1. Pediatric Health Supervision Flashcards
What are disorders of growth and development often associated with in the general health and well being of children?
Disorders of growth and development are associated with disease ranging from severe and chronic illness as well as indicator of neglect and abuse.
Periodic monitoring is done to monitor and screen for disease state. Accurate measurements of height, weight and head circumferences should be obtained at every health supervision visit.
What is the routine office visit schedule for the first 3 years of life as according to the American Academy of Pediatrician (AAP)?
2 weeks
1, 2 ,4, 6, 9, 12, 15, 18 months
24, 30, 36 months (2, 2.5, 3 years)
Describe the purpose and types of growth charts by age.
Purpose
- abnormalities may be from endocrine imbalance or other issues.
Growth charts: (WHO 0-2 y/o; CDC >2 year old)
- head circumference
- length/height chart
- weight
- body mass index (BMI)
What is the rule of thumb in growth for weight in a newborn?
- Weight loss first few days - 5-10% of birth weight
- Return to birth weight - 7-10 days
- Double birth weight - 4-5 months
- Triple birth weight - 12 months
How is the trajectory of growth affected by inadequate caloric intake?
Weight falls first.
Then height.
Finally, head circumference.
List the possible causes of reduced caloric intake.
- Inadequate feeding.
- Child not receiving adequate attention/stimulation.
- Increased caloric needs due to chronic illness (heart failure and cystic fibrosis).
Describe possible causes of increased head circumference.
- Familial megacephaly.
- Hydrocephalus.
- “Catch-up” growth in a neurologically normal premature infant.
List and be able to interpret specific growth patterns requiring evaluation.
WEIGHT, LENGTH, HEAD CIRCUMFERENCE < 5th %-ILE.
DIAGNOSIS TO CONSIDER
- familial short stature
- constitutional short stature
- intrauterine insult
- genetic abnormality
FURTHER EVALUATION
- midparental heights
- evaluation of pubertal development
- examination of prenatal records
- chromosome analysis
List and be able to interpret specific growth patterns requiring evaluation.
DISCREPANT PERCENTILES (e.g. weight 5th, height 5th, head circumference 50th, and other)
DIAGNOSIS TO CONSIDER
- normal variant (familial or constitutional)
- endocrine growth failure
- caloric insufficiency
FURTHER EVALUATION
- midparental heights
- thyroid hormones
- growth factors, growth hormone testing
- evaluation of pubertal development
List and be able to interpret specific growth patterns requiring evaluation.
DECLINING PERCENTILES
DIAGNOSIS TO CONSIDER
- catch-down growth
- caloric insufficiency
- endocrine growth failure
FURTHER EVALUATION
- complete history and physical exam
- dietary and social history
- growth factors, growth hormone testing
Define FAMILIAL versus CONSTITUTIONAL short stature.
FAMILIAL (genetic)
- parents tend to be shorter height than average
- lower weight, length, and head circumference but is genetically normal
CONSTITUTIONAL
- (pre)adolescent child by age who starts puberty later than others
- short stature with normal growth rate for bone age, delayed pubertal growth spurt but eventual achievement of normal adult stature
- usually a family member had delayed growth/puberty
- lead to delays in secondary sexual development
Know how to plot and interpret a growth chart.
Just know it!
Describe the MORO REFLEX during the newborn period.
Allowing infant’s head to gently move back suddenly resulting in a startle.
Aduction / upward movement of arms –> adduction / flexion.
Flexion of the legs.
Appears: Birth
Disappears: 6 months
Describe the ROOTING REFLEX during the newborn period.
Touching the root of the newborn’s mouth resulting in the lowering of the lower lip on the same side with tongue movement toward the stimulus. Face turns toward stimulus.
Appears: Birth
Disappears: 4-6 months
Describe the SUCKING REFLEX during the newborn period.
Almost any object placed in the newborn’s mouth resulting in vigorous sucking.
Later replaced by voluntary sucking.
Describe the GRASP REFLEX during the newborn period.
Placing finger in palm results in flexing of infant’s fingers.
Appears: Birth
Disappears: 6 months
Describe the ASYMMETRIC TONIC NECK REFLEX during the newborn period.
Infant in supine position and turning head to a side. Placement results in ipsilateral extension of the arms and the leg into a “fencing” position. Contralateral side is flexed.
Delay warrants a CNS evaluation.
Define development surveillance and development screening.
Development SURVEILLANCE.
- informal process of comparing skill levels to list of milestones
- used at every office visit
Development SCREENING.
- tests to identify children who require further diagnostic assessment
- done at 9, 18 and 30 months
Be familiar with common development milestones.
2 WEEKS
2 weeks
- moves head side to side
- regards face
- alerts to bell
Be familiar with common development milestones.
2 MONTHS
2 months
- lifts shoulder while prone
- tracks past midline
- smiles responsively
- cooing, searching for sounds with eyes
Be familiar with common development milestones.
4 MONTHS
4 Months
- lifts up on hands, rolls front to back, no head lag
- reaches for object, raking grasp
- looks at hand, begins to work toward toy
- laughs and squeals
Be familiar with common development milestones.
6 MONTHS
6 Months
- sits alone/independently
- transfers object hand to hand
- feeds self, holds bottle
Be familiar with common development milestones.
9 MONTHS
9 Months
- pulls to stand, gets into sitting position
- starting to pincer grasp, bangs two blocks together
- waves bye-bye, plays pat-a-cake
- “Dada” and “Mama” nonspecific, two syllable sounds
Be familiar with common development milestones.
12 MONTHS
12 Months
- walks, stoops and stands
- puts block in cup
- drinks from a cup, imitates others
- “Dada” and “Mama” specific, say 1-2 other words
Be familiar with common development milestones.
15 MONTHS
15 Months
- walks backward
- scribbles, stacks two blocks
- uses spoon and fork, helps in homework
- says 3-6 words, follows command
Be familiar with common development milestones.
18 MONTHS
18 Months
- runs
- stacks 4 blocks, kicks a ball
- removes garment, feeds doll
- says at least 6 words
Be familiar with common development milestones.
2 YEARS
2 Years
- walks up and down stairs, throws overhand
- stacks 6 blocks, copies line
- washes and dries hand, brushes teeth, puts on clothes
Be familiar with common development milestones.
3 YEARS
3 Years
- walks, steps alternating feet, broad jump
- stacks 8 blocks, wiggles thumb
- uses spoon well, spilling little, puts on T-shirt
- names pictures, speech 75% understandable, say 3 word sentences
- understands concept of tomorrow, today
Be familiar with common development milestones.
4 YEARS
4 Years
- balances well on each foot, hops on one foot
- copies O maybe +, draws person w/ 3 parts
- brushes teeth w/o help, dresses w/o help
- names colors, understand adjective
Be familiar with common development milestones.
5 YEARS
5 Years
- skips, heel to toe walks
- copies box
- counts, understand opposites
Be familiar with common development milestones.
6 YEARS
6 Years
- balances on each foot for 6 seconds
- copies triangle, draws person w/ 6 parts
- defines words
- begins to understand “right” and “left”
Recognize the benefits and limitations of developmental screening.
- Uses standardized tests
- Children living in poverty still test every visit
- Some done by professionals, some at home
- 30% screened may be over-referred for testing
- 20-30% with disabilities are not detected by single admin will likely be identified by repeat screening at future visits.
Denver II and the four categories of development.
- Personal-social: can do certain skills without help (get dressed, bush teeth)
- Fine motor-adaptive: copies or draws a person with six parts
- Language: defines words
- Gross motor: balance on each foot for 6 seconds
Identify at which ages and how autism screening is performed.
Autism screening age: 18-24 months.
Screening
- office-based questionnaire that asks parents about child’s typical behaviors
- positive: +2 predictive behaviors or 3 total behaviors
- positive: requires further assessment to distinguish normal behaviors from children needing referral
Differentiate the speech production expectations of ages 1 through 5 (Rules of Thumb).
1 - one to three words
2 - two to three-word phrases (50% understandable)
3 - routine use of sentences (75% understandable)
4 - routine use of sentence sequences, conversation give and take
5 - complex sentences, extensive use of modifiers, pronouns and prepositions
- speech/language delay = also consider hearing deficit
- stuttering should elicit further testing if at 3-4 y/o
Demonstrate how to perform developmental assessment after a child’s 6th birthday.
- School readiness
- Assess specific pre-academic skills
- Motor skills
- Paren observations
List the various factors that contribute to behavioral problems.
Child Factors
- health, developmental status
- temperament, coping mechanisms
Parental Factors
- misinterpretations of stage-related behaviors
- mismatch of parental expectations and characteristics of child
- mismatch of personality style between parent/child
- parental characteristics
Environmental Factors
- stress, support, poverty
List the components or recommended topics for Health Supervision Visitis.
Focus on the Child
- concerns, past problem FU, immunization and screening test update, routine care, development progress, behavioral style and problems
Focus on the Child’s Environment
- Family (caregiver schedule, parent/sibling-child interactions, family role, stresses, support
- Community (caregiver, peer interaction, school/work, recreational activities)
- Physical environment (safety, appropriate stimulation)
Describe recommended screening tests for health children and know at which ages the tests should be performed.
NEWBORN (before discharge)
NEWBORN
- metabolic: tests phenylketonuria, galactosemia, congenital hypothyroidism, maple sugar urine disease, organic aciduria and immunoreactive trypsinogen for CF and bilirubin
- Hgb: sickle cell disease
- hearing: conduction and associated brain transmission
Describe recommended screening tests for health children and know at which ages the tests should be performed.
HEARING & VISION
HEARING & VISION
Infants & toddlers
- inferences from patients
Hearing
- responses to sound/speech as well as speech/language development
- 0-2 months: startle/blink to noise, calms to voice/music
- 2-3 months: change position/face to sound
- 3-4 months: turns eyes and head toward sound
- 6-7 months: listen to voices and conversation
- 3 y/o: visual sreening with re-exams 3-6 months intervals
- 4 y/o: audiological testing with headphones
Describe recommended screening tests for health children and know at which ages the tests should be performed.
ANEMIA
ANEMIA
- Birth and 4 months: if low birthweight or premature
- 12 months (high prevalence of iron deficiency)
Describe recommended screening tests for health children and know at which ages the tests should be performed.
LEAD
LEAD
- 12 and 24 months with screening questions from 6 months to 6 years
Describe recommended screening tests for health children and know at which ages the tests should be performed.
TUBERCULOSIS
TUBERCULOSIS
- 1, 6 and 12 months then annually
- in contact with persons known to have TB or is TB+
- health care workers, foreign-born persons
