CA powerpoint-- Normal Growth and Development Flashcards by Sasha Bonney

considered primary care

pediatrics

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pediatrics Patient population

newborn to age 21

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how do we measure growth and development?

height
weight
vital signs

measure to same gender and age!

milestones they have to meet

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overall goal of well child visits

disease prevention and health promotion

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Frequency of well child visits

1-2 weeks then at 2, 4, 6, 9, 12, 15, 18, 24 months then annually thereafter

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what are you addressing at a well child visit?

concerns of parents caregivers
check growth and development
immunizations
screening tests
anticipatory guidance

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physical exam, growth charts, milestones

thing checked in growth and development part

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disease and health prevention at a young age can result in _______ health outcomes for decades

improved

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ASK!
Build report
provide written informaiton

address concerns of parents/caregivers

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-> 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

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physical
cognitive
social
environmental
diseases

various factors that affect development

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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

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when do you start checking BP and how often

at age 3, check annually

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physical exam

growth charts

MIlestones

other things to check for growth and development

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Physical Development (fine motor skills, gross motor skills)

Cognitive and language development

Social and Emotional Development

Milestones

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Typical child follows trajectory of increasing physical size & increasing complexity of function

Normal Growth & Development

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Child _____ birth weight within 1st year

triples

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child achieves _______ of brain size by age 2.5-3 years old

two-thirds

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birth to 36 months

infant

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Growth Chart

Infants, birth to 36 months

Length-for-age and weight-for-age

Head circumference-for-age and weight-for-length

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2 to 20

children and adolescents

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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)

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in children normal BP is based on

age, gender, height

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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

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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

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 :