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WELL CHILD CARE Powered By Docstoc

Becky Risinger, MD, FAAP

1. Interpret growth data for children 2. Counsel parents on the proper diet for children 3. Perform appropriate physical exam for age of the child and understand abnormal and normal findings 4. Working knowledge of developmental milestones 5. Know appropriate laboratory screening tests and how to interpret them 6. Know which immunizations are needed for each age and the common side effects 7. Be able to give anticipatory guidance 8. Perform an age appropriate exam


Greet the parent and the child Interim History Recent History Hospitalizations
Any Problems-Open Ended What is their agenda for this visit?

Growth Parameter Norms
Weight *Weight loss in first few days 5-10% *Returns to birth weight by 7-10 days *Double birth weight by 4-5 months *Triple birth weight by 2 years *Average annual weight gain 5 lbs/year from 2 years old through puberty

Growth Parameter Norms
Height 20 inches at birth 30 inches at 1 year 36 inches at 3 years 40 inches at 4 years
Average annual growth rate 2-3 inches per year from 1 year old through puberty

Growth Parameter Norms
Head Circumference *35 centimeters at birth *Increases 2 centimeters/month first 3 months *Increases 1 centimeter/month from 4 through 12 months *After 1 year old increases only 10 centimeters for life

Growth Parameter Problems
Height Below the 5th percentile 1) Growing along his/her own curve-follow 2) Plateau Hypothyroidism Chronic Disease (congenital heart disease, renal disease, etc.)

Growth Parameters-Problems
Weight Above the 95th percentile If other parameters are on the same percentile-not a problem If the height is less than the 75th percentile, then take a detailed diet history and counsel on proper diet for age or refer to a nutritionist for counseling

Growth Parameter-Problems
What weight is a problem? A weight less than 80% of the median weight for height is failure to thrive. Weight loss in an infant is always cause for alarm and requires a work-up. Recent illness Inadequate intake-infants require 110 kcal/kg/day Unless the cause is obvious (like milk intolerance), the baby should have a work-up.

Growth Parameters-Problems
Head Circumference >95th Percentile Deserves a work-up (unless height and weight are the same percentile) Work-up includes: *Head ultrasound to rule-out hydrocephalus *Rapid growth of head since last visit should be a work-up ASAP *Can measure the family’s head size, familial macrocephaly

Growth Parameters-Problems
<5th Percentile Rule out microcephaly Causes: Familial microcephaly(benign) Infectious disease (TORCH) (Check eyes and hearing if they have this) Craniosynostosis-requires surgical correction

Growth Parameters-Problems
Failure to Thrive When a child is not growing, it is reflected first in the weight then the height finally if severe, in the head size

Breast Milk Nurse every 2-3 hours, 15 minutes per side 5-8 wet diapers/ day No vitamins for babies

Formula 3-4 ounces every 3-4 hours Total volumes: 1 week 18-24 ounces 1 month 22-26 ounces 2-3 months 28-32 ounces

Two-Three Months
Breast Feeding 5-6 feedings per day About 6 wet diapers per day Vitamins Tri-vi-flor 0.25mg with Iron 1 ml po q day

Two-Three Months
Formula 28-32 ounces per day Spitting up: Not a problem unless baby has a poor weight gain or aspiration. 1)After eating, keep at an angle for 30 minutes 2)Thicken feedings with cereal 3)Change formula Cow’s milk protein Soy bean protein Casein hydrolysate

Four-Five Months
Breast Milk or Formula Cereal/Apple Juice Vegetables Fruit

Six to Eleven Months
Breast Milk or Formula Cereal/Fruit/Vegetable/Meats 6-8 months 4 feedings/day 9 months 3 feedings per day Table food can be started as early as 6 months Beware of Choking

Over One Year Old
Food Group Fruits Vegetable Grains Milk*, Cheese, Yogurt Meat, Fish, Poultry Beans, Eggs, Nuts Fats, Oils & Sweets # Servings 2 or more 3 or more 6 or more 2 or more 3 or more
In moderation

Younger children may eat smaller serving sizes *Children <2 years old should drink whole milk

Age Performance 1 month While prone, lifts head off table 2 months Smiles responsively; vocalizes 3 months Laughs 4 months Head erect and steady when held in sitting position; squeals; grasps 5 months Smiles spontaneously; rolls over. 6 months No head lag if pulled to sitting position 9months Sits alone for 5 seconds after support is released; transfers block from hand to hand; feeds self finger foods. 10 months Pulls to standing position; pincer grasp; says “ma-ma” or “da-da”; plays peek-a-boo, anxiety toward strangers

Development Continued
Age Performance 12 months Cruises, stands alone for 2-3 seconds; bangs 2 blocks together; imitates vocalizations. 18 months Walks well; points for wants; drinks from cup without assistance; mimics household chores 21 months Says 3 words (in addition to “ma-ma” and “da-da”); removes article of clothing besides hat. 2 years Scribbles spontaneously; points correctly to one body part; does simple household tasks. 3 years Pedals tricycle; sentences of 3 words and uses plurals; washes and drives hands. 4 years Copies circles and cross; dresses with supervision 5 years Dresses without supervision; can tolerate separation from parent for 5 minutes without anxiety. 6 years Copies a square, draws a man with 6 parts 7 years Copies a triangle; draws man with 12 details, reads several one-syllable printed words; rides bicycle (without training wheels) 8 years Ties shoes; copies diamond; draws man with 16 details; knows days of the week

Age Stages of Development Examples 2-4 months Cooing Noises, mostly vowel sounds 4-12 months Babbling Mama,gaga,baba 12-18 months Single Words Daddy, ByeBye, no, Juice 18-24 months Two word phrases Baby up, Read book, go byebye 24-36 months Simple sentences Sasha go to park now, Mommy make dinner

Development-Speech (cont.)
When should you worry?
*Doesn’t make eye contact/disinterested in social
interaction *Has other areas of developmental delay *Not smiling socially by 2 1/2-3 months of age *No cooing by 4-5 months *No babbling by 7-9 months *No attempts to gain parents attention withsounds by 12 months *Doesn’t say “Mama,” “Dada,” “Papa” by 12-14 months *Doesn’t say first word by 14-16 months (excluding Mama, Papa, Dada) Doesn’t say 2-word sentences by 24-28 months *Doesn’t link together nouns and verbs by 28-30 months

What is required *Second neonatal screen *Hemoglobin or Hematocrit *Lead Screening

Laboratory Cont.
Neonatal Screen Congenital Adrenal Hyperplasia Phenyketonuria Galactosemia Sickle Cell Anemia Hypothyroidism

Laboratory Cont.
Lead Screening 1. Do lead surveyif any “yes” responses, do a lead screen at 6 months if all “no” responses, do a lead screen at 12 months 2. Results of the lab test less than 10 micrograms/dL, no follow up needed 10-14 microgm/dL -rescreen every 3-4 months until either: *2 subsequent consecutive measurements are less than 10 microgm/dL, OR *3 subsequent consecutive screens are less than 15 microgm/dL -screen every year 15-19 microgm/dL refer to a physician >19 microgm/dL Medical Emergency, refer that day for a work-up

Laboratory Cont.
Hemoglobin Anemic when the Hemoglobin is less than: 10.5 at 6 months 11.0 at one year 12.0 at two years

Laboratory Cont.
1. 6 MG elemental Iron/kilogram/day divided TID 2. Recheck hemoglobin in one month after treatment is started.

Infant-Toddler Exam
Begins as you visit with the parent and start to observe the child.
Position of the child-may do better in the parent’s lap * Head-palpate sutures and fontanels, examine hair and scalp * Ears-external ear and canal otoscope/check hearing * Nose-look in Can listen with stethoscope to see if air is moving well in each side * Eyes-red reflex, extra-ocular movements, pupil (reaction to light and shape) light reflex, cover test * Mouth-look at the oral mucosa and palate, check teeth * Neck-nodes, thyroid, range of motion, clavicles

Vision Screening
Birth Check Red Reflex Children 0-2 years Red reflex, Pupils react equally to light, Cover test for children over 6 months Children 3-4 years Child should be able to read more than half of the 20/40line or four out of six H;O;T;V; symbols Cover Test Children 5 years and up Should be able to read majority of 20/30 line or four out of six H;O;T;V symbols Cover Test

Tuberculosis Screening
Since your child’s last skin test: -Has anyone in your family had tuberculosis? _Do you know of any situation where your child was around an adult who has been diagnosed or suspected as having TB? -Was your child born in or has our child visited a foreign country where there is a lot of TB? -TB can cause fever of long duration, unexplained weight loss, weakness, chest pain, a bad cough, hoarseness or coughing up blood. -To your knowledge, has your child had contact with anyone who is/has been an intravenous (IV) drug user? -HIV-infected? -In Jail/prison? -Recently moved to the US from a foreign country?

Infant-Toddler Exam (cont.)
* Chest-movements (retractions), breath sounds
* Heart-look for precordium movement, feel for any thrills or heaves, listen for rate, rhythm, murmurs, systolic and diastolic sounds, extra sounds, check pulses, note color * Abdomen-listen for bowel sounds, palpate liver and spleen, any masses (may need to flex the legs to get a good exam) * GenitaliaMale-meatus and testes down Female-separate labia * Rectum-look for separating buttocks * Back & Extremities-observe sacral area, straightness of the back, observe legs, knees, ankles, observe feet, leg length equality, folds, hips, range of motion of joints upper and lower.

Infant-Toddler Exam (cont)
* Neurological Mental Status
Response to stimuli Developmental level Cranial Nerve (observe facial movements) Open mouth, smile, show teeth, close eyes, wrinkle brow, gag Motor Muscle mass and tone Strength, coordination-handling toys, spontaneous play, sitting, walking, crawling

Reflexes Infantile Moro, suck, tonic neck Deep tendon clonus Babinski

Newborn Exam
Head-observe for molding, cephalohematoma, caput, palpate sutures, fontanels Eyes-red reflexes (for cataracts) Mouth-palate intact Chest- palpate breasts, check clavicles Abdomen-examine cord, may be able to palpate kidneys Genitalia-Male, check for hypospadias and undescended testes Back-sacral dimple Extremities-Check for dislocated hips Skin-jaundice

Newborn Exam (Cont’d)
Neurological-Muscle strength and tone Grasp Rooting Sucking Moro Head Control Stepping and Placing Deep Tendon Reflexes Babinski Tonic Neck Reflex Observe for Cranial Nerve Changes

Newborn Exam (Cont’d)
Reflex Disappears
Moro 1-3 Months Rooting 3-4 Months Palmer Grasp 4 Months Tonic Neck Reflex 5-6 Months Plantar Grasp 8-15 Months Suck Response 12 Months Babinski 1-2 years Most of the special reflexes observed in the newborn age group are called “Primitive” and will disappear as the infant’s central nervous system myelinates. The retention of the Special reflexes beyond the expected age of disappearance indicates pathology, including cerebral palsy or other central nervous system defects.

Heart Exam
Requires a Quiet Patient *Inspection General appearance Physical abnormalities Color of skin and mucous membranes Cyanosis Pallor Jaundice Clubbing Respiration

Heart Exam (cont’d)
Palpation Peripheral pulses

Chest Precordium PMI Thrill/Heave Listen Rate Rhythm S1-S2 Systolic/Diastolic Four limb blood pressure Bottom line: is it normal?

Birth Hepatitis B#1 2 months DPT, IPV, Prevnar, HIB 4 months DPT, IPV, Prevnar, HIB 6 months DPT, Prevnar, HIB, Hep B#2 9 months HepB#3, IPV 12 months MMR, HIB, Varicella, Prevnar 15-18 months DPT 2 years Hepatitis A 2 1/2 years Hepatitis A 4 years MMR, DPT, IPV 12-13 years DT 18 years Meningococcal vaccine

Health Education Birth-12 Months
Nutrition Formula/Breast Introducing Foods Feeding Technique Safety Bath Safety Smoke Detectors Car Seats
Childproofing Poisoning Information Walkers/Jumpers Toxin/Lead Exposures

Health Promotion Immunization Information Choking Teething/Bottle Caries Exposure to Smoking Medical Resource Use Treatment of Minor Acute Illnesses

Family Siblings Family Planning Family Concerns

Health Education 1-4 Years
Nutrition Basic Foods Good Snacks Appetite Control Choking Health Promotion Immunization Information Dental Education Toilet Education T.V. Habits Exposure to Smoking Medical Resource Use Safety Firearm Safety Smoke Detectors Car Seats Water Safety Poisoning Information Childproofing

Family Set Limits/Discipline Reward Good Behavior Sibling Relations Read/Play Together

Health Education 5-12 Years
Nutrition Basic Foods Good Snacks Appetite Control Health Promotion T.V. Habits Medical Resource Use Tobacco Alcohol/Drugs Regular Exercise Tooth and Gum Care Pubertal Changes/Sex Safety Seat Belts/Auto Safety Bicycles/ATV Skating/Athletics Water Safety Smoke Detectors Firearm Safety
Family Security Discipline Patterns Handling Responsibility Communication Handling Losses