Infants, Toddlers and Young Children Flashcards
Heath supervision visit schedule
Birth
3-5 days
1, 2, 4, 6, 9, 12, 15, 18 months
2 years
2.5 years
3 years
annually
Goals of pediatric visits
Disease detection, disease prevention, health promotion, anticipatory guidance
Components of pediatric visit
- interval history
- ROS
- Surveillance of development
- Observation of parent/child interaction
- physical exam (measurement of growth)
- Screening (universal, risk assessment)
- Immunizations
- Anticipatory guidance (social determinants of health)
What is one thing you should always ask during interval history?
Are there any parental concerns?
What are social aspects of health
living situation, family supports, food insecurity, substance use, partner violence
What drives development across a lifespan
ecology and biology
Biology
physiologic adaptations and disruptions
Ecology
The social and physical environment
Development
Learning, behavior and health
Child stressors
abuse, neglect, chronic fear state, natural disaster, accidents and illness, exposure to violence, disabilities/chronic disease
Parent/family stressors
parental dysfunction, substance abuse, domestic violence, mental illness, divorce, poverty
Positive physiologic stress response
brief duration, mild/moderate severity, sufficient social/emotional buffering, long-term return to baseline
Tolerable physiologic stress response
sustained duration, moderate/severe severity, sufficient social/emotional buffering, long-term return to baseline
Toxic physiologic stress response
sustained duration, severe severity, insufficient social-emotional buffering, long term changes to baseline
Surveillance of development are also called
milestones
4 main areas of milestones
- social and emotional
- language and communication skills (expressive and receptive)
- Gross motor skills
- Fine motor skills
When are milestone checks done?
Every visit
Expected milestones for a Newborn-1 Week
Makes brief eye contact when held, cries with discomfort, calms to adult voice, reflexively moves arms and legs, turns head to side when on stomach, holds fingers closed, reflexive grasp
Expected milestones 1 month
calms when picked up or spoken to, looks briefly at objects, alters to unexpected sound, short vowel sounds, holds chin up while prone, holds fingers more open while at rest
Expected 2 month milestones
smiles responsively, vocalizes/coos, lifts head and chest when prone, opens and shuts hands
Expected 4 month milestones
laughs aloud, turns to voice, vocalizes/extended cooing, rolls over to prone when supine, supports on elbows and wrists while prone, keeps hands unlisted, plays with fingers in midline, grasps objects
Expected 6 month milestones
smiles at reflection, turn head with name, babbles, rolls over, sits briefly without support, reaches/transfers objects, rakes small object with 4 fingers, bands objects on surfaces
Expected 9 month milestones
uses basic gestures (arms out for pick up), looks for dropped objects, picks up food with fingers, feeds self, turns when name is called, days “dada” or “mama”, sits without support, pulls to stand, transitions between sitting and lying, balances on hands and knees, crawls, picks up small object with 3 fingers and thumb, releases objects intentionally
Expected 12 month milestones
looks for hidden objects, imitates new gestures, “dada” or “mama” specifically, 1 other word than parent names, follows verbal commands that include a gesture, first steps, stands without support, drops objects in a cup, picks up small objects 2-finger pincher grasp
Expected 15 month milestones
imitates scribbling, drinks from a cup, points to objects, 3 words, jargon, follows verbal commands without a gesture, squats to pick up objects, climbs onto furniture, begins to run, makes mark with crayons
Expected 18 month milestones
plays with others, helps with dressing, points to pictures and objets of interest, turns at looks at adults, scoop with spoon, 6-10 words, identify 2 body parts, walks 2 feet with hand held, sits in small chair, carries a toy while walking, scribbles, throws a small ball while standing
Expected 2 year milestones
Parallel play, remove clothing, scoops with spoon, 50 words, 2 words into short phrase or sentence, follows 2-step command, words that are 50% unintelligible for strangers, kicks ball, jumps with 2 feet, runs with coordination, stats objects, turns book pages, use hands to turn objects
Expected milestones 2.5 years
urinates in a potty, engages in pretend play, spears with a fork, uses pronouns correctly, begins to walk up steps (alternating feet), runs well without falling, grasp crayon with thumb and fingers instead of fist, catches large balls
Expected milestones 3 years
Potty by themself, plays in cooperation and shares, puts on coat/shirt, beginning imaginative play, eats independently, 3 word sentences 75% intelligible to strangers, understands simple prepositions (on, under), pedals tricycle, climbs on and off couch, jumps forward, draws a single circle, draws a person with head and 1 other body part, cuts with child scissors
Expected 4 year milestones
Uses bathroom/BM alone, brushes teeth, dress/undress, well-developed imaginative play, 4 word sentences, words that are 100% intelligible to strangers, climbs stairs alternating feet without support, skips on 1 foot, draws a person with 3 body parts, draws simple cross, unbutton/button medium buttons, grasps pencil with thumb and fingers (no fist)
I can jump and kick a ball- how old am I
2 years
I can pull myself up and stand, I can wave bye, I imitate sounds - how old am I
1 year
I can hop on one foot and my speech is clear, I can copy a circle- how old am I
4 years
Developmental screening
use of standardized tools to identify children at risk for developmental disorder
When do you do developmental screening?
Anytime a parent has a concern
What developmental screening do you do at the 9 month visit
identify motor issues, visual, hearing issues
What developmental screening do you do at the 18 month visit
communication and language delays, mild motor delays
What developmental screening do you do at the 30 month visit
most issues can be identified
Autism screening is recommended when by the AAP?
18 month visit
24 month visit
What category screening is autism screening?
USPSTF Category I
Developmental screening tools
Ages and stages questionnaire (ASQ)
Parent’s evaluation of developmental status (PEDStest)
Survey of wellbeing of young children (SWYC)
Autism screening tool
Modified checklist for autism in toddlers revised with follow-up (M-CHAT-R/F)
What do you measure for the growth chart
head circumference, weight, length
When do you do growth chart measurements
every visit
When do you stop head circumference measurement?
2 year visit
How much weight does a infant lose in the first week of life?
10% of birth weight
When should the infant be back to birth weight?
14 days
When should an infant have doubled their birth weight
4-6 months
When should an infant have tripled their birth weight
1 year
Average growth rates
2” and 2kg per year from 2 to puberty
How much weight do neonates gain to 3 months
1 once/day (30grams)
How much weight do infants gain per day between 3-6 months
0.67 ounce (20 grams)
How much weight do infants gain per day between 6-12 months
0.33 ounce (10grams)
Average length at birth
~20 inches
How much do infants grow in their first year
~10 inches
How much do toddlers grow between 12-24 months
~4 inches
How much do toddlers grow between 24-48 months
~3 inches
When are children half of adult height
24-30 months
How much do people grow between 4 years and puberty
~2 inches/year
Remember that growth is _________
pulsatile
When should you plot growth?
every visit
When do you start plotting BMI for age
age 2
When do you stop plotting weight for length
age 2
Growth is tracked based on
percentile
Which growth chart is better for breastfed infants
WHO
Growth charts for breastfed infants are different because
slower weight gain between 3 and 4 months
What would happen if you plotted a breastfed baby on CDC
may lead to earlier solids and less breast milk
When do you use WHO
up to age 2, then CDC from ages 2-19
What age does WHO go to
5
What do you do if you have no EMR
measure 2-3 times and plot as accurately as possible
What is a common recommendation for infant physical exam
use toys for distraction
Where should the baby lay during physical exam
in the parent’s lap as much as possible during exam
When should you do heart and lungs
when the baby is quiet
When should you do invasive exams (mouth and ears)
for last
Young children physical exam tips
use a reassuring voice, let the child see and play with your tools, make it a game, do NOT ask for permission from a child
Instead of asking for permission for a child what do you do instead
State what you are going to do and do it
Who should undress a young child during the physical exam
the parent
As children age you need to be sensitive to _______
modesty
Spread to the child _______
directly
differences in children: head size
larger
differences in children: abdomen
“square” until age 2 less muscle
differences in children: bladder
at umbilicus at birth
differences in children: breathing
obligate nose breathers
difference in children: ribs
not very flexible, not as protective
differences in children: organs
much larger and more exposed
Early childhood is when
1-4 year
In early childhood how much does does growth slow
50% of that infancy
Early childhood exam sequence
start with seated (eyes, palpate neck, percuss/auscultate), move to supine (abdomen, MSK, nervous system, examine genitalia last), upright (look at throat and ears last
When do you start measuring blood pressure
age 3
is adenopathy is ______ in children
common
Early childhood eye exam
cover and cover/uncover test for position and alignment of eyes
Expected eye findings in early childhood exam
normal corneal light reflex
Esotropia
eye deviates nasally
Exotropia
eye deviates temporally
strabismus
eyes are not aligned
Cover test you are examining
the uncovered eye
Cover/uncover test you are examining
the covered eye
Cover for 5 seconds (drifting indicates phoria)
When looking for a tympanic membrane in a child it can be _____ to see
hard
How can you assist in visualizing tympanic membrane in children
pull up, out and back
+/- insufflator
Are brachial or radial pulses easier to feel in children
brachial
Normal abdominal exam in childhood
protuberant abdomen, liver span 1-2cm below costal margin, spleen edge 1-2cm below costal edge
When should you expect the testes to descend into the sac
if not descended by age 1, refer out
A normal musculoskeletal finding in children
bowlegged
When are children knock-kneed
18 months-4 years of age
When do you inspect for scoliosis
any child who can stand
When is universal screening recommended
all children
When is selective screening recommended
at risk children, risk assessment should be done regularly
Who makes pediatric recommendations
American Academy of Pediatrics via Bright Futures
United States Preventative Services Task Force
Centers for disease control and prevention
School requirements
Newborn screening
genetic and metabolic screen
Critical congenital heart disease (pulse ox)
hearing
bilirubin
When is hearing screening recommended
all newborns and risk assessment for all children up to age 21
Audiology screening schedule for all children
age 4,5,6,8,10 years
Vision screening under age 5 for
amblyopia, strabismus and decreased visual acuity
When do you screen for iron deficiency
H&H at 12 months
What is being removed from universal screening
lead
Misc screening for young children
iron, lead, oral health, blood pressure, cholesterol
When do you start screening for cholesterol
age 9-11 and again at 17-21
What is anticipatory guidance
identify upcoming issues that a child and family face, give advice that is developmentally consistent
Anticipatory guidelines must be 3 things:
Timely: given at the right age
Appropriate: for this child and family
Relevant: so that families will adopt them
What domains do anticipatory guidance fall into
social determinants of health
behavior and development
discipline
nutrition and feeding
safety
Surveillance is ______
Screening is ________
every single visit, if a parent has a concern
If a child +/- 2 lines on growth chart
concern for failure to thrive or metabolic disorder
