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The Well-Child visit, Growth and Development, and Anticipatory guidelines
Terms in this set (113)
What is measured at each pediatric well visit?
Height and weight
What is measured at well visit if they are younger than 36 months
When is BMI added to the list of required measurements during well visit?
After 24 months
Before 24 months, they have a weight-for-length measurement
How is weight and height measured in infants and young children during well visit?
Weight infants and young children with their clothes off (including shoes)
Use same scale each time
Measure length in recumbent position until age 2 years, then measure standing height
For head circumference, use the tape measure around the greatest circumference of the occipo-frontal area - do this 3 times and take the greatest of the 3 measurements
What determines growth?
Genetic factors involve our potential from parents
Environmental factors include many different aspects, most importantly nutrition
Hormonal factors (discussed more later)
What is normal weight gain in healthy, full-term newborns?
15-30 grams per day for the first 3 months of life
What is normal weight gain from age 3-6 months?
Daily weight gain: 20 g
Monthly weight gain: 1.25 lbs
What is normal weight gain from age 6-9 months?
Daily weight gain: 15 g
Monthly weight gain: 1 lb
What is normal weight gain from age 9-12 months?
Daily weight gain: 12 g
Monthly weight gain: 13 ounces
What is normal weight gain from age 1-2 years?
Daily weight gain: 8 g
Monthly weight gain: 8 ounces
What is normal weight gain from 2 years up to adolescence?
Daily weight gain: 2-3 g
Monthly weight gain: 6.6 ounces
When is birth weight regained?
Birth weight is regained by days of life 10-14
When does birth weight double?
Birth weight doubles by 4 months
When does birth weight triple?
Birth weight triples by 12 months
When does birth weight quadruple?
Birth weight quadruples by 24 months
What is the average height of a newborn?
The average height of a newborn is 20 inches in length
What happens to birth height by 1 year of age?
By 1 year of age, the birth height increases by 50%
What happens to birth height by 4 years?
Birth height doubles by 4 years
What happens to birth heigh by 13 years?
Birth height triples by 13 years
What is the average height increase after 2 years of age?
Average height increase is 2'' per year until adolescence
What is 50th percentile for head circumference of girls and boys at birth?
Girls: 35 cm
Boys: 36 cm
What is the fastest rate of growth for head circumference?
0.5 cm per week between 0-2 months
At what percentiles are major divisions noted?
3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, 97th
What is abnormal interpretation of growth chart for height?
Length/height for age < 5th percentile is indicative of stunting
What is healthy weight on growth chart?
BMI for age between 5th and 85th percentiles
What is underweight on growth chart?
< 3 years: weight for length < 5th percentile
2 years or more = BMI for age < 5th percentile
What is overweight on growth chart?
> 2 years: BMI for age 85th-95th percentile
What is obese on growth chart?
< 3 years: weight for length > 95th percentile
2 years or more: BMI for age is greater than or equal to 95th percentile
What does the PE of the infant begin with?
Head: evaluate shape, size, sutures, fontanelles
Look for flattening of different areas (positional plagiocephaly), macrocephaly or microcephaly
Evaluate different sutures in the skull, for abnormalities, early closure, etc.
Describe the physical exam findings of the fontanelle
Find anterior fontanelle (should be open, soft, and fairly flat)
Might notice pulse through open fontanell
Abnormal: bulging or sunken
When does fontanelle closure occur?
Posterior fontanelle usually closes around 1-2 months old
Anterior fontanelle usually closes around 12 months old (with normal range from 6 - 24 months)
What can result from early fontanelle closure?
What do you focus on during the eye exam?
Look at position on face, symmetry, color of sclera, reactivity of pupils to light, movement of extraocular muscles, red reflex
Note that absence of red reflex (leukocoria) can indicate various disesae processes such as congenital cataracts or retinoblastoma
What do you focus on during the ear exam?
Notice their general appearance, location on head (low-set - can be seen in various different genetic syndromes), presence of skin tags or pits
Skin tags have no bony or cartilaginous components and do not communicate with the ear canal or middle ear
What does preauricular pits on physical exam indicate?
Preauricular pits have potential to cause cellulitis or abscess but are otherwise benign lesions
What do you focus on when examining the nose?
Bilateral nares, any obvious internal defects (polyps)
Look for midline location
What do you focus on when examining the mouth?
Use gloved or washed finger to explore the inside of an infant's mouth looking for palate and lip defects (clefts)
Look for normal tongue positioning and tone, gum abnormalities
Feel for soft palate
What do you focus on when examining the neck?
Observe any masses anterior/posterior on the neck, positioning of neck
Move to the base of the neck and palpate clavicles (look for birth trauma fractures)
What are the possible issues found on PE of the neck?
Thyroglossal duct cysts: fluid filled remnant from the thyroid gland formation (usually midline)
Branchial cleft cysts: improper closure during embryonic life (often non-midline)
Ectopic thyroid tissue: failed travel of thyroid tissue during development (midline)
Torticollis: abnormal twisting of neck
What do you focus on when examining front and back of infant?
Ensure bilateral chest expansion with each breath
Listen for heart sounds (murmurs, extra sounds, rate)
Listen to breath sounds (clean air entry vs. crackles vs. wheeze)
Reactive airway disease < 2 years old
Asthma > 2 years
What do you focus on when examining the infant's abdomen?
Observe for umbilical hernias
Palpate for masses or organ enlargement
Listen for bowel sounds
What causes umbilical hernias?
When part of the intestine protrudes through the umbilical opening in the abdominal muscles
Ensure that they are easily reducible
Most close by 1-2 years
What do you focus on in the examination of the reproductive organs?
Male and females: look for inguinal hernias (bulging in groin), ensure anal patency
Females: observe for labial adhesions or other external abnormalities
Males: be sure to comment on circumcision status and palpate for both testicles within the scrotum
What should be referred to pediatric surgeons when found on exam?
Cryptorchidism - undescended testicle where into cannot be "milked" into the scrotum
Risk of testicular cancer and infertility
Surgical correction (orchiopexy) must be performed between 6-12 months if hasn't spontaneously descended by 4 months of life, it won't
What do you focus on when examining the infant's back and buttock
Pay close attention to look for neural tube defects (open defects, tufts of hair) and sacral pits as they could be signs of spina bifida
What do you focus on when examining infant's hips?
Assess for developmental dysplasia of the hips
Barlow: test will dislocate hip (started with hip reduced)
Ortolani: test will redice hip (started with hip dislocated)
What imaging must be done before referral if + for developmental dysplasia of the hip?
What is developmental dysplasia of the hip?
Spectrum of pathology in the development of the immature hip joint, in which the head of the infant's femur is able to be dislocated
What are risk factors for developmental dysplasia of the hip?
Positive family history of developmental dysplasia of the hip
Breech presentation at delivery
Large birth weight
What do you focus on during examination of the infant's extremities?
Count all 10 fingers and toes (looking for polydactyly or syndactyly)
Observe movement of bilateral arms and legs (equal and all moving?)
What is the last part of the PE of an infant?
Assess overall tone
What are extra considerations to make during the PE of a young child in comparison to an infant?
They're more aware of where they are and may be more fearful during exams (shots)
May want to do as much of exam as possible with patient in parent's lap to ensure comfort
Scoliosis is also checked: look at shoulders, hips, run hand down spine
When should hemoglobin and hematocrit be checked?
As early as 9 month visit or typically at 12 month well visit to assess for anemia
Can be a finger stick test for Hgb ONLY
What is the MC cause of anemia in this age group?
Iron deficiency anemia: generally caused by a lack of dietary intake of iron-rich foods and an over-abundance of intake of cow's milk
How can iron deficiency anemia be prevented through counseling?
Breast-fed infants absorb iron 2-3 times more efficiently
Formulas should be iron-fortified
Introduce iron-rich cereals at 4-6 months
Limit cow's milk consumption to < 20 ounces per day after age 1
When should lead screening begin?
Begin asking questions about risk factors around 6 months
Levels should be checked at 12 month or 24 month well visit
Why do lead levels need to be checked?
Lead toxicity is known to cause negative cognitive effects as well as behavioral effects such as hyperactivity, brain damage, neuropathy
What are PE findings of increased lead levels?
Lead lines on fingers and teeth
What are sources of lead?
Old paint chips, dust, soil, parent who works in welding/plumbing/construction, lead-based gasoline, imported toys, antique toys, living in house with renovations
Is routine urinalysis during well-visit recommended?
No, there is no cost-effective screening test and therefore not recommended routinely
There are screening recommendations for sexually-active adolescents with symptoms of UTI
When doe blood pressure screening begin?
At age 3 years in otherwise healthy children
At age less than 3 years for children who have an abnormal medical history (prematurely born infant, infant/toddler with congenital heart defects, infant/toddler with any kidney disease
How is hypertension diagnosed in children?
Elevated blood pressure in 3 separate readings over a period of days to weeks
Ensure that corrected BP cuff size is used
Repeated elevated automated BP with manual
When is cholesterol screening recommended?
All children aged 9-11 due to growing epidemic of obesity in kids
Those with parents/grandparents with hx of heart attack, CAD, stroke at 55 or younger in men, 65 or younger in women
What is an acceptable, borderline, vs. high total cholesterol and LDL?
Acceptable: total cholesterol < 170 and LDL < 110
Borderline: total cholesterol 170-199, LDL 110-129
High: total cholesterol > 200, LDL > 130
When should hearing be screened?
All infants should be screened for hearing prior to 3 months of life and preferably prior to discharge home from the hospital
What are the two methods for screening hearing?
Auditory Brainstem Response (ABR) and Otoacoustic Emissions (OAE)
What is ABR?
Preferred method of screening for infants < 6 months as it is more specific for detecting hearing loss and measures how cranial nerve VIII (vestibulocochlear nerve) responds to sound
What is OAE?
Measures soundwaves produced in the inner ear, but has a lower specificity (may incorrectly identify more children with problems)
What are the AAP recommendations for formal hearing screens?
All children at age 3,4,5 and then every 2-3 years until adolescence
Also screen any patient with language delay
What are common concerns regarding hearing that the parent/caregiver may express and would warrant screening?
Speech is not developing
History of bacterial meningitis
History of neonatal TORCH infection
Certain genetic syndromes associated with hearing loss
Family history of childhood impairment
What are the AAP recommendations for visual screening?
Annually at age 3
Use schematic picture from age 3-5
Starting at age 6 years, an adult Snellen chart can be used
What additional test should performed for toddlers/preschool children?
Unilateral cover test
- Have child look straight ahead at an object 10 feet away: cover and uncover each eye
- Movement in the uncovered eye when the opposite is covered or uncovered suggests potential ocular misalignment (strabismus) which can result in vision loss (amblyopia)
- Seen in up to 4% of kids < 6 years old
- Note: look for movement as the opposite eye is uncovered
What are developmental milestones for newborns?
Gross Motor: Move head side to side
Fine Motor/Adaptive: None
Personal-Social: regards face
Language: alerts to bell
What are developmental milestones for 2 months of age?
Gross Motor: Lift shoulders in prone
Fine Motor/Adaptive: Tracks past midline
Personal-Social: smiles responsively (social)
What are developmental milestones for 4 months of age?
Gross Motor: Lifts up on hands, Rolls (stomach to back)
Fine Motor/Adaptive: reaches for objects, raking grasp
Personal-Social: Looks at hand
Language: Laughs and squeals
What are developmental milestones for 6 months of age?
Gross Motor: Sits alone, rolls (both directions)
Fine Motor/Adaptive: Transfers object hand to hand
Personal-Social: feeds self, holds bottle
What are developmental milestones for 9 months of age?
Gross Motor: Pulls to stand
Fine Motor/Adaptive: Bangs 2 objects together, immature pincer grasp
Personal-Social: Stranger Danger!, waves bye-bye
Language: Says Dada and Mama (nonspecific)
What are developmental milestones for 12 months of age?
Gross Motor: Walks
Fine Motor/Adaptive: puts block in cup, mature pincer grasp
Personal-Social: Drinks from cup
Language: Says Dada and Mama (specific), 1-2 other words
What are developmental milestones for 15 months of age?
Gross Motor: Walks backwards, *ABNORMAL TO NOT WALK
Fine Motor/Adaptive: Scribbles, Stacks 2 blocks
Personal-Social: Uses spoon/fork, helps with simple housework, points
Language: Says 3-6 words (besides Mama and Dada), Follows simple commands
What are developmental milestones for 18 months of age?
Gross Motor: Runs, kicks a ball
Fine Motor/Adaptive: Stacks 4 blocks
Personal-Social: Removes clothing
Language: Says at least 6 words (besides Mama and Dada)
What are developmental milestones for 2 year olds?
Gross Motor: Walks up and down stairs
Fine Motor/Adaptive: Copies line
Personal-Social: Puts on clothes, brushes teeth
Language: 2-word sentences, speech understandable 50%, knows body parts
What are developmental milestones for 3 year olds?
Gross Motor: walks steps with alternating feet, broad jump
Fine Motor/Adaptive: Stacks 8 blocks
Personal-Social: Uses spoon well
Language: 3 word sentences, speech understandable 75%
What are developmental milestones for 4 year olds?
Gross Motor: Balance on one foot, Hops on one foot
Fine Motor/Adaptive: Copies circle, draws person with 3 parts
Personal-Social: Dresses without help
Language: Names colors, speech understandable 100%
What are developmental milestones for 5 year olds?
Gross Motor: Skips, heel-to-toe walks
Fine Motor/Adaptive: Copies square, writes name
Language: counts, understands opposites
What are developmental milestones for 6 year olds?
Gross Motor: Balances on one foot
Fine Motor/Adaptive: Copies triangle, ties shoes, writes name (first & last)
Personal-Social: Imaginative play
Language: Defines words
What are developmental milestones for school age/pre-teen?
Identify learning disabilities!
What are developmental milestones for adolescents?
Puberty and independence!
Peer interactions, body image concerns, high risk activities
Concrete thinking abstract thinking
What are developmental screening tools?
Denver Developmental Screening test II (expensive)
Ages & Stages Questionnaire (ASQ) at ages 2,4,6
What is (S)HEADSSS assessment and when is it performed?
At age 11-12 years
S - strength
H - home
E - education
A - activities
D - drugs/alcohol/vaping
S - sex
S - safety
S - suicidality
What are recommendations for autism screening?
Persistent difficulties in the social use of the verbal and nonverbal communication
All children screened at age 18 months and 24 months of age
What is the autism screening tool?
Modified checklist for autism in toddlers (M-CHAT):
Answers should be NO to 2,5, and 12 and YES to all others
If severely abnormal, refer children for diagnostic evaluation and early intervention
What is involved in psychosocial assessment?
Hereditary + environment = behavior
Mom is screened for post-partum depression until baby is 1 year old
Affects: bonding, attachment, autonomy, school readiness, and adolescence
What are methods of operant conditioning in parents?
Positive reinforcement: increased behavior by reward/favorable event
Negative reinforcement: increase behavior by removal of aversive stimulus
Extinction: decrease by behavior by ignoring
Punishment: decrease behavior by unpleasant consequences
When is crying in an infant normal?
Most of the time
2-6 weeks old cry up to 2-3 hours per day
After 12 months, about 1 hour per day
Peaks at 2 months, give positive reinforcement
What indicates colic?
Rule of 3s:
3 hours per day, 3 days per week, for more than 3 weeks
Risk of abuse
Emotional, neglect (highest rate), physical, sexual
When are temper tantrums normal?
18 months - 4 years old
Holding breath spell can occur
Best treatment: extinction/punishment
How is Attention Deficit/Hyperactivity Disorder (ADHD) diagnosed?
History is key
Rule out possible underlying medical or developmental problems
Laboratory studies are not routinely indicated
Differential diagnosis: normal, hyperthyroidism, lead poisoning, sleep deprivation, learning disabilities
Symptoms present prior to age 7 in 2 or more settings with clear evidence if impairment in social, academic, and occupational functioning (Vanderbilt questionnaire)
Parent and teacher evaluations: 6 or more in inattention and hyperactivity-impulsivity symptoms
What is treatment for ADHD?
Stimulant medication is 1st line
can try non-stimulants as well
Side effects: dry mouth, weight loss, no tolerance, increased risk of suicidality
What are targets of anticipatory guidelines?
Fostering optimal development
What are anticipatory guidelines for newborns?
CRITICAL period! Crying, crib safety (no Co-sleeping!), car seats, caregiver bonding, counseling on nutrition
Ask about firearms
What are anticipatory guidelines from 2-4 months?
Hot water safety, parents return to work, ask about childcare plans
What are anticipatory guidelines from 4-6 months?
Introduction of solid jar foods, warn about rolling/injury risk, DROP the bed down in crib
What are anticipatory guidelines for 9 months?
INGESTIONS/POISONING prevention, stress importance of formula/breast milk as main source of nutrition, assess sleep, No cows milk yet!
What are anticipatory guidelines for 12 months?
Auto-pedestrian safety, discuss discipline, trash the pacifiers and bottles!, introduce whole cow's milk, safe exploration
What are anticipatory guidelines for 18-24 months?
High yield punishment, fall prevention, discuss behavior, look at growth charts and have discuss diet, start conversation about toilet training
What are anticipatory guidelines for preschool ages (3-4 years old)?
School readiness, TV/media violence, optimal eating
What are anticipatory guidelines for 5-6 years old?
Bicycle safety, water/pool safety, recommend swimming lessons, rules/limit setting, library card/at home review of school topics
What are anticipatory guidelines for 7-10 years old?
Sports safety, firearm safety, assess family dynamics, media violence/screen time, assess school performance, introduce smoking/substance prevention (BASIC)
What are anticipatory guidelines for 11-13 years old?
Sports safety, assess for bullying, media/screen time, diet (junk food), assess school performance, more in-depth discussion of smoking/substance prevention, sex education (abstinence)
What are anticipatory guidelines for adolescents?
Motor vehicle safety, family dynamics (curfew, parental relationship, etc.), career goals, substance abuse, dating/sex/sexuality, STD screening/prevention, violence
Birth: Hepatitis B
2 mo: Hepatitis B, DTaP, Hib, Polio, Prevnar, Rota
4 mo: DTaP, Hib, Polio, Prevnar, Rota
6 mo: Hepatitis B, DTaP, Hib, Polio, Prevnar, Rota
12 mo: MMR, Varicella, HepA
15 mo: DTaP, Hib, Prevnar
18 mo: Hep A
4 yo: MMRV, DTaP, Hib
11 yo: Tdap, Menactra, HPV
16 yo: Menactra booster
Car seat guidelines
Infants younger than 2 yo AND less than 20 lbs Rear facing infant seat
Children 2 yo and 20-40 lbs Front facing infant seat
Children 4-8 yo and 40-80 lbs Use a booster seat (until seat belt no longer lies across neck or lap belt across abdomen)
Children 12 yo and younger, or less than 4'9" BACK SEAT ONLY, seat belt use 100%
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