Mike Smith, MD (Host): Welcome to Meaningful Medicine, the Novant Health Podcast dedicated to providing you access to leading doctors who answer questions they wish you would ask. I'm Dr. Mike, and joining me today is Dr. Ryan Aubuchon, a Pediatrician with Novant Health. In this episode, we're going to be diving into everything you need to know about your child's development from 18 months to three years, and we're calling this, Is This Normal? I love that title. Hey, thanks for joining me, Dr. Aubuchon. I appreciate it.

Dr. Ryan Aubuchon: Hey Mike. Thanks for having me on the pod. That's what we call these, right? The pod?

Host: The, the pod. Sounds great. The pod. I'm excited about this one because I know, I have some young nieces and nephews who are becoming parents, and they got kids in this age group and they're all nervous. I love the title of Is This Normal. So let's just start off with what are those key milestones we should be looking for in this age group?

Dr. Ryan Aubuchon: This is one of the joys of my job and getting to witness human development firsthand is like watching magic happen, live. And, it's a real joy. In this age range, from 18 months to three years, children change so fast. I mean, the first year or so they change fast, but it's almost warp speed, in this stage.

And, generally speaking, children will be able to walk independently by 18 months, pretty well, move pretty fast, so parents will be chasing them around. They're usually able to gain a lot of words and be able to communicate pretty effectively with their family. And so by two years of age, they're usually saying a lot of words.

And they are usually just interacting more with the world around them, doing lots of new things. They have a lot of visits in the first three years of life, and so we get to check in with their development just to make sure children are kind of progressing as they should.

Host: So a lot of those milestones though, you mentioned walking, talking, that kind of stuff. Even let's say potty training, something that parents do. I was a parent. I did this is you kind of, you compare your child to other children, right? The neighbor's 18 month, they're already walking and ours is barely. How much variability is allowed in these milestones?

Dr. Ryan Aubuchon: There's a lot of variability and I tell parents, it's impossible to not compare your child to other children. Whether it's your own other children, your other daughter or your other son, or a niece or nephew. We want to make sure that our child is developing like they're supposed to.

And so that's a big part of our job is that we can have parents kind of think about what's been happening in the last, three months, six months. And so, there is a lot of variability and so, we also offer developmental screenings at all the wellness visits to be sure that a child is moving through the milestones, but not everything's black and white. There's a lot of gray. And so, since we get to visit so frequently and we develop this relationship, we can talk with families about if we feel like this is maybe a child's a little bit behind, but they're not too far behind. And so we can see how, the next little interval goes to see if they're, they're making gains.

I mean, one, rule of thumb, at least for gross motor development, just be an example would be like if a child's not walking by 18 months, they should be evaluated and they probably need to see a, a pediatric physical therapist. So.

Host: And that's why follow up appointments with pediatricians like yourself are so important, right? Because you're gonna catch when there may be is an issue, when a parent may not. So follow up has to be key, right?

Dr. Ryan Aubuchon: Yeah, that's, it is really important. And I will say, I tell, I mean parents, they are the proxy for their children. And so, they usually know if something's, off. And that's an advantage for me in my work. And so if a parent's concerned, I want to know what they're concerned about.

 So any parent should know that, especially first time parents. It's, it's very daunting entering into being a parent. There's so much you don't know. There's no reason you would know it. You can read all the books in the world, but, nothing's an education, like, real world experiences.

So I tease with families and I've got my oldest, I've got four, my oldest is 10. So I can, I can speak with expert guidance on up to 10 years of age, right? So I'm, no, expert in the adolescent realm yet, but I know.

Host: It is coming. You're going to be,

Dr. Ryan Aubuchon: Yeah, I'll be one day, but right, right now we're the little kid stage. But that's a, a fun part of my job is just to kind of apply common sense and kind of pediatric knowledge to different scenarios when things might be a little atypical, but ultimately end up being okay.

Host: And like you mentioned, you know, parents, they kind of know when something doesn't look right. So we encourage them. Like if that's the case, go make another appointment. Bring it up. You don't always have to wait to that next scheduled appointment if you're nervous about something, right.

Dr. Ryan Aubuchon: Absolutely. I mean, I, most, pediatric providers that are I'd say good at their job, know that you have to set aside time at the visit to address concerns, especially at the wellness visits. There's things that we need to do. That can be cumbersome, but we do it for a reason and we try to follow the same process so that if we, if we find a pattern, it's a lot of pattern recognition.

So if we find something that deviates from a pattern in a child's growth and development, then we can, we can talk more about it and address it. And so parents will fill out a lot of questionnaires and it may feel kind of pointless, but it's helpful for us to kind of get another sort of perspective, an adjacent perspective, on their growth and development and to make sure that everything's, moving along as it should. So.

Host: Let's talk about play. Just playtime. How important do you rank play in the cognitive and emotional development of this age group?

Dr. Ryan Aubuchon: If it's not number one, it's right behind, eating, drinking, breathing. Playing is, it's the most important thing. I mean, maybe neck and neck with reading to your child. Play is so important. Children of all ages, not just early childhood, learn through play and, they learn so much from playing with their parents, from playing with their siblings.

 Just the kind of back and forth, the relational aspect of play. Playing at parks, playing with toys, figuring out how something works is really good for their cognitive development. Their fine motor skills, their gross motor skills. So there's so much that is enriching about play and then typically around this age, between year and a half, two, three, they start having imaginative play, which is just hilarious to see what, what they want to do.

I've got a three and a half year old at my house, and, he never ceases to amaze us with the stuff he comes up with. And he is just, he's so, so funny, and clever. And so, yeah, play, play is very important Reading too. I'll just kind of lump that in with play is, we think that, reading books to your children has so many benefits.

 Even young infants, like even newborns and, one month olds, two month olds, just that, the bond that's created, the, the words that they're hearing, that stimulation visually that they get from looking at a book. And I, I'm try to make sure the families know there's some, wonderful resources out there.

You've probably heard of the Dolly Parton Imagination Library. Dolly Parton is a hero. She's a legend in literacy space. This program, parents can go online, Dolly Parton Imagination Library. It's in Guilford County, it's in Forsythe County. And, sign up and their child can get a free book every month, just sent to their house, mailed to them. It's a really neat thing. A lot of pediatric offices have a program called Reach Out and Read.

 Which is a national program where it promotes early literacy and it's really neat. It's a program where the provider is able to give a book to the child at every wellness visit from birth through five. And so, it's a really powerful thing, right?

Host: Love it. That sounds great. So, obviously eating, drinking big. Gotta do that. Plays pretty close. Reading's really close. I wanted to talk a little bit more about language though in this age range because and I don't know, correct me if I'm wrong, but to me it seems when you look at the basic milestones for this age range, let me just ask you, is language the one that has the most variation?

Dr. Ryan Aubuchon: There seems to be. This has come up a lot at the, one year or the 15 month checkup and apparently will be my child's not really saying any words. And of course there's a cousin that's like a little chatter box. And so, we'll hear that. And there does seem to be a good bit of variation in this area.

We certainly see some children that maybe their little bodies and brains are working real hard, at their gross motor development, and they're walking when they're seven or eight months of age, which is super early. And most children walk between 12 and 15 months of age. So I get the question a lot around 12 and 15 months that, my child's not really saying anything, saying any actual words.

They're babbling very well. Usually we just want to make sure that they have good, receptive language, even if there's not much in the way of expressive language. We know that at this age, if there's good receptive language, we know that with time, the expressive language or, the words will follow.

Additionally, this can be a clue to us if a child has poor receptive language or displays, poor joint attention, we would potentially be concerned a child might have autism spectrum disorder. And so, that would be something that we always kind of want to follow up on.

But, more often than not, I see children back at 18 months and two years of age and the parent that was worried about their child not talking can't get them to stop. So, as far as like helpful benchmarks, I'd say most 2-year-old children can say about 20 words or more.

This is average. They're usually doing two word sentences and a stranger could understand about half of what they're saying. 3-year-old, this increases incrementally, right? And there's so much variability, but they're saying, a few word sentences, a stranger can understand three-fourths of what they say.

And then by four, most children typically are fully intelligible and are talking all the time. And really with this conversation, I try to think with parents about, let's think back to three to six months ago, and from that time to now, are we seeing progress? And that's, encouraging and usually portends that they'll continue to progress.

 Now if a child is ever losing developmental skills, that's a red flag every time. A child should never have a skill and then lose it.

Host: Okay. Yeah. So meaning they've done something and now they're not doing it.

Dr. Ryan Aubuchon: Correct. Yeah. That can be worrisome for certain genetic diagnoses. That child would not only need early intervention, but also need to be evaluated by a developmental pediatrician to ascertain what else is going on. But typically we see if children are developing slowly in a certain area, they almost always catch up.

Host: I want to back up just for a sec, just to make sure the listening audience understands this, you said something about language. You said receptive language. Can you define that for us?

Dr. Ryan Aubuchon: Yeah. Like if your child could follow a command, right? So if, Hey, Bobby, go pick up your toy. Hey Bobby, grab your water bottle. It really kind of goes back to joint attention. So what happens when you, when you look at your child, are they looking back at it to you, are they connecting with you? And we can get some sense for this earlier on, right? So if a child's not responding to their name, or like responding to you talking to them, sometimes it's an early sign that there may be some sort of disconnect between, you and them. But usually what happens is parent will say, well, they're not saying very much, but they understand everything.

And, know so much and so usually that's a favorable thing. Just to remind family, there's so many great resources. You don't just have to see your pediatrician to talk through this. The CDC has a, a pretty robust website in the area of childhood development. They even have a, an app. There's an app for everything, right? So the CDC'S milestone tracker. put it on your phone and kind of plug in what your child's doing and see if it's typical or if they're behind. And there's one other resource I use a lot. It's the American Academy of Pediatrics, parenting website.

It's called healthychildren.org. And it's a fantastic resource. It's all pediatrician curated information and, all the areas of, childhood and could, could be a big help.

Host: And of course if you use those services and those kind of apps, fantastic. If you notice something's not quite right? Call your pediatrician. Don't self-diagnose. Don't do anything like that. Make sure you're, stay in touch with your doctor. Let's, change the conversation now to nutrition and sleep, during this age group, what kind of patterns are developing in those two areas, in this age group?

Dr. Ryan Aubuchon: Well, there's a saying in pediatrics, you learn this in medical school and residency, that children are not just tiny adults. I think in the area of sleep and nutrition, they really are. We're learning so much here lately about the benefits of sleep and of course the benefits of a healthy diet and nutrition and for a child in this age group who's growing and, and developing rapidly, their brain is growing rapidly and their brain is making all these new connections. It's vital that they have, healthy sleep patterns and healthy diet. And so, there's a reason that toddlers can get hangry they can have more tantrums and meltdowns if they're hungry or sleepy. It's their little body's way of telling us, Hey, I, I need these things. These are important to my health.

Host: I have 50-year-old friends that act like that.

Dr. Ryan Aubuchon: Yeah. That's right. That's right. They're not, they're not that unlike us. Right. You get, you get hungry and

Host: Yeah. That's great. That's great. And I'm sure there's good resources too there. If, somebody wants to learn a little bit about how maybe to, to improve a sleep pattern or improve some nutrition I'm sure that CDC, there's all kinds of resources, right?

Dr. Ryan Aubuchon: There is. And then, typically a child's pediatrician has some kind of pro tips about places you can go or, maybe some sage advice, something that worked for their child or, something that's worked, for their other patients. And I wonder if maybe you were cueing in on some of the picky eating as well at this stage, which is pretty common too. So really kind of goes back to children just sort of at this age, they're gaining independence, they're having opinions that they want to express. And so it's not uncommon for children at this stage to become pretty picky eaters. Which can be a big stressor for parents, wanting to feed their children healthy food.

Host: Right. I just learned in my experience, you can't force it. You try to sneak in some good nutrition here and there, but all my kids are eating fine now. I promise it's not a big deal.

Dr. Ryan Aubuchon: We think about their nutrition in the course of a week, right? Because toddlers can be so finicky, they'll have a good meal, bad meal, a good day, a bad day. And so I try to encourage families just to think about the course of a week. Do we, do we get a little bit of this, little bit of that. Drink plenty of water, and then they, children won't starve themselves, but, they certainly will show a preference for what they like.

Host: Okay, so any tips for the terrible twos?

Dr. Ryan Aubuchon: Oh boy. Well, you know, I'll share my first, he's now 10, that term really ultimately frustrated me because we experienced the terrible twos, but then, little did we know that having a threeager is actually probably harder. So, uh, yeah, this is a really demanding stage for a parent. And, I think it's important for us to just kinda remember that, this is normal for children to want to gain independence and start expressing opinions. This is good. A lot of times they are unable to express how they're feeling and it comes out by way of a tantrum or, misbehaving or, or being defiant. And so these are all normal parts of early childhood. And so I just, try to encourage families like, this is okay. This is normal. It is important though for us as parents to, to set boundaries and limits.

I mean. We are their parent for a reason. They can't just do whatever they want. And they know, they, they look at you, you see the look in their eye. They know what they're doing and they can be quite persuasive and, and defiant. And so, we think about redirecting. So if you know there's something that's going to be a problem, let's just kind of move past that.

And even little periods of time out, you know, a couple minutes, two minutes for a 2-year-old just to kinda have a pause and a reset. But, it can be very intense.

Host: Yeah, so, so with the tantrum, there's a lot of debate about how to handle tantrums, right? You just kind of said something that I kind of did, which was the redirect. But there are some people who say, no, let the tantrum just go. Others say, you've gotta stop it right there. So you're in the redirect category maybe with this.

Dr. Ryan Aubuchon: I don't know. It is sort of like, that's really up to the parent. I mean, they know their child the best. It's sometimes the redirect or the ignore it, I mean, ends up to be like three hours of a child just losing their mind. I mean, it also depends if you're at Walmart or Target or the grocery store, or if you're home. If they're at their home and a child's throwing a tantrum, I'm of the ilk that just like, just let them tantrum because we can create a cycle where they realize they get attention for this behavior, assuming they're in a safe environment. Right? So, tantruming on the sidewalk next to a busy street is different than in your bedroom or your house. We have a little more agency to help them through that.

Host: Yeah, I just know also with the redirect, you gotta be careful. Let's see what you think about this. You don't want to be redirecting with candies and sweets all the time. Because that kind of sets, they learn that.

Dr. Ryan Aubuchon: Yeah, they know. Yeah, they're smart. I mean, they know and then they figure out how they can kinda, uh, massage things to kinda get what they want. So, and they're persistent, some of these kids, they just will not stop. And you just can't imagine someone screaming and crying for that long, but they can do it.

Host: I know, I know. Speaking of being out and about with your child and everything in this age group, let's talk about social interactions, but specifically with their peers. How important is that at this state?

Dr. Ryan Aubuchon: Yeah, it's important. I mean, a lot of one year olds and two year olds, it's a lot of kind of parallel plays they're playing, but maybe they're not noticing children around them. They, from two to four, we see a little more cooperative play, I'd say. But, play in general, with your parent, with your siblings.

I mean, these are important interactions. You call this just sort of good relational health in the first three years is so, important. I mean, they learn a lot from just sort of the back and forth of playing. Helps build healthy connections in their brains. They understand about boundaries between others. Social cues, right and wrong. Sharing sometimes, usually not. This is mine. No, this is mine.

Host: Yeah. But they learn in that interaction too there, right?They're learning things.

Dr. Ryan Aubuchon: Yeah, that's right. They learn a lot in these things. That's where there's a lot of, kinda evidence that like, we need all of our children in preschool, right? So for so long, preschool has just sort of been a privilege for people that can afford it. And so, there's a lot of these initiatives. There's one in my area in Winston State, called the pre-K priority. This idea that children benefit in early childhood from being in like a school type of setting and not for, three or four hours or so, but there's so much that happens when in their, setting that sets them up for success when they, um, enter into kindergarten.

Host: Top red flags that parents should definitely seek help with. I think we already mentioned one if a child was meeting a milestone and they're not, let's connect with your doctor, right? Any other red flags like that?

Dr. Ryan Aubuchon: That developmental regression is the biggest one. Like we've mentioned, we have so many visits in the first three years that a parent could feel confident that they're not missing something if they're going to their regular visits. Right. So it would be have to be the ultimate Swiss cheese model.

Like, they weren't noticing things at home. Preschool teachers weren't noticing things at school. We didn't notice anything in the room, which is, wouldn't happen. They didn't fill out the developmental questionnaire. And so there's lots of opportunities for us to see something emerging and maybe it's too early to know if it's an actual problem or if it's something that's going to get better on its own.

 But it's a big part of why we have so many visits, in the first three years. So I'd say other than a developmental, like a, regression from a developmental milestone, I'm talking about a major regression. So let's say a child that was running and walking, then could no longer walk, or a child that was talking in sentences and then started babbling. And these are extremely rare instances. So, yeah, we get to visit so much that we can sort of understand if, the last three to six months if we're seeing progress, that's, typically great.

Host: Let's end with this. Given this age range and all the different stuff we just talked about, the milestones you gave some great tips. What's the last thing? What's kind of the summary statement you would like to give to the listening audience?

Dr. Ryan Aubuchon: This is such a wonderful stage. It's a joy for parents. It's so amazing to see your child grow and change and you feel so proud of all the new things that they do. You just want to tell everyone and take pictures. It's hard, it's extremely hard and exhausting and like, that's okay, you're going to make it, it will get easier. So I think a lot of my role is just to encourage parents that they're doing a good job and that it's kind of validate that this could be a really, it's really fun, but it's a really intense stage.

And then one last thing is sort of a PSA, I guess, but I am seeing a trend of like lots of toddlers walking into my office with tablets. You asked about misconceptions. I think there are some misconceptions out there that there's a lot of benefits or health to some of these educational apps. So, we would say we don't think that's true. Less is more with screen time. You asked about play, like play, play, play, read, read, read. All these things. We don't know that there's much benefit to looking at a screen in this age group. So.

Host: And that's unfortunately, I don't know if those are going to go anywhere.

Dr. Ryan Aubuchon: Yeah, they're not, and, I'm not judging my, my three-year-old loves PAW Patrol, my kids watch shows, but, with supervision, I understand it can be very helpful. It's a helpful break for parents when they're, they need to cook. It's just like, it is helpful.

Let your child kind of.

Host: But like with a lot of things, there's a balance there and we gotta learn what all of us as a society, we need to learn what that balance probably is.

Dr. Ryan Aubuchon: Yeah, absolutely all of us, we could all do a lot less of this.

Host: 100%. This was a fantastic discussion. Thank you for coming on the show today.

Dr. Ryan Aubuchon: Yeah. Thanks for having me on, Mike. Appreciate it.

Host: That was Dr. Ryan Aubuchon, sharing invaluable insights on early childhood development. To find a physician or learn more, please visit novanthealth.org and for additional health and wellness information from our experts, you can check out healthyheadlines.org. If you'd liked this podcast, please share it on your social channels and explore our entire podcast library for topics that interest you. This has been Meaningful Medicine. Thanks for listening.