3: 3-year-old male well-child visit Flashcards
Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Social
- The social environment plays a major part in how children develop.
- It is necessary to understand the family context before giving advice.
- To enter this arena, ask about changes and family stressors in a non-threatening way.
Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Nutrition
- Preschoolers can suffer from poor nutrition. Inadequate fruit, vegetable, and iron intake is quite common.
- Calcium and vitamin D deficiencies also are common.
- Children should receive vitamin D supplementation as it is very difficult to attain the recommended daily allowance through nutritional sources or from sun exposure.
Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Exercise
Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity.
Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Toilet Training
- Toddlers at age 3 may not have achieved full toilet “independence” - especially toddlers with intense, willful temperaments.
- Requiring assistance toileting is not a clear sign of developmental delay at this age, but may preclude attendance at child care or preschool.
Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Dental
(AAPD) and the AAP both state that all children should be seen within six months of the first tooth eruption or by 1 year of age.
–Additionally, the AAP states that all children should be screened by 6 months old to see if they are at a higher risk of developing caries. –Many general dentists feel that the first visit should be at age 3 years.
Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Safety
- Car seats are often used inappropriately; toddlers are moved too soon to booster seats.
- toddlers >24 mo or who have outgrown the weight and height limits on their car seats should be in a forward-facing car seat in the car’s back seat.
- Older children should stay in a booster seat until they reach a height of 4’ 9” (142 cm).
- Injuries are a major morbidity in the preschool years.
3 socio-emotional
- Brushes teeth (with assistance)
- Feeds self
4 socio-emotional
- Knows gender and age
- Friendly to other children
- Plays with toys/engages in fantasy play
5 socio-emotional
- Listens and attends
- Can tell difference between real and make- believe
- Shows sympathy/concern for others
3 communication
- Speaks in 2- to 3-word sentences
- 75% understandable
4 communication
- States first and last name
- Sings a song
- Most speech clearly understandable
5 communication
- Articulates well
- Tells a simple story using full sentences
- Uses appropriate tenses and pronouns
- Counts to 10
- Follows simple directions
3 cognitive
Knows name and use of “cup, ball, spoon, crayon”
4 cognitive
-Names colors
-Aware of gender
-Plays board games
-Draws person with 3 parts
-Copies a cross

5 cognitive
Asking the parents about school performance is as important as the following milestones:
- -Draws a person with > 6 body parts
- -Prints some letters and numbers
- -Copies squares and triangles
3 Physical
- Builds tower of 6-8 cubes
- Throws a ball overhand
- Rides a tricycle Copies a circle
4 Physical
- Hops on one foot
- Balances for 2 seconds
- Pours, cuts, and mashes own food
- Brushes teet
5 Physical
- Balances on one foot
- Hops and skips
- Ties a knot
- Has mature pencil grasp
- Undresses/dresses with minimal assistance
Eczema and Allergies
Although eczema often occurs without a history of allergies, such a hx would support an atopic diathesis and should prompt you to ask additional questions about allergic triggers and asthma symptoms.
Eczema (Atopic Dermatitis): Fhx
While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear environmental (allergic) triggers.
Eczema (Atopic Dermatitis): Ddx
- -Psoriasis: Although psoriasis can occasionally first look like eczema, it is rare in young children. When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection.
- -Seborrhea: This should also be part of the differential diagnosis, especially in early infancy (e.g., cradle cap). It is unusual to have a new case of seborrheic dermatitis at age 3.
basic tenets of the treatment of eczema
- Protecting skin by lubricating extensively
- Using anti-inflammatories in short bursts
- Treating associated skin infections aggressively.
Eczema Pharm: Steroids
- Prescribe topical steroid, alternating a higher potency for severe flares with a lower potency for minor bouts.
- Often over-the-counter hydrocortisone is inadequate.
Eczema Pharm: Topical anti-inflammatories
-Calcineurin inhibitors are considered second-line therapy. Although effective, safety concerns remain for long term use.
Eczema Pharm: Antihistamines
- non-sedating antihistamines approved for children, loratidine, fexofenadine and cetirizine may be effective.
- Traditional antihistamines (with sedative side effects) such as diphenhydramine and hydroxyzine are often used at bedtime to decrease itch.
Common Dietary Issues in Early Childhood: Inadequate nutrition
- only taking 80% of the recommended fruit servings/day, but only 30% of the recommended vegetable servings/day.
- Iron is of crucial importance to normal development in this age group due to its role as a CNS co-catalyst.
- Iron intake in toddlers occurs predominantly from meat, legumes, and iron fortified cereals.
Common Dietary Issues in Early Childhood: Milk and Juice intake
no more than 4-6 ounces of juice per day
Common Dietary Issues in Early Childhood: Early childhood caries
- Bathing teeth throughout the day with milk or juice from a bottle can result in early dental caries.
- Early childhood caries typically have a lag time before visible decay. Thus the patterns established when a child is 1 to 3 years old may result in caries when the child is 3 to 5 years old.
- routine bedtime use of the bottle can lead to cavities.
- It is recommended that parents discontinue the bottle by the time the child is 12- to 15- mo.
Common Dietary Issues in Early Childhood: Control battles about food
Food rewards and punishment in preschoolers may promote obesity by interfering with children’s ability to regulate their own food intake.
Important causes of injury in a toddler include
- Car accidents
- Swimming pools
- Falls
- Firearms
- Poisonings
- Fires
Children and Guns
- 52% of parents who owned guns thought that their children were “too smart” or “knew better,” even though only 40% had given specific instructions to their children regarding guns. (In this survey only 12% of parents who owned guns locked them.)
- When given the opportunity, boys ages 8-12 would handle a gun (76%) and pull the trigger (48%).
- -Parents’ opinions about whether or not their child would handle a gun were not predictive of which boys would handle the gun.
Lead screening
- lead absorption is higher in younger children than in older children and adults.
- Iron deficiency, which is common in toddlers, increases lead absorption
Common sources of lead exposure include
- House paint used before 1978 - and particularly before 1960. Deteriorating paint produces lead-containing dust, particularly during renovation.
- Soil
- Plumbing, pipes
- Hobbies, occupational exposures Imported toys, ceramics, candy, cosmetics
- Folk remedies
AAP policy recommends blood lead testing for
- All children 12-24mo in areas where > 25% of housing was built before 1960 or where the prevalence of blood lead levels > 5 μg/dL in children is 5% or greater.
- Individual children who live in or regularly visit homes/facilities built before 1960 that are in poor repair or have been renovated within the past 6 months.
TB risk factors
- -Spending time with an individual known or suspected to have TB disease
- -Being infected with HIV or another condition that weakens the immune system
- -Having symptoms of TB disease
- -Living in (or coming from) a country where TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia)
- -Living somewhere in the U.S. where TB disease is more common (e.g., a homeless shelter, migrant farm camp, prison or jail, and some nursing homes)
- -Use of injected illegal drugs.
Iron Deficiency Anemia: Epidemiology
preschoolers deficient iron stores may occur in up to 35% of low-income children (versus only 7% in other preschoolers), with up to 10% having iron-deficiency anemia.
Iron Deficiency Anemia:
Association with Cognitive Difficulty
association between iron deficiency in infancy and later cognitive deficits
Iron Deficiency Anemia: Causes
most likely acquired cause of iron-deficiency anemia.
Iron Deficiency Anemia: Therapy
In children whose anemia is mild, many providers will provide a trial of iron rather than do any further workup at this point. If the hemoglobin recovers to the normal range after a trial period, that is sufficient evidence of iron- deficiency anemia.
Other Causes of Anemia; In children of Mediterranean, Asian or African descent, hemoglobinopathies should be considered, including:
-alpha thalassemia
-G6PD deficiency
-sickle cell disease
(In these cases, the child’s newborn screening hemoglobin electrophoresis would have been abnormal.)
more severe anemia (Hgb less than 9 g/dL (90 g/L) d/t:
- Decreased marrow production (e.g., aplastic anemia)
- Hemolytic anemia
- Vitamin deficiencies (e.g., folate and B6)
Unusual acquired causes of anemia include chronic or severe illnesses
- Collagen vascular disease
- Malignancy
- Other chronic illnesses
Strabismus
misalignment of the eyes. Strabismus can lead to amblyopia, or poor visual development if not managed.
Two methods of assessing presence and degree of strabismus
- The Hirschberg light reflex
- The cover/uncover test
Physical Exam of the Toddler and Preschooler: MSK
- Several gait variants occur at this age. The most common is intoeing.
- Intoeing in toddlers is usually caused by tibial torsion. In tibial torsion, when the patella faces straight ahead, the foot turns inward. Tibial torsion resolves naturally with weight bearing - usually by 4 years of age.
- Intoeing in preschool- and school-aged children is usually caused by femoral anteversion. In femoral anteversion both the feet and knees turn inward. Femoral anteversion usually resolves spontaneously by 8-12 years of age.
Neurodevelopmental Exam of a 3-Year-Old
- -Language (speaks in short sentences; 75% of language is intelligible to a stranger)
- -Fine motor (holds a pencil or crayon; copies a circle)
- -Gross motor (hops; can ride a tricycle)
- -Cognitive (draws a person with three body parts)
Improving Toddler Eating Habits
- Stop the bottle now.
- Limit the child’s eating to three meals and two snacks, stopping the food and drink grazing.
- No bargaining or cajoling
- Gradually change his diet content
Anemia Screening
- Typically, screening for anemia is done at 12 months and again at preschool or kindergarten entry.
- The initial 12-month window coincides with a period in development when diet, particularly iron sources, is often in flux.
- If there are risk factors for anemia, then testing may be done at any visit.
- Results of a screening hemoglobin can be known immediately.
- Spun hematocrit still relies on blood volume, and hydration status can falsely affect the result.
