NG-381

🧩 Play, toilet training, teeth & immunizations

The everyday teaching questions — and the four kinds of play, which get asked about far more than they deserve.

🧩 The four kinds of play

🧠 Two toddlers in the same sandpit ignoring each other is parallel play, and it is normal. Parents often worry it is antisocial — it is not.

In the hospital: therapeutic play lets a child act out what is happening to them. A preschooler giving an injection to a doll is doing real work.

🚽 Toilet training

Usually somewhere between 18 and 24 months — but the age is not the point. Readiness is the point, and all three kinds have to be there.

Kind	What it looks like
Physical	Stays dry about 2 hours; walks to the toilet; can pull pants down
Cognitive	Recognizes the urge and can tell you about it; follows a simple instruction
Emotional	Wants to please; imitates; is not in the middle of a big upheaval

Bowel control comes before bladder. Daytime before night.
Night dryness can take until 4 or 5 and is not a problem before then.
Short sits, praise the sitting rather than the result, and never punish an accident.
Regression during illness, hospital stays or a new baby is expected. Say so before it happens.

🦷 Teeth

When	What
Before any teeth	Wipe the gums with a clean damp cloth after feeds
~6 months	First tooth — usually a lower central incisor
By 12 months, or 6 months after the first tooth	First dental visit
~30 months	All 20 primary teeth are usually in
6–7 years	Primary teeth start being lost; first permanent molars arrive

Never put a baby to bed with a bottle of milk, formula or juice. Pooled sugar against the teeth all night causes early childhood caries.

Brushing: a smear of fluoride toothpaste under 3, a pea-sized amount from 3. An adult brushes or supervises until about 7 or 8, because that is when the hand skill is good enough.

💉 Immunizations — types first, dates second

Knowing which vaccines are live is worth more marks than memorizing the calendar, because that is what changes the nursing action.

LIVE — handle with care	NOT live
MMR	DTaP / Tdap
Varicella	IPV (polio)
Rotavirus (oral)	Hepatitis A and B
Intranasal influenza	Hib, pneumococcal, meningococcal, HPV, injectable influenza

Live vaccines are avoided in pregnancy and in significant immunosuppression.
Two live vaccines go on the same day, or at least 4 weeks apart.
Rotavirus is oral and has an age ceiling — it is not started late.

✅ Not a reason to postpone

A mild illness, with or without a low fever
Currently on antibiotics
Prematurity — give by chronological age, not corrected age
Breastfeeding
A family history of reactions

🚨 Genuine contraindications

Anaphylaxis to a previous dose or a component
A live vaccine in pregnancy or serious immunosuppression
Encephalopathy within 7 days of a pertussis-containing vaccine
A moderate or severe acute illness — wait until it settles

📋 The schedule, in landmarks

Age	Usually given
Birth	Hepatitis B
2, 4, 6 months	DTaP, IPV, Hib, pneumococcal, rotavirus, hepatitis B
12–15 months	MMR and varicella — the first live ones — plus Hib and pneumococcal boosters, hepatitis A
4–6 years	DTaP, IPV, MMR and varicella second doses — the school-entry set
11–12 years	Tdap, HPV, meningococcal
Every year from 6 months	Influenza

Schedules are revised, so check the current published schedule before teaching a specific family — these are the landmarks to recognize, not a substitute for it.

🧹 Giving the injection

Age	Site
Infant / toddler	Vastus lateralis — the biggest muscle they have
From about 3 years, once walking well	Deltoid may be used
Never in a child	Dorsogluteal — sciatic nerve risk

Comfort: give the most painful last, hold the child upright against a parent, and let an infant feed or take sucrose. Say “this will pinch” — never “it will not hurt”.

READINESS→ TEACHING→ PROTECTION

NG-381 · Pediatrics unit · ADHD-friendly visual edition