Transcript HEALTH SUPERVISION III VISIT GUIDELINES

HEALTH SUPERVISION
VISIT GUIDELINES
SCHOOL-AGED CHILD
SUZANNE LEFEVRE MD
GENERAL APPROACH TO THE WELL
CHILD VISIT
INTERVAL HISTORY/OBSERVATION
NUTRITION
ELIMINATION
SLEEP PATTERNS
DEVELOPMENT/BEHAVIOR/SCHOOL
PERFORMANCE
PHYSICAL EXAM
ANTICIPATORY GUIDANCE
DISEASE PREVENTION/HEALTH
PROMOTION AND INJURY PREVENTION
4 YEAR OLD VISIT
Interval history/ Interview with behavioral observations
– Child: How are you? How old are you? Do you go to
school? Where?
– Parent: Have there been any illnesses, hospitalizations
or ED visits since our last visit? How is your child doing
in pre-school or child care? Do you have any particular
concerns you’d like to discuss?
4 Year Old Visit
Nutrition
– Child: What do you like to eat?
– Parent:: Do you have any concerns about your child’s eating habits?
– Describe a typical dinner in your home?
Anticipatory Guidance:
– Kids age 4-8 need 800mg of Calcium per day; one 8 oz glass of milk contains 300mg
– Recommend limiting juice to no more than 6 oz of 100% fruit juice.
– Food jags (favoring 1 or 2 foods) and picky eating are normal behaviors.
– Explain the growth chart
Suggestions for picky eaters
– Offer small portions first, then second helpings
– Try to create a pleasant atmosphere at meal time
– Include child in conversation at the dinner table
– Offer a variety of foods and repeat them
4 YEAR OLD VISIT
Elimination
– Parent:: Does the child use the toilet for urination and having
bowel movements?
– Have you noticed any discomfort when the child has a bowel
movement?
By age 4, 95% of children are bowel trained
90% are dry during the day
75% are dry at night
– Anticipatory Guidance
No specific interventions are warranted for night time wetting
because it’s so common at this age.
Stress importance of balanced diet in preventing constipation
4 Year Old Visit
Sleep Patterns
– Child: Where do you sleep?
– Parent:: How does your child get to sleep at night? Does your
child nap? Does your child experience nightmares, night terrors,
or sleepwalking?
– Nightmares are common and involve vivid, scary or exciting
events which are easily recalled by the child upon awakening.
– Night terrors are common particularly in boys ages 5-7 but can
see as early as 4. They occur in 1 – 3% of children and are
usually short lived. Characterized by sudden onset, usually
between midnight and 2:00am during stage 3 or 4 of slow wave
sleep. The child screams, appears frightened, tachycardic and
may hyperventilate. Child my thrash violently, there is little or no
verbalization and cannot be consoled. Sleep follows in a few
minutes and there is total amnesia of the event upon waking.
4 Year Old Visit
Sleep Patterns
– Anticipatory guidance
Encourage children to sleep in their own beds if
that is compatible with the family’s culture
Create a calm bedtime ritual like reading or story
telling
Reassure parents that nightmares and night terrors
are common
4 Year Old Visit
Development and Behavior
– Child: What sort of things are you good at doing? Can you get
yourself dressed?
– Parent: What skills do you expect of a 4 year old that your child
cannot perform?
– Ages and Stages Questionnaire
– Milestones
Gross motor: Pedals tricycle, hops on one foot, balances on one foot, walks up
and down stairs with alternating gate
Fine motor: Draws a circle and cross, draws a person with 3 to 6 body parts, cuts
with scissors
Cognitive skills: complex pretend play, may have imaginary friend, recognizes
some of the alphabet
Language skills: Uses full sentences of at least 6 words, 100% intelligible
Social skills: engages in interactive play, able to share, can play a board or card
game.
Self-help skills: Able to put on shirt, pants, socks, able to button and zip; able to
brush teeth; toilet trained
4 Year Old Visit
Physical Exam
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Height
Weight
Blood Pressure
General physical exam to include
Visual acuity- objective
Hearing screen- objective
Check for obvious dental caries
Check gait, spine and extremities
Be alert for signs of abuse
– Screening: Hemoglobin if at risk for anemia (i.e., special health
needs, low iron diet or environmental factors
– Immunizations: See current recommended schedule (DTaP,
IPV, MMRV)
4 Year Old Visit
Injury Prevention
Toys should be age
appropriate
Falls are common
Keep dangerous
materials out of reach;
matches, tools and
poisons
Helmets for tricycle safety
Car seats and seat belts
Start booster seat at
40lbs and 40 inches
tall
Adult supervision near
water, consider swimming
lessons
Good touch/bad touch
Careful around strange
dogs
Gun safety: AAP
recommends that they be
removed from the home
Teach child how to dial
“911”
UV protection
4 Year Old Visit
Close the visit
– Are there any issues that we missed?
– Set time and reason for next appointment
5 YEAR OLD VISIT
Interval History/ Interview with Behavioral
Observations
– O.K. to talk to child alone for a few minutes. As the child
grows older the time period gradually increases. This is
patient and family dependent
– Child: Have you been sick since I saw you last? How
many brothers and sisters do you have?
– Parent: How is your family doing? Have there been any
changes in the family?
5 Year Old Visit
Nutrition
– Child: What are your favorite snacks?
– Parent: Do you have any concerns about your child’s weight?
– Anticipatory Guidance
Same as the 4 year old visit
Discuss healthy snacking
5 Year Old Visit
Elimination
– Child: do you have any problems with bowel movements
(“poop”) or urinating (“pee”)?
– Parent: Does your child wet the bed at night?
At age 5 approximately 20% of children wet the bed at least
monthly.
Approximately 5% of boys and less than 1% of girls wet the bed
nightly
– Anticipatory Guidance
No specific interventions are warranted for night time wetting
at this age.
5 Year Old Visit
Sleep Patterns
– Same as 4 year old visit
5 Year Old Visit
Development and Behavior
– Child: Can you write your name?
– Parent: Can your child tie his shoes? Is your child comfortable in
speaking to others?
– ASQ (Ages and Stages Questionnaire)
– Milestones
Gross motor: balances on one foot, hops, skips
Fine motor: able to tie a knot, has mature pencil grasp, draws a person
with at least 6 body parts, able to copy squares and triangles.
Language: Names at least 4 colors, counts to 10, tells a simple story
using full sentences, appropriate tenses, pronouns.
Social skills: follows simple directions, able to listen and attend, dresses
and undresses with minimal assistance.
5 Year Old Visit
Physical Exam
– Same as the 4 year old visit
Screening
– Urinalysis
– Other screening as indicated by risk: lead,
hemoglobin, PPD
5 Year Old Visit
Anticipatory Guidance
Injury Prevention/Health Promotion
– Fire safety (alarms,
fire escapes, home
plan for emergencies)
– Dealing with strangers
– Discourage skate
boarding or in-line
skating unless
helmets, wrist, elbow
and knee pads are
used
– Violence prevention
– Pedestrian and bicycle
safety
– Regular
exercise/family
activities
– Brush teeth at least 2
times per day. See
dentist 2 times per
year.
– TV viewing should be
limited and monitored
– Encourage interaction
with other kids,
grandparents and
adults
– Spend time playing
with child every day
6-7 Year Old Visit
Interval History/Interview with Behavioral
Observations
Child: What grade are you in? Have you been sick
since our last visit? Any broken bones or stitches?
Parent: Have there been any family crisis or stressors?
Is your child on any medications?
6 – 7 Year Old Visit
Nutrition
– Child: Do you eat fruits
and vegetables?
– Parent: What does your
child eat for protein? How
much milk does your child
drink?
– Anticipatory Guidance:
Continue to promote
well-balanced diet.
Avoid junk foods
Consider need for
vitamins, iron
supplements
Encourage regular
exercise
Elimination
– Child: Do you have a
bowel movement every
day? Is it hard or soft?
Does it hurt?
– Parent: Does your child
have problems with day
time wetting, night time
wetting or soiling?
– Anticipatory Guidance
By age 6 only 10% of
children will wet the bed
If problems are
identified, enuresis,
constipation and
encopresis.
6 – 7 Year Old Visit
Development and Behavior
– Child: Can you ride a bike? Show me your left hand?
– Parent:: How would you evaluate your child’s abilities in sports?
How are your child’s abilities to draw and write?
– Milestones:
Gross motor: skip
Fine motor: Draw a picture of a person with 8 to 10 features
Language/Cognitive: Recount a personal story about a
recent event, count to 20
6 – 7 Year Old Visit
Physical Exam:
– Same as 5 year old
Screening:
– Same as 5 year old
Injury Prevention/Health promotion:
– Same as 5 year old
School Readiness
Years from 3 to 6 are historically called “preschool”
because of their importance for preparing the child for
the tasks of school
Determine any parental concerns about school
readiness by asking trigger questions
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How does your child feel about going to school?
How are you feeling about John/Jane going to school?
When you were John’s/Jane’s age, did you enjoy school?
How did John/Jane do in preschool?
Is there anything you would like checked before he/she goes to
school?
– Is there anything the school or teacher should know?
School Readiness
Parental concerns regarding developmental milestones
Communication/Language
– Knowledge of letters,
words and symbols
– Ability to recognize letters
and numbers
– Articulate speech
Behavioral/Emotional Skills
– Ability to take another
persons point of view and
follow rules
– Separation anxiety
– Social shyness
– Temper tantrums and
tendency to be aggressive
when fearful are indicators
of emotional immaturity
Gross motor/Fine motor
– Ability to print letters and
numbers
– Good gross motor
coordination can provide
important status with peers
and is a source of selfesteem through athletics.
This is least predictive of
school achievement when
compared with other areas
of development.
– Physical size and stature
Developmental milestones necessary for
Elementary School Success
Cognitive
– Long term memory, storage and recall
This is the ability to acquire skills that are “automatic”
Deficit: Delayed mastery of the alphabet, slow handwriting and the
inability to progress past basic mathematics
– Selective Attention
Ability to attend to important stimuli and ignore distractions
Deficit: Difficulty following multi-step instructions, completing
assignments and behaving well
– Sequencing
Ability to remember things in order
Deficit: Difficulty organizing assignments, planning, spelling and telling
time
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004
Developmental Milestones necessary for
Elementary School Success
Perception
– Visual Analysis
Ability to break a complex figure into components and
understand spatial relationships
Deficit: Persistent letter confusion (between b,d and g),
difficulty with basic reading and writing and limited sight
vocabulary
– Proprioception and fine motor control
Ability to obtain information about body position by feel and
unconsciously program complex movements
Deficit: Poor handwriting often with overly tight pencil grasp,
difficulty with timed tasks
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004
Developmental Milestones necessary for
Elementary School Success
Language
– Receptive
Ability to comprehend constructive function words like: if,
when, only, except. Ability to understand nuances of speech
and extended blocks of language (e.g. paragraphs)
Deficit: Difficulty following directions, wandering during
lessons and stories, problems with reading comprehension,
problems with peer relationships
– Expressive
Ability to recall required words effortlessly (word finding), to
control meanings by varying position and word endings, to
construct meaningful paragraphs and stories
Deficit: Difficulty expressing feelings and using words for selfdefense, with resulting frustration and physical acting out;
struggling during “circle time” and language based subjects
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004
References
Bright Futures, Health Supervision III
Guidelines 2008 AAP Publication
Caring for your Baby and Young Child
AAP Publication
Nelsons Textbook of Pediatrics 2004
Pediatrics: A Primary Care Approach,
Carol Berkowitz, MD, FAAP, 2008
General Approach to the Well Child Visit
Interval History/Behavioral Observation
Nutrition
Elimination
Sleep Patterns
Development/Behavior/School Performance
Physical Exam
Anticipatory Guidance
Disease Prevention, Health Promotion, Injury Prevention
8 – 9 Year Old Visit
Interval History/Interview with Behavioral Observations
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Child: How are things going?
Parent: Have there been any changes in your child’s health?
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Middle childhood is marked by considerable development in academic skills,
physical abilities, social interactions and emotional regulation. School success
and home life are both important for self-esteem.
Nutrition
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Child: How is your appetite? What do you eat for breakfast?
Parent: How is your child’s appetite?
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Encourage child to eat breakfast daily
Reinforce need for balanced diet avoiding junk food
With a balanced diet and exercise there should be no need for dieting
8 – 9 Year Old Visit
Elimination
– Child: How often do you have bowel movements?
– Parent: Do you have any concerns about your child’s toilet habits?
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Enuresis: Defined as normal voiding that occurs at an inappropriate
time or involuntarily in a socially unacceptable setting.
Defined as occurring at least 2 per week for at least 3 consecutive months
Diagnosis is reserved for girls older than 5 and boys older than 6
Diurnal enuresis occurs during the day
Nocturnal enuresis occurs at night
Primary enuresis refers to kids who have never achieved sustained
dryness
Secondary enuresis refers to kids whose urinary incontinence occurs after
3 to 6 months of dryness
75% to 80% of kids with enuresis have primary enuresis
Incidence of secondary enuresis increases with age and makes up 50% by
age 12
Causes of primary enuresis include faulty toilet training, maturational
delay, small bladder capacity, sleep disorders, nocturnal polyuria
Causes of secondary enuresis include UTI’s, diabetes mellitus and
insipidus, genitourinary anomalies, seizure disorder, medication use
8 – 9 Year Old Visit
Sleep Patterns
– Child: What time do you go to bed at night? How many hours do you
sleep on a school night?
– Children age 8 frequently sleep 9 to 12 hours per night.
School
– Child: What subjects do you like? What do you think about your
grades?
– Parent: How are your child’s reading and writing skills? What did you
learn at the parent-teacher conference?
– If school failure is suspected discuss need for comprehensive approach
involving parents, school and pediatrician.
8 – 9 Year Old Visit
Development and Behavior
– Child: What do you like to do for fun? How many hours each day do
you watch T.V?
– Parent: What are your expectations for your child in terms of sports and
extracurricular activities? How does your child get along with friends
and peers at school?
– Parents should encourage peer play outside the home, i.e. clubs,
camps or athletic teams.
– Parents should consider giving an allowance to encourage
independence and responsibility.
– Recommend fair, understandable rules about chores, T.V., outside
activities, homework and bedtime.
– Encourage follow through with stated consequences when rules are
broken.
– Consider discussing puberty.
8 – 9 Year Old Visit
Physical Exam
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Height
Weight
Blood Pressure
Look for signs of puberty
Screening
– Hemoglobin, PPD if high risk
Injury Prevention/ Health promotion/ Disease Prevention
– Discuss participation in team sports where emphasis is fun and not
winning
– For those children that don’t like team sports, encourage individual
sports like swimming, tennis, dance or gymnastics
– Trampoline use should be discouraged
– Children can learn CPR at this age
– Gun Safety
– Smoke detectors in the home
10 – 11 Year Old Visit
Interval History/ Interview with Behavioral Observations
– Speak to child alone during some portion of the visit
– Explain confidentiality to the child and parents
– At this age peer groups become an increasingly important influence on
style, attitudes and values. They may begin risk-taking behaviors such
as cigarette smoking or drinking alcohol.
Nutrition
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Child: What is meant by a well balanced diet?
Parent: Is there a history of elevated cholesterol in your family?
Encourage child to eat breakfast before school
Encourage regular exercise
Advise parent and child about adequate hydration during warm climate
sports or outdoor activities
10 – 11 Year Old Visit
Elimination
– Child: Do you experience pain or burning with urination?
Sleep Patterns
– Child: How do you feel when you wake up in the morning?
– Parent: How much sleep does your child get at night?
– Children this age should still get at least 9 hours of sleep per night
Development/ Behavior
– Child: Where do you spend your time after school?
– Parent: What are the most enjoyable activities you do together? What
activities are most likely to cause friction or problems?
– Age 10 is a prime year for sports competition. Year round participation
in multiple sports my reduce over-use injuries of same muscle groups.
– Strength training is appropriate with proper supervision.
– Parents should discuss tobacco, alcohol and illicit drug use.
– Encourage parents to prepare girls for menarche.
10 – 11 Year Old Visit
Physical Exam
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Height
Weight
Blood Pressure
Make sure to include assessment for scoliosis, Tanner staging and
exam of genitalia
Screening
– Hemoglobin for menstruating females
– Urine dipstick should be done between 11 and 21
– Cholesterol and PPD for high risk kids
Injury Prevention
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Seat belts
No power tools unless supervised
Water activities should be supervised
Children this age should not operate personal watercraft
Sunburn protection
School Failure
Failure in school can have lifelong consequences. The causes of
school failure are often multiple including: chronic illness,
behavioral, emotional and social issues
Background
– 10 – 15% of school age children repeat or fail a grade
– More likely among males, minorities, low socio-economic status and
single parent households
– Children with disabilities are nearly 3 times as likely to repeat a grade as
those with no disability
Disability
– Learning
– Speech or language impairment
– Mental retardation
– Emotionally disturbed
– Children who are small for gestational age are nearly twice as likely to
experience school failure
School Failure
Background
– Grade failure is linked strongly to subsequent dropping out of high
school
10% of drop-outs had no failures
22% of drop-outs failed one grade
39% of drop-outs failed 2 grades
– Grade failure causes children to be older than their same-grade peers
Old for grade high school students are more likely to report smoking
regularly, chewing tobacco, alcohol use, driving in a car with someone who
has been drinking, using alcohol prior to a sexual experience and using
cocaine or other illicit drugs.
They have more suicidal ideations, risky sexual behavior and violent
behaviors
Grade retention alters peer group formation
Grade retention has a negative impact on self-esteem, social adjustment,
behavior, self-confidence, attitudes towards school and is stressful for
children
School Failure
Conditions and Associated Factors
Endogenous Factors
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Chronic disease
Anemia
Asthma
Sleep Apnea
Cystic Fibrosis
SLE
Crohn’s Disease
Acute conditions causing school absence
Sensory impairment
Vision
Hearing
Perinatal conditions
Prematurity
FAS
In utero drug exposure
Maternal conditions affecting pregnancy
Neurologic disorders
Brain injury
Tic disorders
Seizure disorders
Toxic exposures
Endogenous Factors
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Learning disability
Language and Speech Disorder
– Phonologic language
– Expressive language
– Receptive language
– Stuttering
Learning disorder
– Reading
– Writing
– Mathematics
Mental Retardation
Communication disorders
ADHD
Autistic spectrum disorders
Genetic disorders: Fragile x
Endocrine disorders: Hypothyroidism
Psychiatric disorders
Oppositional defiant disorder
Conduct disorder
OCD
Anxiety disorders: phobias, panic
Substance abuse
School Failure
Conditions and Associated Factors
Exogenous Factors
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Family
Divorce/Separation/conflict
Poverty
Frequent moves
Substance abuse
Depression
Attitudes towards education
– Low level of family support
– Inadequate
accommodations for studies
at home
Neglect/Abuse
Environment
Neighborhood/housing
TV/computers
Peers
Peer pressure for low
performance
Substance abuse
Exogenous Factors
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Competing priorities: excessive
extramural activities
Social
Work
Sports
School
Mismatch between student and
teacher
Unrealistic expectations
Inadequate school environment
– Violence/safety
– Classroom size
Transitions
Third grade
Elementary school to middle
school
Increases in testing standards without
increasing educational support
Excessive testing
School Failure
Medical Assessment and Subsequent Interventions
History
– School history
Details of current difficulties
School setting
Educational support
School absences
Achievement
Onset of problems
Results of educational testing
Preschool performance
Communication with the school
– Attention profile
Attention
Hyperactivity
Impulsivity
– Family history
Educational achievement and difficulties
Mental retardation
ADHD
General conditions
– Tic disorders
– PKU
– Thyroid disease
Psychiatric disorders
– Pregnancy complications
– Birth complications
Prematurity
Hypoxia
Low Birth weight
History
– Developmental history
Motor milestones
Language milestones
Regression
Social skills
Temperament
– Current Medical Conditions
Acute
Chronic
Medications
– Past medical history
Head trauma
CNS conditions
– Sleep history
– Social history
Peer group
Family stress: poverty, conflict, single
parent
Family orientation toward education
Mobility
Extracurricular activities
Substance abuse
Sexual behavior
– Nutrition: diet
– Strengths
Developmental Assessment
Vision and Hearing Screen
Physical Exam
Laboratory screening
School Failure
Medical Assessment and Subsequent Interventions
School Failure Interventions
– As indicated by assessment
(e.g., treatment of
hypothyroidism)
– Advocate for more complete
assessment
– Attend school meetings
– Advocate for IEP that consists
of more than simply having a
child repeat the grade that
was failed
– Advocate for alternatives to
grade retention
Mixed-age classes
Individualized instruction
Tutoring
Home assistance program
Smaller class size
Alternative education settings
Guidance counseling
– Help families get more
involved in their child’s
education
– Assist families with peer group
issues
– Improve environment for
learning at home
Limit amount of television
watching
Provide a quiet place to do
homework
– Help develop child’s strengths
– Assess siblings for school
problems and take the
opportunity to promote school
readiness prior to the failure of
a younger sibling
School Failure
Medical Assessment and Subsequent Interventions
Prevention
– Promote school readiness during health supervision visits
– Assess children’s strengths and weaknesses
– Assess educational progress at all health supervision visits
– Implement some interventions listed previously before failure occurs
– Assess peers, activities, and health-impairing behaviors