3: 3-year-old male well-child visit

Question 1

Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Social

Answer 1

-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.

Question 2

Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Nutrition

Answer 2

-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.

Question 3

Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Exercise

Answer 3

Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity.

Question 4

Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Toilet Training

Answer 4

-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.

Question 5

Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Dental

Answer 5

(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.

Question 6

Important Review Topics for a 3-Year-Old’s Health Maintenance Visit: Safety

Answer 6

-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.

Question 7

3 socio-emotional

Answer 7

-Brushes teeth (with assistance)-Feeds self

Question 8

4 socio-emotional

Answer 8

-Knows gender and age-Friendly to other children-Plays with toys/engages in fantasy play

Question 9

5 socio-emotional

Answer 9

-Listens and attends-Can tell difference between real and make- believe-Shows sympathy/concern for others

Question 10

3 communication

Answer 10

-Speaks in 2- to 3-word sentences-75% understandable

Question 11

4 communication

Answer 11

-States first and last name-Sings a song-Most speech clearly understandable

Question 12

5 communication

Answer 12

-Articulates well-Tells a simple story using full sentences-Uses appropriate tenses and pronouns-Counts to 10-Follows simple directions

Question 13

3 cognitive

Answer 13

Knows name and use of “cup, ball, spoon, crayon”

Question 14

4 cognitive

Answer 14

-Names colors-Aware of gender-Plays board games-Draws person with 3 parts-Copies a cross

Question 15

5 cognitive

Answer 15

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

Question 16

3 Physical

Answer 16

-Builds tower of 6-8 cubes-Throws a ball overhand-Rides a tricycle Copies a circle

Question 17

4 Physical

Answer 17

-Hops on one foot-Balances for 2 seconds-Pours, cuts, and mashes own food-Brushes teet

Question 18

5 Physical

Answer 18

-Balances on one foot -Hops and skips-Ties a knot-Has mature pencil grasp-Undresses/dresses with minimal assistance

Question 19

Eczema and Allergies

Answer 19

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.

Question 20

Eczema (Atopic Dermatitis): Fhx

Answer 20

While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear environmental (allergic) triggers.

Question 21

Eczema (Atopic Dermatitis): Ddx

Answer 21

–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.

Question 22

basic tenets of the treatment of eczema

Answer 22

-Protecting skin by lubricating extensively-Using anti-inflammatories in short bursts-Treating associated skin infections aggressively.

Question 23

Eczema Pharm: Steroids

Answer 23

-Prescribe topical steroid, alternating a higher potency for severe flares with a lower potency for minor bouts.-Often over-the-counter hydrocortisone is inadequate.

Question 24

Eczema Pharm: Topical anti-inflammatories

Answer 24

-Calcineurin inhibitors are considered second-line therapy. Although effective, safety concerns remain for long term use.

Question 25

Eczema Pharm: Antihistamines

Answer 25

-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.

Question 26

Common Dietary Issues in Early Childhood: Inadequate nutrition

Answer 26

-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.

Question 27

Common Dietary Issues in Early Childhood: Milk and Juice intake

Answer 27

no more than 4-6 ounces of juice per day

Question 28

Common Dietary Issues in Early Childhood: Early childhood caries

Answer 28

-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.

Question 29

Common Dietary Issues in Early Childhood: Control battles about food

Answer 29

Food rewards and punishment in preschoolers may promote obesity by interfering with children’s ability to regulate their own food intake.

Question 30

Important causes of injury in a toddler include

Answer 30

-Car accidents -Swimming pools -Falls-Firearms -Poisonings -Fires

Question 31

Children and Guns

Answer 31

-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.

Question 32

Lead screening

Answer 32

-lead absorption is higher in younger children than in older children and adults. -Iron deficiency, which is common in toddlers, increases lead absorption

Question 33

Common sources of lead exposure include

Answer 33

-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

Question 34

AAP policy recommends blood lead testing for

Answer 34

-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.

Question 35

TB risk factors

Answer 35

–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.

Question 36

Iron Deficiency Anemia: Epidemiology

Answer 36

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.

Question 37

Iron Deficiency Anemia: Association with Cognitive Difficulty

Answer 37

association between iron deficiency in infancy and later cognitive deficits

Question 38

Iron Deficiency Anemia: Causes

Answer 38

most likely acquired cause of iron-deficiency anemia.

Question 39

Iron Deficiency Anemia: Therapy

Answer 39

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.

Question 40

Other Causes of Anemia; In children of Mediterranean, Asian or African descent, hemoglobinopathies should be considered, including:

Answer 40

-alpha thalassemia -G6PD deficiency -sickle cell disease(In these cases, the child’s newborn screening hemoglobin electrophoresis would have been abnormal.)

Question 41

more severe anemia (Hgb less than 9 g/dL (90 g/L) d/t:

Answer 41

-Decreased marrow production (e.g., aplastic anemia) -Hemolytic anemia-Vitamin deficiencies (e.g., folate and B6)

Question 42

Unusual acquired causes of anemia include chronic or severe illnesses

Answer 42

-Collagen vascular disease -Malignancy-Other chronic illnesses

Question 43

Strabismus

Answer 43

misalignment of the eyes. Strabismus can lead to amblyopia, or poor visual development if not managed.

Question 44

Two methods of assessing presence and degree of strabismus

Answer 44

-The Hirschberg light reflex -The cover/uncover test

Question 45

Physical Exam of the Toddler and Preschooler: MSK

Answer 45

-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.

Question 46

Neurodevelopmental Exam of a 3-Year-Old

Answer 46

–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)

Question 47

Improving Toddler Eating Habits

Answer 47

-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

Question 48

Anemia Screening

Answer 48

-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.