Growth and Development Flashcards
well child visit elements
-Growth, development, and nutrition
-Physical examination, screening tests, and immunizations
-Anticipatory guidance
-Evaluation and management of parental concerns
normal growth
-Frequent visits in 1st 2 yrs of life are more than physicals!
-Processes of growth and development are intertwined:
-Growth = increase in size
-Development = increase in function of processes related to body and mind
-Genetic makeup and the physical, emotional, and social environment of the individual determine how a child grows and develops throughout childhood
-One goal of pediatrics: Helping each child achieve individual potential through periodically monitoring and screening for the normal progression or abnormalities of growth and development
routine office visits
American Academy of Pediatrics (AAP) recommends routine office visits in:
-first week of life (72hrs)
-by 1 month of age
-at 2, 4, 6, 9, 12, 15, and 18 months
-2, 2.5, and 3 years
-then annually through adolescence/young adulthood
length/height, wt, head circumference
-obtained at every health visit and compared with statistical norms on growth charts
-Serial measurements (growth trend) -> more useful than single measurements for detecting abnormal growth patterns
-Large shifts in percentiles, large discrepancies in ht, wt, and head circumference (up to 2 years of age) percentiles warrant attention
-with caloric deficit you see decrease in wt first, then ht, then head circumference
disorders of growth
-MC reasons for deviant measurements are technical (equipment, human error)
-Variability in body proportions occurs from fetal to adult life -> NORMAL
-kids follow parents’ growth patterns – Familial short stature
-Osseous maturation (often utilized for dx) determined via radiography
Constitutional short stature
-Preadolescent/adolescent (by age), starts puberty later than others
-late bloomers
Catch-down growth
-Start out in high growth percentiles then decrease wt
-many children assume a lower percentile between 6-18 months until they match their genetic programming; then grow along, new, lower percentiles
Catch-up growth
-Infants born SGA/prematurely, ingest more breast milk/formula in first 6 months
-recommend to feed until they cant anymore (vomiting)
normal development: evaluation: new born
Primitive neonatal reflexes are unique in the newborn period and can further elucidate/eliminate concerns over asymmetric function
-muscular development (MSK)
-if the primitive reflex isnt going away at a normal time -> problem
-primitive reflexes- NOT ON TEST
normal development: evaluation: later infancy
-Progressively able to control posture > proximal musculature > distal musculature
-Orthopedic deformities – Is it fixed, or can it be moved passively into the proper position?
-Evaluation of vision/ocular movements is important to prevent strabismus
-muscle weakness in eye -> strabismus -> anopia (vision loss)
normal development: evaluation: school age/pre-adolescent
Comprehensive sports H&P that includes a careful examination of the cardiovascular system
normal development: evaluation: adolescence
-Annual comprehensive health assessments to ensure progression through puberty without major problems
-Sexual maturity, scoliosis/orthopedic screening, and obesity
developmental milestones/screening
-Compare pts behavior with normal kids
-Developmental Surveillance: at every visit -> comparing skill levels to lists of milestones
-Developmental Screening: use screening tests to identify pts who require further dx assess (CDC recommends at 9, 18, and 30 months)
-MC screeners includes Ages and Stages Questionnaires and Parents’ Evaluation of Developmental States (PEDS)
-After 6th birthday – adolescence, developmental assessment -> asking ab school performance
-With adolescents, emphasis placed on building physician relationship distinct from parental relationship
autism screening
-Mandated for all children at 18 and 24 months of age
-Modified Checklist for Autism in Toddlers – Revised (M-CHAT-R)
-If demonstrates > 2 of 3 total behaviors -> further assessment with interview algorithm is indicated to distinguish normal variant behaviors from those children needing a referral for definitive testing
-EARLIER YOU FIND THE BETTER
language screening
-if speech or language delay -> must consider hearing deficit and screening
-Dysfluency (stuttering) is common in a 3-4 yo (unless accompanied by tics or unusual posturing) -> want to get out all their thoughts
-by age 5-6 yo it should go away
developmental milestones: 1-2 months
-Regards faces and follows objects through visual field/tracks past midline
-dolls eyes are normal
-Becomes alert in response to sound/voice- hearing
-Holds head erect and lifts head - tummy time
-Turns from side to back
-Drops toys
-Parent reported:
-Recognizes parents
-Engages in vocalizations
-Smiles responsively
developmental milestones: 3-5 months
-Lifts up on hands, rolls front to back- proximal arm muscles
-Sits with support
-Reaches for/grasps cube (raking), brings object to mouth
-Cooing, squealing (not using lips)
-Makes “raspberry” sound (spitting)
-Parent reported:
-Laughs
-Anticipates food on sight
developmental milestones: 6-8 months
-Sits alone for short period
-Passes object from hand to hand in midline
-Imitates “bye-bye”
-Feeds self/holds bottle (learned)
-Babbles
-Parent reported:
-Rolls from back to stomach (using legs/hips)
-Inhibited by “no”
developmental milestones: 9-11 months
-Pulls to stand (alone)
-Pincer grasp- choking
-Imitates pat-a-cake and peek-a-boo
-Separation anxiety
-Two-syllable sounds
-Parent reported:
-Walks by supporting self on furniture
-Follows 1-step verbal commands (“come here,” “give it to me”)
developmental milestones: 12 months
-Walks independently
-Releases cube into cup after demonstration
-Tries to build tower of 2 cubes
-Says “mama” and “dada” with meaning
-Gives toys on request
-Parent reported:
-Points to desired objects
-Says 1 or 2 words
developmental milestones: 18 months
-Runs
-Seats self in chair
-Builds tower of 3-4 cubes
-Throws ball
-Carries and hugs doll
-Parent reported:
-Walks up and down stairs with help
-Says 4-20 words
-Understands 2-step command
developmental milestones: 24 months
-Kicks ball, stands on either foot alone
-Jumps off floor with both feet
-Builds tower of 6-7 cubes
-Points to/names objects or pictures
-Speaks in short phrases, 2 words or more
-Uses pronouns
-Parent reported:
-Pulls on simple garment
-Turns pages of book singly
-Play with domestic mimicry
-Verbalizes toilet needs (not full control of bladder yet)
developmental milestones: 30 months
-Begins to hop on 1 foot
-Builds tower of 8 cubes
-Holds crayon in fist
-Points to objects described by use
-Uses prepositions
-Refers to self as “I”
-30-36 months- control over bladder
-Parent reported:
-Helps put things away
-Carries on a conversation
developmental milestones: 3 years
-Holds crayon with finger
-Builds tower of 9-10 cubes
-Gives first and last name
-Three-word sentences
-Parent reported:
-Rides tricycle using pedals
-Dresses with supervision
developmental milestones: 3-4 years
-Climbs stairs with alternating feet
-Begins to button and unbutton
-“What do you like to do for fun?” (Answers using plurals, personal pronouns, and verbs)
-Responds to place toy in, on, or under table
-Draws circle when asked to draw person
-Knows own sex
-Gives full name
-Parent reported:
-Feeds self at mealtime
-Takes off shoes and jacket
developmental milestones: 4-5 years (didnt go over)
-Runs and turns without losing balance
-Stands on 1 leg for at least 10 seconds
-Copies circle/+ sign
-Draws a person (head, 2 appendages, 2 eyes)
-Buttons clothes and laces shoes
-Gives appropriate answers to: “What must you do if you are sleepy, hungry, cold?
-Knows the days of the week
-school age
-Parent reported:
-Self care at toilet
-Plays outside for at least 30 minutes
developmental milestones: 5-6 years (didnt go over)
-Can catch a ball
-Skips smoothly, heel-to-toe walks
-Copies a square
-Draws recognizable person with at least 6-8 details
-Counts
-Knows L/R hand
-Can describe favorite TV program in some detail
-Parent reported:
-Tells age
-Performs simple home chores
-Goes to school unattended or meets school bus
developmental milestones: 6-7 years (didnt go over)
-Copies triangle
-Knows morning/afternoon, time
-Draws person with 12 details
-Reads several 1-syllable printed words
-Defines words
developmental milestones: 7-8 years (didnt go over)
-Ties shoes
-Copies a diamond
-Draws person with 16 details
-Enhanced reading
-Counts by 2s and 5s
-Adds and subtracts 1-digit numbers
developmental milestones: 8-9 years (didnt go over)
-Defines words better than by use (an orange is a fruit)
-Enhanced reading
-Borrowing and carrying processes in addition and subtraction
developmental milestones: 9-10 years (didnt go over)
-Knows month, day, and year – names months in order (15 seconds, 1 error)
-Enhanced reading, sentence construction
-Simple multiplication
developmental milestones: 10-12 years (didnt go over)
-Enhanced reading, comprehension
-Multiplication and simple division
developmental milestones: 12-15 years (didnt go over)
-Enhanced reading, comprehension
-Reduce fractions, long division, adds/subtracts fractions
recommended screening tests for kids
-Only recommended are newborn metabolic screening with hemoglobin electrophoresis, hearing and vision evaluation, anemia and lead screening, TB testing, and dyslipidemia screening
-Metabolic Screening
-Mandated in every state
-Includes phenylketonuria, galactosemia, congenital hypothyroidism, maple sugar urine disease, and organic aciduria (some states screen for CF)
-prevent develop delays
-Hemoglobin Electrophoresis
-Higher risk for infections/complications
-sickle cell
-risk to encapsulated bacteria
-prophylaxis with PCN until 5yo
-vaccines
-Critical Congenital Heart Disease Screening
-AAP now mandates screening with pulse oximetry of R hand and foot (pass if > 95% and difference is < 3% points; fail if < 90%)
-coarctation of the aorta if difference is found
-Hearing Evaluation
-Performed before discharge from newborn nursery
-Screen by 1 month, follow-up (if abnormal) by 3 months, intervention by 6 months
-prevent speech delay
hearing and vision screening of older children
-Infants and Toddlers:
-Inferences from asking parents about response to sound, speech/examining speech, and language development closely
-Screened by auditory evoked responses or behavioral audiology (sounds of varying frequencies/intensities filtered into soundproof room)
-Inferences about vision made by examining gross motor milestones and PE of eye
-Screened by visual evoked responses and/or referral to ophthalmologist
-3yo +:
-Snellen eye chart (standard or shapes)
-Audiologic testing with headphones should begin at 4 yo
important milestones
talk, walk, crawling (6-7 months), vocab, mama, dada, 4-20 words
anemia screening
-All infants screened at 12 months -> when iron deficiency is greatest (bc of diet change away from formula)
-Infants at risk (low birthweight/premature) screened at birth and 4 months
-Therapeutic trial of iron may be used when deficiency strongly suspected (no testing required)
TB screening
-Screened at 1 month, 6 months, 12 months, then annually
-Standard PPD intradermal test used with evaluation 48-72 hours following placement
-15 mm induration is positive, 10 mm in high-risk, 5 mm in HIV pts, recent TB contact, healed TB CXR, or immunosuppressed
-QuantiFERON-TB Gold blood test is a newer test – single office visit, but pricey
lead screening
-CDC recommends routine blood lead screening at 12 and 24 months
-Lead intoxication (plumbism) may cause developmental and behavioral abnormalities
-Risk factors: living in older homes with cracked/peeling lead-based paint, industrial exposure, use of foreign remedies, and use of pottery with lead paint glaze
-affects the CNS
-vague symptoms:
-Early: Weakness, irritability, weight loss, vomiting, personality changes, ataxia, constipation, headache, and colicky abdominal pain
-Late: Developmental delays, convulsions, and coma associated with increased intracranial pressure
if lead is +
-Investigation warranted if levels of 20 mcg/dL on 1 time test or persistent 15 mcg/dL over 3-month period (decontamination techniques used once source identified)
-Succimer is an oral chelator recommended in asymptomatic children with levels > 45 mcg/dL
-IM dimercaprol/BAL and IV calcium sodium edetate in symptomatic children with encephalopathy or levels > 70 mcg/dL
cholesterol screen
-AAP recommends dyslipidemia screening for at-risk populations by obtaining a fasting lipid profile
-Screening levels are the same for 2-18 years of age (170 mg/dL normal, 170-199 mg/dL borderline, 200 mg/dL is elevated)
STI testing
-Sexually experienced adolescents should be screened for STIs and have an HIV test at least once between 16 and 18
-at least an annual evaluation for STIs by physical (genital warts, genital herpes, pediculosis) and lab testing (chlamydia, gonorrhea, syphilis, HIV)
-Pap smears at 21 years of age
depression screening
All adolescents, starting at age 11, should have annual screening (PHQ2/PHQ9)
immunizations
-Checked at each visit and appropriate ones administered
-Live-attenuated: Measles/Mumps/Rubella, Varicella, Influenza (nasal), Polio (PO), Rotavirus!!!!!!
-Inactivated/killed viruses: Polio (IM), Hepatitis A, Influenza (IM)
-Recombinant: Hepatitis B, HPV
-Immunogeneic components of bacteria: Pertussis, H. influenzae type b, N. meningitidis, and S. pneumoniae; including toxoids (Diphtheria, Tetanus)
-Schedule includes up to 23 injections in 4-5 visits by 18 months of age
-Children behind on immunizations should receive catch-up as rapidly as possible
-Infants premature should be vaccinated based on chronological age (same schedule)
-Administered following informed consent from parents
-he said the main thing to know is the live vaccines
-know the chart- ex. 12mo pt presents assuming they are up to date with vaccines -> Which vaccine would you now recommend
-passive immunity- breast feeding
-active immunity- vaccine
immunization catch up schedule
just know this exists
vaccines summed up
anticipatory guidance- birth to 6mo
-Information conveyed to parents verbally, in written materials, or online resources to assist them in facilitating optimal growth and development for their children
-burns
anticipatory guidance: 9mo-4years
-swim
-poisoning- safety locks
-2-3 potty training
anticipatory guidance: 5-21yo
-sexual development
-goals
anticipatory guidance: car safety
-MCC of death for infants 1 month to 1 year of age is MVA
-Most states have laws mandating use of safety seats until 4yo or at least 40 pounds:
-Infants and toddlers in !rear-facing safety! seat until at least 2 years old
-Toddlers and preschoolers over age 2 should use forward-facing car seat with harness
-School-aged children should use !belt-positioning booster! seat until vehicle seat belt fits properly (4 ft 9 in and between 8-12 year of age)
-Older children should always wear lap and shoulder seat belts (protects from air bags)
anticipatory guidance: sleep safety
-Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year that remains unexplained after a thorough case investigation
-Sudden unexpected infant death syndrome (SUID) is a sudden and unexpected infant death (explained or unexplained) – now the preferred term
-Includes deaths due to infection, ingestions, metabolic diseases, cardiac arrhythmias, and trauma
-Incidence peaks between ages 2 and 4 months
-Most deaths occur at night
-Risk factors: Socioeconomically disadvantaged populations (continued prone positioning, sharing beds), preterm birth, low birth weight, recent infection, young maternal age, high maternal parity, maternal tobacco or drug use, and crowded living conditions
-Pathological findings most common for SUID deaths from unknown cause (SIDS): Intrathoracic petechiae, mild inflammation/congestion of the respiratory tract, findings consistent with chronic hypoxia prior to death
sleep safety tx/prevention!!!!!!
-Back to Sleep initiative has resulted in a 60% decline in SIDS rates since 1990
-Supine positioning
-Sleep in parents’ room, close to parents’ bed but on a separate surface designed for infants at least for the first 6 months of life
-Remove soft objects/loose bedding, stuffed animals, or wedge positioners from infant’s sleep area
-Breastfeeding is recommended
-Pacifier at naptime and bedtime
-Avoiding cigarette smoking during pregnancy and after birth
-Avoid car seats, swings, and baby slings for sleep
-Avoid use of adult beds and bed rails (increases risk of suffocation)
teething
-can mimic ear infection
-Remedies for teething pain:
-OTC teething gels or liquids that contain benzocaine
-Systemic analgesics
-Chewing on teething object (distraction)
-Eruption Cysts: Localized, red/purple, round, raised, and smooth lesion, resolved with eruption of tooth (NORMAL)
-All children 1yo+ should have dental exam by dentist at least annually and cleaning every 6 months
-Preventative measures: Brushing, flossing, concentrated fluoride topical treatments (dental varnish) and acrylic sealants on molars
-Recommended PCPs apply dental fluoride varnish to infants and children every 3-6 months between 9 months and 5yo
-Fluoridation of water or fluoride supplements in communities that do not have fluoridation are important in prevention of caries
colic
-Episodes of uncontrollable crying or fussing in an otherwise healthy infant
-Paroxysmal, characterized by facial grimacing, leg flexion, and passing flatus
-Wessel rule of threes:
-Crying for > 3 hours/day
-At least 3 days/week
-> 3 weeks
-Etiology: Unknown, likely multifactorial
-Cow’s milk intolerance
-Change in fecal flora
-Increase in serotonin secretion
-Poor feeding technique
-Maternal smoking may be associated
colic: guidance and management
-Techniques for calming infants (Dr. Harvey Karp’s “5 Ss”):
-Swaddling
-Side/stomach holding
-Soothing noises
-Swinging/slow rhythmic movement
-Sucking on pacifier
-Educating parents on hunger cues, avoiding excessive caffeine and use of alcohol in nursing mothers, ensuring adequate bottle/nipple flow, and cautioning overfeeding
Effectiveness of dietary changes, herbal supplements, and/or medications very limited
-Prognosis
-No evidence of long-term adverse outcomes for patient or parents
-Most serious complication of colic is nonaccidental trauma
temper tantrums
-Brief episodes of extreme unpleasant behavior disproportionate to situation, in response to frustration or anger
-whining, crying, screaming, stomping, flailing, head banging, hitting, throwing objects, and biting
-Etiology
-Normal human developmental behavior
-1-4 yo have increasing desire for independence and are often unable to effectively communicate physical needs and emotions
-Triggers include fatigue, hunger, discomfort, and frustration
temper tantrum work up
-History: Evaluate for other behavioral, psychologic, or physiologic conditions
-Important to differentiate between typical and atypical tantrums
-Physical examination:
-Focus on identifying signs of underlying illness and include vision, hearing, and developmental exams
-Behavioral observations
-Dysmorphic features may reveal a genetic syndrome, skin exam (anemia, nonaccidental trauma), neurologic exam
-Laboratory studies: Screening for iron deficiency anemia and lead exposure
temper tantrum guidance and management
-Communicate clear, consistent, and developmentally appropriate expectations and consequences
-Provide positive reinforcements for good behavior
-Maintain routine and structure in a child’s environment
-Use distraction techniques
-Avoid known triggers
-Help children learn to communicate desires, needs, and emotions
-Provide children with choices among acceptable alternatives (support autonomy)
-Parents should remain calm and meet physical/safety needs without complying to child’s demands, do not punish for tantrum
sleep habits
-Behavioral sleep disorders most prevalent from infancy through preschool age
-Affect 30% of children, with bedtime resistance in 10-15% of toddlers and difficulty falling/staying asleep in 20-30% of school-age children and 10% in adolescents
-Behavioral Insomnia of Childhood
-Sleep-onset association subtype: Frequent, prolonged nighttime awakenings that occur in infants/children
-Limit-setting subtype: Bedtime resistance or refusal that stems from caregiver’s unwillingness or inability to enforce bedtime rules/expectations
sleep habits workup and tx
-History
-Sleep habits, typical bedtime, sleep onset/wake times, and schedule variation from day to day
-Description of sleep environment (type of bed, sharing bed, ambient noise, and temperature)
-Dietary practices and household routines
-Physical examination to rule out organic causes of sleep disturbances
-Prevention and Treatment
-Consistent and appropriate bedtime routine/close attention to sleep hygiene
-Behavioral interventions mainstay of treatment
-Systematic ignoring: Not responding to a child’s demands for parental attention at bedtime
-Strategic napping
-Positive reinforcement
-Behavioral therapy (nighttime fears)
-No FDA approved medications for treating insomnia in children
summary
