiosity lead to accidents and injuries from firearms, falls, automobile accidents and drowning. Anticipate that your child may make errors in judgment because he or she is trying to imitate peers. Educate and reinforce the principles of safety especially since the 10-year-old is usually under less adult supervision. Anticipate that your child may make errors in judgment due to increased risk-taking behavior. Anticipate providing less direct supervision. Continue to ensure that your child wears a seat belt in the car at all times. Reinforce with your child the safety rules for swimming pools. Teach your child how to swim. Ensure that your child puts on sunscreen before he or she goes outside for long periods of time. Continue to keep your child's environment free of smoke. Test smoke detectors to ensure they work properly. Change batteries yearly. Reinforce with your child the safety rules for the home, including what to do when home alone. Discuss visitors, not tying up the telephone for long periods of time and what to do in case of fire or other emergencies. Conduct fire drills at home. Reinforce safety rules for bicycles. Ensure that your child always wears a helmet when riding a bicycle. Reinforce sports safety with your child, including the need to wear protective sports gear such as a mouth guard or a face protector. Teach your child to avoid high noise levels, especially when using music headsets.

Health Promotion

Supervise your child's activities with peers. Be a role model for your child by having a healthy lifestyle. Ensure that your child gets adequate sleep. Encourage regular physical activity. Enforce reasonable television/music standards. Supervise your child's personal care and hygiene. Counsel your child about avoiding the use of alcohol, tobacco and drugs. Ensure that your child's school curriculum includes information about substance abuse.

Dramatic physical changes are the hallmark of early adolescence and these physical changes are important to your adolescent. They signify that he or she is developing like his or her peers. Generally, girls begin puberty an average of two years earlier than boys. During early adolescence, most girls experience a rapid growth spurt, changes in fat distribution, and the development of secondary sexual characteristics such as pubic hair and breasts. For most boys, the early adolescent period marks only the beginning of the biological changes of puberty, with increased abdominal fat deposits, testicular growth, voice changes and the development of acne, pubic hair and nocturnal emissions. Since many young adolescents are unaware that the onset and rate of puberty vary greatly, they need reassurance that their own growth and development are normal, and they will benefit from learning about the progression of physiological changes. Many young adolescents, preoccupied with their attractiveness, will try to change their appearance through dieting or consumer fad food products. Anorexia and bulimia may occur especially among females. Some males use supplements and steroids for bodybuilding. While some teens exercise regularly and develop bodies that are extremely fit, others remain sedentary and have poor physical fitness. These behaviors are often predictors of fitness habits later in life. Most 12-year-olds focus on social life, friends and school. They continue friendships with members of the same sex. Sometimes, a teenager's best friends becomes a parent substitute and confidante. These friendships, however, may change abruptly, causing hurt feelings. Teens need to learn to respect the rights and needs of others. They should follow family rules, such as those for curfews, television viewing, and chores, and share in household chores. Parents need to serve as a positive ethical and behavioral role model. School activities are important in the life of a 12-year-old adolescent. Social activities often center around sports events. Teens meet together in groups or pairs. Parents should learn the signs of adolescent depression and drug abuse!

Characteristics of "teen friendly" parents:

Growth Milestones - 12 Years

Understands the normal growth and development of adolescents. Praises, approves, supports and shows interest in their adolescent. Attends events in which their son or daughter is a participant. Encourages reasonable independence, friendships and interests outside of the home. Finds time to be with and listen to the adolescent. Establishes realistic expectations for family rules and enforces them, with increasing responsibility given to the adolescent. Establishes and communicates clear limits and consequences for breaking rules. Does not repeatedly warn or threaten. Simply follows the protocol already agreed upon and is consistent. Is present at home or makes arrangements for the adolescent's supervision in the parent's absence.

Assigns chores around the home and provides an allowance. Demonstrates interest in the adolescent's school activities and emphasizes the importance of school. Takes pleasure in their son's or daughter's abilities and achievements. Trusts the adolescent and understands what he or she is experiencing. Respects the adolescent's privacy. Does not criticize the other parent. A teen needs to love and respect both parents. Enhances the adolescent's self-esteem by providing praise and recognizing positive behavior and achievements. Minimizes criticism, nagging, derogatory comments and other belittling or demeaning messages. Does not try to be the teens best friend. Remembers that their role is to teach and parent. Shows respect for their teen. Listens to the adolescent's side without interrupting or judging. Gets to know their teen's friends, and avoids making quick judgments based on appearances only. Whenever possible, avoids downgrading his or her friends. Encourages their son or daughter to invite peers home. Allows their son or daughter to make age-appropriate decisions and selections (for example, choosing clothes). Involves their teen in decision making regarding their role in family chores, supervision of younger sibling, etc. Assumes a role in the teen's sex education, perhaps with the help of books recommended by the physician.

Your adolescent child should eat three meals per day. Breakfast is especially important. Do your best to make sure he or she has a nutritious breakfast daily. Choose a variety of healthy foods. Choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Choose plenty of fruits and vegetables; breads, cereals and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Include foods rich in calcium and iron in your child's diet. Girls may suffer anemia at this time so make sure they are receiving sufficient iron in their diet to replace menstrual losses. Select a nutritious meal from the school cafeteria or pack a balanced lunch. At this age it is especially important to evaluate your 12year old's food consumption in relation to the amount of exercise he or she does. Obesity can be a problem in 12- and 13-year-olds. Studies have shown that children who are overweight at this age group have a greater chance of being overweight as an adult. Achieve and maintain a healthy weight. Manage weight through appropriate eating habits and regular exercise

Sleep You may think that your 12-year old "sleeps" his or her life away (especially on weekends), but many children this age are actually sleep-deprived. Children this age need nine-10 hours of sleep per night. Lost sleep can not be made up later. Sexuality for the Adolescent

Traits of the adolescent who is doing well:

Believes that he or she will do well. Has self-confidence and a sense of pride and competence. Enjoys close interactions with peers (especially samesex friendships). Enjoys recreational activities. Recognizes the need for rules and fair play. Is energetic, enthusiastic and vital. Has reasonable athletic ability, or has dramatic, artistic or musical talents. Does well in school or performs at or near ability in school. Takes appropriate responsibility for homework with little prodding. Assumes responsibility for his or her own health. Is comfortable in asking parents questions. Generally cooperative and considerate, although at times is inconsistent and unpredictable.

Find a supportive adult who can give you accurate information about sex. Ask your doctor about any questions you have about body changes during puberty, including variations from individual to individual. Ask any questions you have about birth control or sexually transmitted diseases. Having sexual feelings is normal, but you should wait to have sex. Not having sexual intercourse is the safest way to prevent pregnancy and sexually transmitted diseases, including HIV infection/AIDS. Learn about ways to say no to sex.

Say "No" to substance use/abuse

Oral Health for the Adolescent

Brush your teeth twice a day with a pea-size amount of fluoridated toothpaste, and floss daily. Take fluoride supplements as recommended by the health professional based on the level of fluoride in your drinking water. Ask the health professional any questions you have about how to handle dental emergencies, especially the loss or fracture of a tooth. Schedule a dental appointment every six months, unless your dentist determines otherwise based on your adolescent's individual needs/susceptibility to disease. As your permanent molars erupt, ensure your dentist evaluates them for application of dental sealants. Do not smoke or use chewing tobacco.

Do not smoke, use smokeless tobacco, drink alcohol, or use drugs, diet pills or steroids. Do not become involved in selling drugs. If you smoke, discuss smoking cessation with the health professional. Avoid situations where drugs or alcohol are easily available. Support friends who choose not to use tobacco, alcohol, drugs, steroids, or diet pills. Become a peer counselor to prevent substance abuse.

Health Promotion

Get adequate sleep. Exercise vigorously at least three times per week. Encourage friends and family members to exercise. Discuss with a health professional or your coach about athletic conditioning, weight training, fluids and weight gain or loss. Limit television viewing to an average of one hour per day.

Nutrition for the Adolescent 12-year-olds seem to eat continuously and appetite rarely is a problem. Unfortunately, many 12- and 13-year-olds consume fast foods daily. They eat snacks that are high in calories and fat.

Growth Milestones - 14 Years "The Age of Rapid Changes" During middle adolescence, puberty is well underway, and is complete in many teenagers. There is a decreased preoccupation with the body and an increased involvement with peers. Parental conflicts develop over independence, since the peer group often serves as the adolescent's reference for their standards of behavior. This age is often called the neglected age of pediatrics, according to pediatrician William Crook, M.D. "It is 'no man's land' between childhood and adulthood." The maturing teen does not want to be treated like a child, and often balks at having to go to the "baby doctor" for checkups. Yet, at the same time, the adolescent does not want to go to a new adult physician who may be unfamiliar with issues important to this age group. The result is that often the youngster ends up going to neither. This is unfortunate since middle adolescence is a period of rapid development during which time checkups are important. This can be a difficult time for parents, who must cope with their adolescent while trying to keep the channel of communication open. Love your teen with no strings attached. Parents do best when they understand the normal characteristics of the middle teen years, otherwise known as the five "I"'s and six "M"'s (courtesy of the Parent and Child Guidance Center, Pittsburg, Pennsylvania) The five "I's"

Impulsive Intense Idealistic Immediate (wanting everything now) Industructable (thinking nothing can hurt them, they can not get pregnant, they will not get into an auto accident, etc.)

The six "M's":

Moody Messy Monosyllabic Mouthy Money-oriented

ME-centered. Parenting and Behavioral

sexual abilities. Will they be normal? Can they perform? How will others perceive them? Parents need to remember that the adolescent's interest in body changes and sexual topics is a natural, normal development and does not necessarily indicate movement into sexual activity. One must take care not to label emerging instinct/behaviors as "wrong," "sick" or "immoral." ." Nor should parents jump to conclusions about behaviors based soley on hunches or feelings. Increased emotionality is a hallmark of the period. Teens can be excessively modest, insecure and feel isolated and alone, as they discover the tenuousness of their peer relationships. Adolescents usually require privacy in which to contemplate changes taking place within their own bodies. Ideally the youth should be allowed to have his/her own room, but if this is not possible some private space needs to be made available so the teen can go and not be bothered by older or younger siblings or parents! Teasing an adolescent child about physical changes is inappropriate, because it may cause selfconsciousness and embarrassment. The teenager's quest for independence is normal development and need not be looked upon by the parent as rejection or a loss of control. Examples include (1) young teenagers may not want to join the family on all family outings; (2) Young teens may not want their parents around the school at social functions as chaperones; (3) Young teens may begin to confide in an adult outside the family rather than in mothers or fathers as in previous years. To be of most benefit to the growing adolescent, parents need to remain a constant and consistent figure, available as a sounding board for the youth's ideas without dominating and overtaking the emerging, independent identity of the young person. Most 14-year olds focus on social life, friends and school. They have chosen friendships with members of the same sex. Sometimes, a teenager's best friends becomes a parent substitute and confidante. These friendships, however, may change abruptly, causing hurt feelings. Teens need to learn to respect the rights and needs of others, follow family rules, such as those for curfews, television viewing, and chores. Share in household chores. Parents need to serve as a positive ethical and behavioral role model. Teach the adolescent techniques for resisting peer pressure. Parents should learn the signs of adolescent depression and drug abuse

Characteristics of the "teen friendly" parent:

Basic survival strategies for parents of adolescents are

1. Choose your battles carefully. Settle for something less than perfection on issues that don't really matter. Remain calm, and don't match his/her level of emotional intensity. 2. Be available to your adolescent without directing or controlling him/her. The time when they want you is often at teen's choosing, not yours. Be there if possible. 3. Help him/her regulate his/her lifeand consider alternatives. 4. Establish networks with parents of your teen's friends, even if they are new to you. 5. Let teens know they can always call you when in trouble, without fear of recrimination.

Parents should remember that adolescents can be especially worried about their bodies, diets and

Praises, approves, supports and shows interest in their adolescent. Attends events in which their son or daughter is a participant. Encourages reasonable independence, friendships and interests outside of the home. Finds time to be with and listen to the adolescent. Is a good ethical and behavorial model. Establishes realistic expectations for family rules, with increasing responsibility given to the adolescent. Establish and communicate clear limits and consequences for breaking rules. Does not repeatedly warn or threaten. Simply follows the protocol already agreed upon and is consistent. Is present at home or makes arrangements for the adolescent's supervision in their absence. Assigns chores around the home and provides an allowance. Demonstrate interest in the adolescent's school activities and emphasize the importance of school.

Takes pleasure in their son's or daughter's abilities and achievements Respects the adolescent's privacy - bedroom, bathroom, mail, phone calls. Enhances the teens self-esteem by providing praise and recognizing positive behavior and achievements. Minimizes criticism, nagging, derogatory comments, and other belittling or demeaning messages. Is not necessarily the teens best friend. Remembers that their role is to teach and parent Shows respect for their teen. Listens to their side without interrupting or judging. Gets to know their teen's friends, and avoids making quick judgments based on appearance only. Whenever possible, avoids downgrading their friends. Encourages their son or daughter to invite peers home. Allows their son or daughter to make age-appropriate decisions and selections (for example, choosing clothes). Involves their teen in decision making regarding their role in family chores, supervision of younger sibling, etc. Assumes a role in the teen's sex education, perhaps with the help of books recommended by the physician

Choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Choose plenty of fruits and vegetables; breads, cereals and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Include foods rich in calcium and iron in your diet. Girls may suffer anemia at this time so make sure they are receiving sufficient iron in their diet to replace menstrual losses. Select a nutritious meal from the school cafeteria or pack a balanced lunch. At this age it is especially important to evaluate your 14-year old's food consumption in relation to the amount of exercise they do. Obesity can be a problem in 14 and 15 year olds. Studies have shown that children who are overweight at this age group have a great chance of being overweight as an adult. Achieve and maintain a healthy weight. Manage weight through appropriate eating habits and regular exercise.

Nutrition for the Adolescent 14-year olds seem to eat continuously and appetite rarely is a problem. Unfortunately, many 14 and 15 year olds consume fast foods daily. They eat snacks that are high in calories and fat.

Traits of the adolescent who is doing well:

Is in good health or functions up to capacity if has a chronic condition; has good food habits. Believes he/she will do well. Has self-confidence and a sense of pride and competence. Enjoys close interactions with peers (especially same-sex friendships). Enjoys recreational activities. Recognizes the need for rules and fair play. Is energetic, enthusiastic and vital. Has reasonable athletic ability. Has dramatic, artistic or musical talents. Does well in school. Takes appropriate responsibility for homework with little prodding. Assumes responsibility for his/her own health. Is comfortable in asking parents questions. Generally cooperative and considerate, although at times is inconsistent and unpredictable

Oral Health for the Adolescent

Eat three meals per day. Breakfast is especially important. Do your best to make sure your 14-year old has a nutritious breakfast daily. Choose a variety of healthy foods. Choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Choose plenty of fruits and vegetables; breads, cereals and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Include foods rich in calcium and iron in your diet. Girls may suffer anemia at this time so make sure they are receiving sufficient iron in their diet to replace menstrual losses. Select a nutritious meal from the school cafeteria or pack a balanced lunch. At this age it is especially important to evaluate your 14-year old's food consumption in relation to the amount of exercise they do. Obesity can be a problem in 14 and 15 year olds. Studies have shown that children who are overweight at this age group have a great chance of being overweight as an adult. Achieve and maintain a healthy weight. Manage weight through appropriate eating habits and regular exercise.

Brushes teeth twice a day with a fluoridated toothpaste and flosses daily. Knows what to do in the cause of a dental emergency, especially the loss or fracture of a tooth. Has seen a dentist within the last six months unless your dentist determines otherwise based on his/her individual needs/susceptibility to disease Does not smoke or use chewing tobacco.

Sexuality for the Adolescent

Nutrition for the Adolescent 14-year olds seem to eat continuously and appetite rarely is a problem. Unfortunately, many 14 and 15 year olds consume fast foods daily. They eat snacks that are high in calories and fat.

Eat three meals per day. Breakfast is especially important. Do your best to make sure your 14-year old has a nutritious breakfast daily. Choose a variety of healthy foods.

Find a supportive adult who can give you accurate information about sex. Ask your doctor about any questions you have about body changes during puberty, including variations from individual to individual. Ask any questions you have about birth control or sexually transmitted diseases. Having sexual feelings is normal, but you should wait to have sex. Not having sexual intercourse is the safest way to prevent pregnancy. and sexually transmitted diseases, including HIV infection/AIDS. Learn about ways to say no to sex. If you have already said "yes," talk with your doctor about ways to prevent pregnancy and STDs. Pay attention to personal safety from physical or sexual assault (that is, do not accept rides from or hitchhike with strangers.

Growth Milestones - 16 years "Friends, Clothes, Music, and More!" By the age of 16, most girls have completed the changes associated with puberty and have menstrual periods, and most boys are well on their way to finishing pubertal development, having gained muscle mass and strength as well as secondary sexual characteristics. Questions about identity center on "Who am I?" as 16 year olds sort out values and beliefs in their quest for a clearer sense of self. As friends assume greater importance, 16 year olds spend less time with their families. Teens of this age are extremely sensitive to the social norms of the peer group, including choices in dress, hairstyle, vocabulary and music. They tend to have a small group of friends who share similar values and behaviors. As adolescents deal with issues of independence, they continue to test rules and question authority. Sixteen year olds often become extremely opinionated and challenging, which frequently results in family conflict, especially over issues such as dress, music and social etiquette. New activities such as driving and dating require negotiating additional family rules. When at home, adolescents often seek privacy in their rooms. Middle adolescents have reached the legal age to drive in most states, gaining a mobility that offers risks as well as new opportunities and choices. Shopping malls and fast food restaurants become popular adolescent gathering places. With their increasing mobility and independence, there is potential for exploration of risky behaviors. Substance use and sexual activity increase with each successive year of high school. By 12th grade, almost 87 percent of students have used alcohol, with 39 percent reporting at least one episode of heavy drinking the previous month. Slighly more than 40 percent of seniors report having used marijuana, and more than 8 percent report having used cocaine. By 12th grade, 30 percent of students report occasional use of tobacco, with almost 16 percent smoking frequently. Many regular smokers report some failed efforts to quit. Chewing or smokeless tobacco poses the risk of oral cancer. Alcohol and drugs are major factors in deaths among adolescents, contributing to motor vehicle crashes, homicides and suicides. Parenting and Behavioral Parents must remember that times are different from those they knew as teenagers. Your adolescent has many more and new obstacles to overcome than you did while still going through the same physical and emotional changes. This can be an extremely difficult time. Parents must learn to cope with their adolescent while trying to keep the channel of communication open. Love with no strings attached. You will find yourself growing in wisdom as you struggle with the issues that teenagers force parents to face. Basic survival strategies for parents of adolescents are: 1. Choose your battles carefully. Settle for something less than perfection on issues that don't really matter. Remain calm, and don't match your teenager's level of emotional intensity.

2. Be available to your adolescent without directing or controlling him or her. The time when he or she will want you is often at the teen's choosing, not yours. Be there if possible. 3. Help your teen regulate his or her lifeand consider alternatives. 4. Establish networks with parents of your teen's friends, even if they are new to you. 5. Let teens know they can always call you when in trouble, without fear of recrimination. (courtesy of the Parent and Child Guidance Center, Pittsburg, Pennsylvania) Feelings of sadness and depression should not be dismissed as "normal" moodiness during this period. Situational lossesincluding the death of a pet, problems with girlfriends or boyfriends, school failure and parental disappointmentcan lead to depression and even suicide. More than onefourth of high school students during the past year have thought seriously about committing suicide, and more than 8 percent have actually attempted it. Effective education in the areas of sex, contraceptives, drugs, alcohol and cigarettes is extremely important. The AIDS problem has increased the importance of educating your child. It is appropriate and important to express your own moral values about these subjects. But try to be flexible and open-minded. Let your child ask questions and express his or her feelings without fear of judgment or punishment. Remember, peer acceptance is extremely important to your adolescent. The group sets their standards for behavior and rejection can be devastating. Listen to your child when situations occur that separate him or her from the group. You do not necessarily have to offer advice. Although it is often difficult, learn to adjust to the variations in hair and clothing. Try your best to be flexible. Adolescents usually require privacy in which to contemplate changes taking place within their own bodies. Ideally the youth should be allowed to have his or her own room, but if this is not possible some private space needs to be made available so the teen can go and not be bothered by older or younger siblings or parents! The teenager's quest for independence is a normal development and need not be looked upon by the parent as rejection or a loss of control. Examples include (1) young teenagers may not want to join the family on all family outings; (2) Young teens may not want their parents around the school at social functions as chaperones; (3) Young teens may begin to confide in an adult outside the family rather than in mothers or fathers as in previous years. To be of most benefit to the growing adolescent, parents need to remain a constant and consistent figure, available as a sounding board for the youth's ideas without dominating and overtaking the emerging, independent identity of the young person. Teens need to learn to respect the rights and needs of others. They should follow family rules, such as those for curfews, television viewing and chores, and share in household chores. Parents need to serve as a positive ethical and behavioral role model. Teach your teen techniques for resisting peer pressure. Discuss with your adolescent possible contingency plans in the event that a car trip is necessary and the adolescent (or the person who is driving) is drunk or has taken drugs.

Parents should learn the signs of adolescent depression and drug abuse!

Takes appropriate responsibility for homework with little prodding. Assumes responsibility for his or her own health. Is comfortable in asking parents questions. Generally cooperative and considerate, although at times is inconsistent and unpredictable.

Characteristics of the "Teen Friendly" Parents: Praises, approves, supports and shows interest in their adolescent. Attends events in which their son or daughter is a participant. Encourages reasonable independence, friendships and interests outside of the home. Finds time to be with and listen to their adolescent. Establishes realistic expectations for family rules, with increasing responsibility given to the adolescent. Establishes and communicates clear limits and consequences for breaking rules. Does not repeatedly warn or threaten. Simply follows the protocol already agreed upon and is consistent. Assigns chores around the home and provides an allowance. Demonstrates an interest in the adolescent's school activities and emphasizes the importance of school. Takes pleasure in their son's or daughter's abilities and achievements. Respects the adolescent's privacy - bedroom, bathroom, mail, phone calls. Enhances the teens self-esteem by providing praise and recognizing positive behavior and achievements. Minimizes criticism, nagging, derogatory comments and other belittling or demeaning messages. Is not necessarily the teens best friend. Remembers that their role is to teach and parent. Shows respect for their teen. Listens to his or her side without interrupting or judging. Gets to know their teen's friends, and avoids making quick judgments based on appearances only.. Whenever possible, avoids downgrading their teen's friends. Encourages their son or daughter to invite peers home. Allows their son or daughter to make ageappropriate decisions and selections (for example, choosing clothes). Involves their teen in decision making regarding their role in family chores, supervision of younger sibling, etc. Assumes a role in the teen's sex education, perhaps with the help of books recommended by the physician. Oral Health for the Adolescent Brushes teeth twice a day with a pea-size amount of fluoridated toothpaste and flosses daily. Takes fluoride supplements as recommended by the health professional based on the level of fluoride in your drinking water. Knows how to handle dental emergencies, especially the loss or fracture of a tooth. Has seen a dentist within the last six months, unless your dentist determines otherwise based on his or her individual needs/susceptibility to disease. Does not smoke or use chewing tobacco.

Nutrition for the Adolescent 16-year olds seem to eat continuously! But many eat an inadequate diet, and others are always on a diet. Many teens, especially females, are obsessed with physical appearance. Crash and fad dieting are common responses to the obsession with self-image. As a result, some teens become too thin. Like being overweight, eating disorders such as bulimia or anorexia are common during adolescence. Make sure your teenager eats three meals per day. Breakfast is especially important. Meals should be eaten with the family or residential group on a regular basis. Choose and prepare a variety of healthy foods. Choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Choose plenty of fruits and vegetables; breads, cereals, and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Include foods rich in calcium and iron in the diet. Select a nutritious meal from the school cafeteria or pack a balanced lunch. Your teen should achieve and maintain a healthy weight. Weight can be managed through appropriate eating habits and regular exercise. It's a good idea for your teen to avoid "empty" calories such as soft drinks, chips, candy and cookies. Many girls develop anemia during this time. They need sufficient iron in their diet to replace menstrual loss.

Traits of the Adolescent Who Is Doing Well: Is in good health and has good food habits. Believes that he or she will do well. Has self-confidence and a sense of pride and competence. Enjoys close interactions with peers (especially same-sex friendships). Enjoys recreational activities. Recognizes the need for rules and fair play. Is energetic, enthusiastic and vital. Has reasonable athletic ability. Has dramatic, artistic or musical talents. Does well in school. Sleep

You may think your 16-year-old "sleeps" his or her life away (especially on weekends), but many children this age are actually sleep-deprived. Children this age need nine10 hours of sleep per night. Lost sleep can not be made up later. Sexuality for the Adolescent Identify a supportive adult who can give you accurate information about sex.

Get accurate information about birth control and sexually transmitted diseases and learn to recognize the signs. Having sexual feelings is normal, but having sex should be a well thought out decision. Do not have sex if you do not want to. Not having sexual intercourse is the safest way to prevent pregnancy and sexually transmitted diseases, including HIV infection/AIDS. Learn about ways to say "no" to sex. If you are engaging in sexual activity, including intercourse, ask the health professional for an examination and discuss methods of birth control. Learn about safer sex. Practice safer sex. Limit the number of partners, and use latex condoms and other barriers correctly. If you are confused or concerned about your sexual feelings (for the same sex or opposite sex), talk to a trusted adult or a health professional.

Get adequate sleep. Exercise vigorously at least three times per week. Encourage friends and family members to exercise. Discuss with your health professional or coach about athletic conditioning, weight training, fluids and weight gain or loss. Limit television viewing to an average of one hour per day.

Growth Milestones - 18 Years "Leaving the Nest" At the age of 18, adolescents begin to recognize that parents can be their best friends. This is the time when parents can help their son or daughter more by being a good sounding board for them rather than making their decisions. As Mark Twain once noted, "18 year olds are sometimes amazed at how much their parents have grown on so little knowledge and how much they have learned in the past few years!" The peer group becomes less important to the late adolescent and is replaced by a few good friends. The young adult's interests now focuses on education or a vocational future. He or she attempts to answer the question frequently asked when he or she was younger: ".......and what do you want to be when you grow up?" The unrealistic fantasies of early adolescence are now replaced by more realistic educational and vocational plans. The mature adolescent is able to understand his or her strengths and applies them to a potential career. Separation from parents is a necessary part of growing up. We expect children to become independent adults. This independence does not mean there cannot be close family relationships, but this relationship should be based on mutual respect. In other words, parents need to recognize that their child has grown up and has come to terms with their sense of loss as the child "leaves the nest." Parenting and Behavioral

Say "No" to Substance Use/Abuse Do not smoke, use smokeless tobacco, drink alcohol, or use drugs, diet pills or steroids. Do not become involved in selling drugs. If you smoke, find out about smoking cessation programs. If you use drugs or alcohol, ask for help (e.g., a substance abuse treatment program). Avoid situations where drugs or alcohol are easily available. Support your friends who choose not to use tobacco, alcohol, drugs, steroids or diet pills. Become a peer counselor to prevent substance abuse.

Safety Advice for the Adolescent Wear a seat belt while driving or riding in the car. If you are driving, insist that your passengers wear seat belts. Follow the speed limit. Learn how to swim. Do not drink alcohol, especially while driving, boating or swimming. Plan to have a designated driver if drinking. Protect yourself from skin cancer by putting sunscreen on before you go outside for long periods of time. Avoid tanning salons. Test smoke detectors in your home to ensure they work properly. Change batteries yearly. Always wear a helmet when on a motorcycle, in an all-terrain vehicle or riding a bicycle. Even with a helmet, motorcycles and ATVs are very dangerous. Wear protective sports gear such as a mouth guard or a face protector. Wear appropriate protective gear at work and follow job safety procedures. Avoid high noise levels, especially in music headsets. Do not carry or use a weapon of any kind. Develop skills in conflict resolution, negotiation and dealing with anger constructively. Learn techniques to protect yourself from physical, emotional and sexual abuse, including rape by strangers or acquaintances. Seek help if you are physically or sexually abused or fear you are in danger.

Health Promotion

The role of parents during this phase in their child's development should be one of support. Parents will usually find that their teenager has a better relationship with them now than he or she did in the early teen years. The adolescent may even seek out your advice! The most common mistake most parents make at this age is being overprotective. Many parents feel their young person will make a serious mistake with career choice or spouse selection. Parents should resist the impulse to make choices for their son or daughter and allow the youngster to come to that conclusion on his or her own. This is mostly true concerning spouse selection when many parents feel their young person has chosen a spouse who would not be right for him or her. In many cases, parents are correct, but it will do no good to impose that feeling upon your adolescent. Your young adult will interpret this as being unjust or unfair, and will push him or her further into the disliked relationship. Late adolescence is less of a struggle between parent and child than it was in earlier years. By the end of this period, most parents will find they like and enjoy their offspring as an emerging young adult. As older adolescents become more comfortable with themselves and their emotional independence, their relationships with family members become more accepting and harmonious. Most 18 year olds have decided whether they will go on to college, join the work force or enter the military. While late adolescence should be a time of choice it can also bring intense frustration to youth with restricted options. Those who have not concentrated on academic performance now confront severely curtailed choices. High unemployment rates among youthespecially those who are unskilled or belong to minority groups underscore the fact that vocational options are limited.

This harsh reality diminishes the young persons sense of hope for the future unless some positive intervention is offered. Establish realistic expectations for family rules, with increasing autonomy and responsibility given to the adolescent. Enhance the adolescents self-esteem by providing praise and recognizing positive behavior and achievements. Minimize criticism, nagging, derogatory comments, and other belittling or demeaning messages. Spend time with your adolescent. Respect your adolescents need for privacy. Teach your young adult techniques for resisting peer pressure. Discuss with the adolescent possible contingency plans in the event that a car trip is necessary and the person who is driving is drunk or has taken drugs. Parents should learn the signs of adolescent depression: o Making statements like "I want to die" or "I feel dead inside." o Previous suicide attempts. o Abuse of alcohol or drugs. o Giving away prized possessions, writing a will or making other "final" arrangements. o Preoccupation with themes of death or expression of suicidal thoughts. o Changes in sleeping patterns (too much or too little), withdrawal from friends or family, or other major behavioral changes. o Changes in school performance (lower grades, cutting classes, dropping out of activities). o Frequent complaints of physical symptoms such as stomachaches, headaches or fatigue. o Sudden and extreme changes in eating habits, or loss or gain of unusual amounts of weight. o Sudden cheerfulness after a prolonged period of depression.

Physically inactive. Anxious or fearful; displays aggressive or acting out behavior (lying, defiance, stealing, temper, vandalism, animal cruelty). Compulsive behaviors, fears, depression and without initiative. Has no marketable skills and cannot find or keep a job. Has no life goals. Is overly dependent on parents.

Life Style Issues

Traits of the Adolescent Who may be Expected to do Well:

Is in good health and has good food habits.SMALL> Believes he or she will do well. Has self-confidence and a sense of pride and competence. Enjoys close interactions with peers of both sexes. Takes advantage of recreational outlets. Recognizes the need for rules and fair play. Is energetic, enthusiastic and idealistic. Has plans for the future and has identified some life goals. Recognizes the consequences of his or her actions. Feels responsible for his or her health. Generally cooperative, understanding and considerate of parents. Has dramatic, artistic or musical talents. Does well in school and/or work. Takes appropriate responsibility for homework with little prodding. Is comfortable in asking parents questions. Generally cooperative and considerate, although at times is inconsistent and unpredictable. Has experienced an intimate relationship and has a firm self-identity.

Youth 1824 years of age are the most infrequent users of health care services. They are also the age group most likely to be uninsured. Many are no longer covered by their parents insurance plan, and those who work often have entry-level jobs that offer no health insurance benefits. Emphasize to your adolescent the importance of exercise. On the other hand, the dangers of overexercise should also be explained. The older adolescent is usually more receptive to information regarding good nutrition. Preaching to adolescence is generally ineffective, but supplying him or her with good factual information about nutrition and being a good role model are worthwhile. Maintains an appropriate weight. Brushes and flosses teeth regularly. Practices routine dental care. Is familiar and does self-examination of breasts and testes. Drives responsibly by always wearing a seat belt and shoulder harness, drives defensively, never drives when drinking or under the influence of drugs or when angry. Never rides in a car whose driver (including parent) has been drinking. Alcohol and Smoking- Older adolescents who live away from home may need to be reminded about the dangers of smoking and drinking. Those adolescents who have chosen not to begin smoking should be constantly commended for their decision and reminded that being in a room with others who smoke is harmful to their lungs. Mental Health: Take on new challenges that will increase your self-confidence. Continue to develop your sense of identity, clarifying your values and beliefs. Accept who you are and enjoy both the adult and the child. Trust your own feelings as well as feedback from friends and adults. Seek help if you often feel angry, depressed or hopeless. Learn how to deal with stress. Set reasonable but challenging goals. Understand the importance of your spiritual and religious needs and try to fulfill them.

Nutrition for the Adolescent

Traits of an Adolescent to be Concerned About:

Has a low self-esteem or lack of friends. Does not communicate well with parents. Does poorly in school or has dropped out of school. Extremely worried to the point of panic concerning what he or she is going to do with his or her life. Delinquent behavior and has been in trouble with the law.

Eat three meals per day. Breakfast is especially important. Eat meals with your family or residential group on a regular basis. Choose and prepare a variety of healthy foods. Choose nutritious snacks rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages such as candy, chips or soft drinks. Choose plenty of fruits and vegetables; breads, cereals, and other grain products; low-fat dairy products; lean meats; and foods prepared with little or no fat. Include foods rich in calcium and iron in your diet. Select a nutritious meal from the school cafeteria or pack a balanced lunch. Achieve and maintain a healthy weight. Manage weight through appropriate eating habits and regular exercise.


Sleep

Many girls develop anemia during this time. They need sufficient iron in their diet to replace menstrual loss.

You may think that your 18-year- old "sleeps" his or her life away (especially on weekends), but many youngsters this age are actually sleep-deprived. Adolescents this age need 9-10 hours of sleep per night. Sexuality for the Late Adolescent

Educate yourself about birth control, sexually transmitted diseases, gay and lesbian issues, celibacy and other issues related to sexuality. Having sexual intercourse should be a well thought out decision. Do not have sex if you do not want to. Not having sexual intercourse is the safest way to prevent pregnancy and sexually transmitted diseases, including HIV infection/AIDS. Learn about ways to say "no" to sex. If you are engaging in sexual activity, including intercourse, ask the health professional for an examination and discuss methods of birth control. Learn about ways to negotiate safer sex and to share your feelings about sexuality with your partner. Practice safer sex. Limit the number of partners and use latex condoms and other barriers correctly. If you are confused or concerned about your sexual feelings (for the same sex or opposite sex), talk to a trusted adult or the health professional.

Say "No" to Substance Use/Abuse

Do not smoke, use smokeless tobacco, drink alcohol, or use drugs, diet pills or steroids. Do not become involved in selling drugs. If you smoke, find out about smoking cessation programs. If you use drugs or alcohol, ask for help (e.g., a substance abuse treatment program). Support your friends who choose not to use tobacco, alcohol, drugs, steroids or diet pills. Become a peer counselor to prevent substance abuse.

Safety Advice for the Late Adolescent

Wear a seat belt while driving or riding in the car. If you are driving, insist that your passengers wear seat belts. Follow the speed limit. Learn how to swim. Do not drink alcohol, especially while driving, boating or swimming. Plan to have a designated driver if drinking. Protect yourself from skin cancer by putting sunscreen on before you go outside for long periods of time. Avoid tanning salons. Test smoke detectors in your home to ensure they work properly. Change batteries yearly. Always wear a helmet when on a motorcycle, in an allterrain vehicle, or riding a bicycle. Even with a helmet, motorcycles and ATVs are very dangerous. Wear protective sports gear such as a mouth guard or a face protector. Wear appropriate protective gear at work and follow job safety procedures. Avoid high noise levels, especially in music headsets. Do not carry or use a weapon of any kind. Develop skills in conflict resolution, negotiation and dealing with anger constructively. Learn techniques to protect yourself from physical, emotional and sexual abuse, including rape by strangers or acquaintances. Seek help if you are physically or sexually abused or fear that you are in danger.