CA powerpoint-- Normal Growth and Development Flashcards
considered primary care
pediatrics
pediatrics Patient population
newborn to age 21
how do we measure growth and development?
height
weight
vital signs
measure to same gender and age!
milestones they have to meet
overall goal of well child visits
disease prevention and health promotion
Frequency of well child visits
1-2 weeks then at 2, 4, 6, 9, 12, 15, 18, 24 months then annually thereafter
what are you addressing at a well child visit?
- concerns of parents caregivers
- check growth and development
- immunizations
- screening tests
- anticipatory guidance
physical exam, growth charts, milestones
thing checked in growth and development part
disease and health prevention at a young age can result in _______ health outcomes for decades
improved
ASK!
Build report
provide written informaiton
address concerns of parents/caregivers
- -> Follows predictable pathway: kids go further they don’t go backwards (ie. if they can stand … if they come in again and can’t stand you have an issue)
- ->Wide range of ‘normal’
- ->Various factors affect development
- ->Child’s developmental level affects how you conduct the history & physical exam
Principles of child development
physical cognitive social environmental diseases
various factors that affect development
Remember – document source of info & reliability
Prenatal history – maternal health (exposure to alcohol, drugs, Rxs)
Gestational age at birth – preterm?
Immediate postnatal history – Apgar, hospital course
Medications/allergies- this might effect growth and development
Past medical history – immunization status, screening tests (blood test taken right after birth)
Family history – inherited d/o
Social history – living arrangement, substance use exposures
History taking for a well child visit
when do you start checking BP and how often
at age 3, check annually
physical exam
growth charts
MIlestones
other things to check for growth and development
Physical Development (fine motor skills, gross motor skills)
Cognitive and language development
Social and Emotional Development
Milestones
Typical child follows trajectory of increasing physical size & increasing complexity of function
Normal Growth & Development
Child _____ birth weight within 1st year
triples
child achieves _______ of brain size by age 2.5-3 years old
two-thirds
birth to 36 months
infant
Growth Chart
Infants, birth to 36 months
Length-for-age and weight-for-age
Head circumference-for-age and weight-for-length
2 to 20
children and adolescents
Growth chart
children and adolescents, 2 to 20
Stature-for-age and weight-for-age
BMI-for-age : start measuring at 2
Weight-for-stature (ages 2 to 5 years only)
in children normal BP is based on
age, gender, height
in children hypertension is defined as:
either systolic and/or diastolic BP >95th percentile measures on 3 or more occasions. the cuff size should be carefully matched to the size of the patients arm to avoid inaccurate measurements
the width of the bladder of the blood pressure cuff should be approximately 40 percent of the circumference of the upper arm midway between the olecranon and then acromion. the length of the bladder of the cuff should encircle 80 to 100 percent of the circumference of the upper arm at the same position
determining appropriate blood pressure cuff size in children
Vital signs – ht, wt, head circumference, BMI, BP
General appearance
Skin – lesions, bruising?
HEENT – head size/shape
Neck – lymph nodes (Hodgkins Lymphoma)
Heart – murmurs?
Lungs – pectoralis excovatum (or somethanng like that), nasal flaring, tripod (epiglotis), retractions
Abdomen – bowel sounds
GU, if indicated
Musculoskeletal – limb length, ROM, curvature/deformities
Neuro - motor (tone), sensory
Physical Exam- WCC
Make it fun!
Approach differs depending on age group
Find ways to distract young patients
Get help to hold, if necessary
Rewards
Code name for “shots”
Work well w/ your nurse
Clinical Pearls for PE
Failure to thrive
Sensory deficits – no response to loud stimuli (no tracking w/ eyes)
Congenital defects: 1 in every 33 babies in U.S. born w/ birth defect
Musculoskeletal disorders
most common dx detected on WCC
Cardiac
Fetal alcohol syndrome
Down syndrome
Cerebral palsy
Congenital defects
abnormal facial features, small head, low birth weight, poor coordination, hyperactive, cognitive defects, poor memory
Fetal alcohol syndrome
Complete physical exam
Are you ready at home?
Review newborn schedule
Safety
Newborn Visit
Circumcision
Screen for critical congenital heart disease w/ pulse ox after 24 hr & before d/c
complete physical exam
feeding: eat every 1-2 hours
sleeping
diapering
bathing
review of newborn schedule
Monitor weight (Should regain or exceed birth weight by 2 weeks)
make sure feeding is going okay
Postpartum depression
1st week visit
“exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.”
AAP’s recommendation for breastfeeding
american academy of pediatrics: AAP
lower rates of:
respiratory tract infection otitis media gastrointestinal tract infections necrotizing enterocolitis SID & infant mortality allergic idsease celiac disease inflammatory bowel disease obesity diabetes childhood leukemia & lymphoma neuro developmental outcomes
AN IMPORTANT ONE IS DECREASING OBESITY IN ADULTS
Benefits of breastfeeding
Social and emotional
- -> begins to smile at people
- -> can breifly calm himself (may bring hands to mouth and suck on hand)
- -> tries to look at parent
Language/communication
- -> coos, makes gurgling sounds
- -> turns head toward sounds
Cognitive (learning, thinking, problem solving)
- -> pays attention to faces
- -> begins to follow things with eyes and recognizes people at a distance
- -> begins to act bored (cries, fussy) if activity doesnt change
Movement/Physical Development
- -> can hold head up and begins to push up when lying on tummy
- -> makes smoother movements with arms and legs
milestones: 2 month visits
…..
4 month slide 25
.... MAY BE SITTING PROPED AND SUPPORTED MORE VERBAL SKILLS MORE NOISES RESPONDING TO THEIR NAME
6 months slide 26
adding food….
4 steps
AT 6 MONTHS
“Baby Food” : (Cereal, Fruits, Veggies, Meat, Snacks): THEY WILL NEED MORE IRON!
Start w/ thin consistency, gradually thicken
Continue w/ breastfeeding and/or formula
Most infants can go through night w/o being fed
.... sitting on their own by themselvels playing games understand word NO maybe pulling up on furniture maybe walking
9 months slide 28
….
ON THE MOVE
but still not coordinated
12 months slide 29
food when turning 1
and other things happening
grazing: smaller stomach eat throughout the day… not really three main meals
can switch from formula/ breastfeeding to whole milk
THEY ARE ON THE MOVE!
….
need to be standing here!
18 Months. slide 31
…..
can say 2-4 words
learn their independence
2 years slide 32
“terrible twos”
food
other things hapening
can switch from whole to skim milk (want to cut down on fat .. but still need calcium from milk… want to cut down on obesity rates)
avoid choking (sit down!!!!!!!)
TOILET READINESS
reassure parents that it is okay .. and to stay calm,… need to support parents and help them
…..
3 years slide 34
…..
4 years slide 35
…..
pre school
5 years slide 36
achievement by trial & error, goal-directed
middle childhood
6-10yrs
Physical
Enhanced strength & coordination
Competence in various tasks & activities
Cognitive
“Concrete operational,” focus on the present
Achievement of knowledge & skills, self-efficacy
Social
Achieving good “fit” w/ family, friends, school
Sustained self-esteem
Evolving self-identity
6-10 years
11-21
adolescence
Physical
Puberty – physical transition from childhood to adulthood
Onset – age 10 for girls & age 11 for boys
End w/ growth spurt by age 14 for girls & age 16 for boys
Duration of puberty varies widely but stages follow same sequence (sexual maturity rating or Tanner stages)
Cognitive
Learn to reason logically & abstractly, consider future implications of current actions
Often erratic, still limited ability to see beyond simple solutions
Moral thinking becomes sophisticated
Social/Emotional
Tumultuous time, marked by transition from family-dominated influences to autonomy & peer influences
Struggle for identity, independence & eventually intimacy
11-21 years
sexual maturity ratings (SMR)
picture coming… slide 39
School (bullying, academic performance, sports)
Mental health (self-esteem, temper issues, independence)
Nutrition & Development (healthy eating, BMI, puberty, exercise, sexuality & orientation)
Oral health (regular dental visits, brush/floss)
Safety (helmets, tobacco/alcohol/drugs, pregnancy, driving, screen time)
Priorities For The Visit:Middle Childhood & Adolescence
Standard and catch-up schedules
Immunization Registry: data base (state or region), “ImmPactII” in Maine
School minimum requirements (state)
Exception information
religious, philosophical or medical reason
parent must submit written statement
Contraindications
severe allergic reaction
severe combined immunodeficiency (SCID)
pregnancy
Immunizations
* if you are immunodeficient you can opt out of vaccines*
Chicken pox- varicella vaccine Diphtheria- DTaP vaccine HiB- Hib vaccine (against hemoaphilus influenzae type B) Hep A: Hep A vaccine Hep B- Hep B vaccine influenza: Flu vaccine Measles: MMR Mumps: MMR Pertussis: Tdap Polio: IPV Pneumococcal: PCV vaccine Rotavirus: RV Rubella: MMR Tetanus: Dtap
all vaccine - preventable diseases and the vaccines that prevent them
Newborn Metabolic Screening
check 24 hours after birth
Hematocrit or hemoglobin
screen at 12 months
risk assessment at 15 and 30 months
because they can start eating table foods…
and if the kid is obsessed with moms breast milk then they are not getting adequate iron
lead screening
screen at 12 months
Tuberculin test
if risk factors present
country with high risk
or someone around them
Visual acuity
start at age 3 (if able), check periodically
hearing
after birth
then at age 4
check periodically
dylipiddemia screening
once between 9-11 years old and again between 17-21 years
STI screening
screen for HIV between 16 and 18 years
additional testing if sexually active, at least annually
pap- NO! but consider a pelvic exam
3-Hydroxy-3-methylglutaryl-CoA lyase deficiency
3-Methylcrotonyl-CoA carboxylase deficiency
Argininemia
Argininosuccinic acidemia
Beta-ketothiolase deficiency
Biotinidase deficiency
Carnitine palmitoyl transferase deficiency Type II
Carnitine uptake deficiency
Citrullinemia
Congenital adrenal hyperplasia
Congenital hypothyroidism
Cystic Fibrosis (CF)
Galactosemia
Glutaric acidemia type I
Glutaric acidemia type II
Homocystinuria
Hyperammonemia Hyperornithinemia Homocitrullinemia (HHH Syndrome)
Isovaleric acidemia
Long-chain acyl-CoA dehydrogenase (LCAD) deficiency
Long-chain hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
Maple syrup urine disease
Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency
Methylmalonic acidemia
Multiple carboxylase deficiency
Phenylketonuria (PKU)
Propionic acidemia
Short-chain acyl-CoA dehydrogenase (SCAD) deficiency
Sickle cell disease/hemoglobin disorders
Trifunctional protein deficiency
Tyrosinemia type I
Tyrosinemia type II
Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency
hahahhahahhahahahahahahahah
memorize this…hahaha jkjk
list of condisitons in a newborn metabolic screening
visual care screening at primary care office
inspections of eye and lids: all ages
red reflex: birth until child can read eye chart
Assessment of fixation and following: starting at 2 months
Corneal light reflex for assessing strabismus: 3 months to 5 years
Cover testing for assessing strabismus: 6 months to 5 years
Fundoscopic examination: starting at 3 years
Preliterate eye chart testing: starting at 3-4 years
Healthy habits Nutrition & healthy eating Safety & prevention of injury Physical activity Sexual development & sexuality Family relationships Emotional & mental health Oral health Recognition of illness Screen time Prevention of risky behaviors School & vocation Peer relationships
Anticipatory guidance
Rear facing seats until at least age:
two
as long as possible, until hgt/wgt max limit by manufacturer
Forward-facing:
up until 4’9” AND age 8-12 yrs
Booster seat:
In rear seats until age
13
there are child seat inspection station locator
k cool.. now you know
“safe to sleep”
increase tummy time.: avoid flat heads??? huh!? haha
reduce risk of SIDS
Pets Plants Stove/oven Water heater Electrical outlets Bathtub Cleaning supplies Adult medications Fertilizer Street traffic
safety proof the house
inside and out
nutrition and healthy eating
my plate
eat together as a family
lets move campaign
… ok so move
aka “baby teeth”
By age 3, 20 teeth
Oral health
primary teeth
1st tooth eruption usually between
4-15 months old
Eruption starts ~5-7 yrs, ends by age 13-14 yrs
permanent teeth
what is the number 1 chronic disease in children?
dental caries
what should we brush with BID
Fluoridated toothpaste
what is a cool way to remember brushing teeth for kids
Brush, book, bed
AAP initiative
structured bedtime
Children from birth through age 5 years
recommended that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride
recommends that primary care clinicians apply fluoride varnish to primary teeth of all infants and children starting at age of primary tooth eruption
Conclude the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental carries performed by primary care clinicians in children from birth to age 5 years.
Recommended for children ages 6 mo – 5 yrs
USPSTF: “Once teeth are present, fluoride varnish may be applied to all children every 3-6 months in the primary care or dental office.”
Fluoride Varnish
pictures of teeth
slide 62
screen time
… like TV or computer or whatever has a screen
AAP screen time recommendations:
Avoided before age 2
Limited to 2 hours for children & teens
“Screen-free zones”
Monitor content
Excessive media use can lead to:
attention problems school difficulties sleep & eating disorders obesity can provide platforms for illicit & risky behaviors
________ are the leading cause of death in children & adolescents after 1st year of life
Injuries
Motor vehicle injuries Bicycle injuries Skiing & snowboarding injuries Firearm injuries Drowning & near drowning Fire & burn injuries Choking
different types of injuries
when do you do depression screening
screen ages 11 through 21
Part A (in past 12 months):
Drank any alcohol
Smoked any marijuana
Used anything else to get “high”
Part B (if “yes” to any in part A):
Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or other drugs?
Do you ever use alcohol or other drugs to RELAX, feel better about yourself, or fit in?
Do you ever use alcohol or other drugs while you are ALONE?
Do you ever FORGET things you did while using alcohol or other drugs?
Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into TROUBLE while you were using alcohol or other drugs?
Alcohol and Drug Use screening tool (CRAFFT):
Repeated urination into clothing during the day & into the bed at night in children >5 years old & pattern must occur at least twice weekly for 3 months
15.5% of 7.5 year olds “bed wet”
Workup – complete H&P and UA/UC
toileting problems: Enuresis
treatment of Enuresis
education limit liquids before bedtime awake child @ night bedwetting alarms desmopressin (DDAVP)
Repeated passage of stool into inappropriate places by child who is >4 years old
90% of cases result from constipation
Often kept secret by family & child
1-3% of children ages 4-11 years suffer from “this”
Workup – complete H&P (w/ DRE)
Toileting Problems:Encopresis
tx of Encopresis
after age of 4 they shouldn’t be doing this!!!! before that whatever….poop in the closet do it do it!
education (avoid shame)
behavioral strategies (i.e., place child on toilet after meals)
treat constipation (start w/ “bowel cleanout”)
Healthy infant cries for >3 hours per day, for >3 days per week, for >3 weeks (“rule of threes”)
Usually peaks by age 2-3 months
Unknown cause
Colic
management of colic
reassurance
learn ways to soothe/comfort:
quiet environment
swaddle
avoid excessive handling
rhythmic stimulation – gentle swinging, rocking, soft music, car rides
rule of threes?
Healthy infant cries for >3 hours per day, for >3 days per week, for >3 weeks
Usually food refusal
Infants & young children
Will refuse to eat if:
painful
frightening
Often causes parental frustration & anger
Recognize different styles & food preferences
Red flag: failure to thrive (often due to poor caloric intake)
Feeding problems
weight
Red flag: failure to thrive (often due to poor caloric intake)
Screaming, thrashing about, sweating, ↑HR & RR and child incoherent & unresponsive to comforting
W/n 2 hours after falling asleep, episode lasts
night tremors
Occurs between ages 4-8 years old
Benign
Ensure that home is safe
sleep walking
Wakes alert
Peak occurrence between ages 3-5 years, w/ incidence 25-50%
Self-limited
nightmares
:trouble initiating sleep and/or waking up at night
Night waking occurs in 40-60% of infant/young children
Good sleep hygiene
Be consistent
Dyssomnias
Common between ages 1-4 years
Occurs ~1x/wk in 50-80% of children in this age group
Usually when child trying to achieve autonomy but thwarted
Management: provide choices, minimize “no,” distraction
Temper tantrums
Occurs during expiration (falls silent)
0.1-5% of healthy children from ages 6 month to 6 years
Often in response to anger or mild injury
Rarely leads to unconsciousness, asystole or seizures
Breath-holding spells
what the hec… kids a weird hahaha
breathe child breathe
Don’t calculate kids BMI before age of :
2
