Case 3 (Benjamin): WCC at 3 years with eczema, malnutrition and anemia Flashcards
Atopic Diathesis (definition and related conditions)
Each of the following may occur in isolation, but given a history of one, you should ask questions to determine the presence of the other conditions:
Eczema
Allergic triggers
Asthma symptoms
Atopic dermatitis/eczema (“the itch that rashes”):
findings, triggers
- Thickening and inflammation of skin
- Tends to be familial, but with multifactorial inheritance
- Often environmental (allergic) triggers
- Anything leading to itching can exacerbate eczema.
Screening for TB, lead poisoning, and anemia:
Tuberculosis (TB):
- Assess risk
- If there is a risk factor, a purified protein derivative (PPD) should be placed and read by a medical professional in 48 to 72 hours.
Lead:
- Assess risk (mouthing objects, pre-1950s housing, housing near busy interstate, or recent immigrant)
Anemia:
- Typically screened for at 12 months and again at preschool or kindergarten entry (if there are risk factors, then testing may be done at any visit).
- The initial 12-month window coincides with a period in development when diet, particularly iron sources, is often in flux.
Anticipatory Guidance: Nutrition of a 3 yo
Inadequate vitamin and iron intake due to poor diet: One study found that preschool-aged children consumed 80% of the recommended fruit servings/day and 30% of the recommended vegetable servings/day. Many of the vitamins preschoolers consume come from fortified foods.
- Vitamin D: Children should receive vitamin D supplementation, as it is very difficult to attain the recommended daily allowance through nutritional sources or from sun exposure.
- Iron: A central nervous system co-catalyst, essential for normal development. Predominant sources in toddlers are meat, legumes, and iron-fortified cereals.
Excess milk and juice intake:
- Diminishes appetite for other foods and results in a diet that lacks iron.
- Can add substantial calories to a diet and contribute to the development of early obesity.
- AAP recommends only one or two servings of fruit juice a day.
- Can result in early dental caries: Recommended discontinuation of the bottle by age 12 to 15 months.
Anticipatory Guidance: Dental concerns of a 3 yo
Controversy about when first dental visit should occur:
- American Association of Pediatric Dentists (AAPD) and the American Academy of Pediatricians (AAP) both state that all children should be seen within six months of the first tooth eruption or by one year of age.
- However, many communities lack pediatric dentists, and many general dentists feel that the first visit should be at age 3 years.
- AAP states additionally that all children should be screened by six months for risk of caries.
Anticipatory Guidance: Safety of a 3 yo
In the toddler years, overall safety issues become increasingly important because of the increased independence, inquisitiveness, and motor skills of preschoolers. Injuries are a major morbidity in the preschool years.The Injury Prevention Program (TIPP) is a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries.
Car seats:
- Older than 24 months, or have outgrown height/weight limits on their car seat, use forward-facing car seat in car’s back seat.
- Older children stay in a booster seat until they reach a height of 4 feet 9 inches (142 centimeters).
Firearms in the home:
- Preferably remove. If cannot, use safety lock, store in locked cabinet, keep ammunition in separate locked cabinet.
- Study showed that 52% of parents who owned guns think their children are “too smart” or “know better”; also showed that, when given the opportunity, boys 8–12 years will handle a gun (76%) and pull the trigger (48%).
- Consider potential suicide risk for teenagers.
Fire safety
Poison control
Car accidents
Risk of lead poisoning
Anticipatory Guidance: Behavior/temperament of a 3 yo
Temper tantrums
Toilet training:
- Requiring assistance toileting at age 3 years is not a clear sign of developmental delay, but may preclude attendance at child care or preschool.
Eating habits:
- Food rewards and punishment may promote obesity by interfering with children’s ability to regulate their own food intake.
Anticipatory Guidance: Developmental screening of a 3 yo
- Especially important in preschoolers so physician can intervene early if necessary.
- Involves physician observation and parental history.
- Parents’ Evaluation of Developmental Status (PEDS) is an evidence-based surveillance and screening tool for children birth to 8 years that elicits and addresses parents’ concerns about their child’s development, behavior, and mental health.
- Modified Checklist for Autism in Toddlers (M-CHAT) is a validated tool for screening toddlers between 16 and 30 months of age to assess risk for autism spectrum disorders (ASD).
- General pediatricians do not conduct official developmental assessments but do practice developmental surveillance and screen for areas of concern during each visit. However, evidence suggests that developmental surveillance by itself is not enough to pick up developmental problems.
- States are mandated to provide developmental assessments and services
for children < 3 years at risk for developmental delays by experts such as early interventionists, developmental-behavioral pediatricians, child psychiatrists, child psychologists, and/or early childhood learning specialists. For children 3 to 5 years, the school systems provide services to help them catch up to their peers.
Anticipatory Guidance: Exercise in a 3 yo
Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity.
Expected Developmental Milestones for a 3 yo
Social/Behavioral:
- feeds self
- dresses self
Communication:
- speaks in 2-3 word sentences
- 75% understandable
Cognitive:
- knows name and use of “cup, ball, spoon, and crayon”
Physical Development
- builds tower of 6-8 cubes
- throws a ball overhand
- rides a tricycle
- copies a circle
Expected Developmental Milestones for a 4 yo
Social/Behavioral
- Knows gender and age
- Is friendly to other children
- Plays with toys
- Engages in fantasy play
Communication
- States first and last names
- Sings a song
- Most speech clearly understandable
Cognitive
- Names colors
- Aware of gender
- Plays board games
- Draws a person with 3 parts
Physical Development
- Hops on one foot
- Balances on one leg for 2 seconds
- Copies a cross
- Pours, cuts, and mashes own food
- Brushes teeth
Expected Developmental Milestones for a 5 yo
Social/Behavioral
- Listens and attends
Communication
- Articulates well
- Tells a simple story using full sentences
- Appropriate use of tenses and pronouns
- Counts to 10
- Follows simple directions
Cognitive
- As children get ready for school, the developmental milestones shift to more cognitive processes.
- Asking parents about pre-k performance is important.
Physical Development
- Balances on one foot, hops, and skips
- Ties a knot
- Mature pencil grasp
- Draws a person with ≥ 6 body parts
- Prints some letters and numbers
- Copies squares and triangles
- Undresses and dresses with minimal assistance
Physical Exam of a 3 year old
Vital signs
- Temperature, heart rate, respiratory rate, blood pressure
- Plot height and weight and body mass index (BMI) on growth chart.
HEENT
Mouth:
- Caries
Ears:
- Middle ear effusions may persist after earlier upper respiratory infection and affect hearing
Eyes:
- Strabismus: Eyes not properly aligned with each other
- Hirschberg light reflex: Screening test for strabismus.
- Cover tests: Determines presence and amount of ocular deviation.
Neck
- Enlarged thyroid is rare in children.
- “Shotty” (pea or marble-sized, nontender, and easily mobile) nodes in cervical and inguinal chains are normal in children and may persist for many years.
Cardiac
- Murmurs
- Most murmurs will be functional
- New murmurs of congenital heart disease are unlikely
- Murmurs of atrial septal defect (ASD) sometimes are appreciated only in older children
Lungs
- Yield likely to be low in a healthy child, but may hear subtle wheezing in a child with history of allergies
Abdomen
- Palpate for organomegaly and masses:
- Most common: Stool
- Occasional: Enlarged kidney
- Very rare: Abdominal tumor (Wilms’ or neuroblastoma)
Musculoskeletal
- Observe for gait variants. In-toeing is most common variant seen at this age:
Usually due to tibial torsion, with or without femoral anteversion.
Tibial torsion usually spontaneously resolves by age 8 years (often well before).
Careful history required to rule out potentially treatable causes.
Often walking will strengthen anterior leg muscles and allow correction.
Persistence has been associated with joint problems later in life.
If in-toeing does not resolve by age 4 years, referral to orthopedic surgeon may be warranted.
Genitals
- Check for hernias.
- Use opportunity to teach about who can appropriately examine the child.
- Girls at this age may have nonspecific vulval erythema due to underdeveloped self-hygiene skills.
Neurological
- Assess muscle tone, strength, coordination, reflexes.
- Look at overall neurodevelopmental status—achievement of gross and fine motor skills, language, social skills.
Differential Diagnosis: Anemia in a 3 yo
- Iron deficiency:
Most likely acquired cause of anemia in a 3-year-old child with poor nutritional intake.
10% of low-income preschoolers have iron-deficiency anemia, versus 7% of other preschoolers.
Unclear whether cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk for iron deficiency. - Chronic blood loss:
May be caused by food allergies or gluten enteropathy - Lead poisoning
- Chronic illness, such as collagen vascular disease, malignancy or other illness
- Hemoglobinopathy
Thalassemia, G6PD deficiency, or sickle cell disease
More commonly found in those of Mediterranean, Asian or African descent
Less likely diagnoses:
Decreased marrow production (e.g., aplastic anemia), hemolytic anemias, and vitamin deficiencies (e.g., folate and B6) are rare in children and present with a more severe anemia (hemoglobin < 9 g/dL).
Differential Diagnosis: Rash in a 3 yo
- Psoriasis
Can occasionally look like eczema
Rare in children this young
When present, occurs as a generalized rash known as guttate (droplet-shaped) psoriasis, and usually precipitated by a strep infection - Seborrheic dermatitis
Unusual to have new case of seborrheic dermatitis at age 3 years, but should be part of the differential diagnosis, especially in early infancy (e.g., cradle cap). - Atopic dermatitis (eczema)
