Lecture 3: 2, 3yo WCC

Question 1

2 year old WCC

Answer 1

• Developmental Milestones
• Medical Responsibilities

Question 2

24 month developmental milestones

Answer 2

• Gross Motor- walks down stairs with both feet on each step, kicks ball independently, throws overhand
• Fine Motor- Stacks 6 blocks, imitates circle and single line (drawing)
• Social- parallel play
• Problem Solving- Sorts objects, matches objects to pictures, shows use of familiar object, can remove shirts without buttons and remove pants
• Language- puts 2 words together, points to pictures, knows body parts; 50 words. Language is 50% understandable by strangers

Question 3

24 mo medical responsibilities

Answer 3

• Hep A vaccine #2
  
  • Hepatitis A is a virus that often causes a diarrheal illness and hepatitis.
  • Fecal-oral transmission
  • Generally a self limited disease.
  • Important for travel overseas, but we are seeing outbreaks in the USA ex. San Diego 2017
  • 2 shot series that is given 6 months apart.
• Recheck lead and Hgb if indicated.
• Start to monitor BMI
  
  • Instead of weight for length, start to transition to BMI for age.
• Fluoride varnish
  
  • Patients should be seen by a dentist at this age if they did not get fluoride varnish at their dentist most pediatric offices will apply it.
    
    • At this stage they should have been or are weaning off the bottle
  • Fluoride treatments protect teeth.

Question 4

2.5 yo (30 mo) WCC

Answer 4

• This visit is mainly for monitoring developmental progress.
• Milestones:
  
  • Gross Motor- Walks up stairs holding rail with alternating feet, jumps in place
  • Fine Motor- Eight cube tower, makes a train of cubes with stack
  • Social- Imitates adult activities
  • Problem Solving- washes hands, puts things away, brushes teeth with assistance, points to small details in pictures
  • Language- Echolalia, jargoning, refers to self with correct pronoun (I), understands 2 step commands

Question 5

3 yo (36 mo) WCC

Answer 5

• No Vaccines!! (If patient is on schedule, then no vaccinations until 4 year WCC; seasonal vaccination of influenza indicated)
• Developmental Milestones

Question 6

36 month developmental milestones

Answer 6

• Gross Motor- Walks Steps alternating feet and no rail, balances on one foot for 3 seconds, catches ball, pedals tricycle
• Fine Motor- Stack Eight Blocks, Wiggles thumb, copies circle, can string beads
• Social- Starts to share, fears imaginary things,
• Problem Solving- Uses Spoon Well, puts on T-Shirt, draws a 2-3 part person, knows own gender
• Language- Names body parts, knows +200 words, Can say three word sentences, 75% of speech understandable to a stranger, uses plurals and pronouns
• 2 yrs = 50 percent of words are understandable and 50 words, 3 yrs = 75%, 4 yrs = 100%

Question 7

pediatric issues in the pre-school years

Answer 7

• Screen Time
• Sleep
• Elimination
• Toilet Training
• Discipline

Question 8

screen time

Answer 8

• General Principles
  
  • Supervised Screen Time (Co-Viewed)
  • Playtime should not be sacrificed
    
    • Concern for displacing physical activity
    • Concern for displacing face to face social interaction
    • Concern for hands on exploration
    • Concern for harming sleep hygiene (amount and quality of sleep)
• Its generally accepted that screen time can contribute to childhood obesity
• Tablets and TVs have become the babysitters and nanny’s for the new generation of children.
• The AAP has developed some recommendations regarding screen time for children:
  
  • Limited to no screen time younger than 18 mo. Video chatting is an exception.
  • 18-24 mo if a screen is going to be utilized then programming should be of high quality and a caregiver should be involved in order to interact with the child and give context to the child.
  • From 2-5 yo screen time should be limited to 1 hour total for the day.
  • Designate Media Free times (dinner, driving, and locations no media in bedroom)

Question 9

healthy newborn and infants

Answer 9

• Longer sleep duration
• REM sleep occurs at sleep onset
• More REM sleep (important because REM sleep à Activation of central and autonomic nervous system à functional maturation of brain function!

Question 10

children and adolescents

Answer 10

• Children
  
  • Sleep onset via NonREM sleep
  • NREM is about 75% of time
  • Alternating REM and NREM throughout the night
• Adolescents
  
  • Physiologic later sleep times
  • Increasing irregularity of sleep-wake patterns (ie weekends)

Question 11

“normal” sleep patterns (keeping in mind, all babies are different!)

Answer 11

• By about 8 weeks of age…
  
  • May sleep 6 to 8 hours at night and omit the 2 AM feeding
  • Most babies at this age spreading their 15-18 hours of sleep evenly between day and night
• By 6 months of age
  
  • May sleep 10-12 hours (although 25% may still wake up)
  • Have started to develop a more regular sleep-wake cycle
  • Breastfed infants wake up more frequently than formula fed infants
  • Usually 2 naps in the daytime
• By 1 year of age
  
  • Stop having a morning nap
• By 3 years of age
  
  • Stop having an afternoon nap
  • Sleep through the night

Question 12

behavioral insomnia

Answer 12

• maladaptive sleep-onset associations and/or poor limit setting by parents
  
  • leads to:
• bedtime resistance, delayed sleep onset and/or nighttime awakenings
  
  • =
• Less time for REM sleep and brain development
• ***Most common in 0-5 years old, but can persist into adolescence***

Question 13

preparing for sleep training: general tips

Answer 13

• Start ~3-6 months old (when sleep-wake cycle becomes regular)
• Introduce a bedtime routine (20-45 minutes, with 3-4 soothing activities):
  
  • Soak in warm water, pajamas, read/sing in a rocking chair, let off some energy (horsey ride, bouncer, etc), play a game (eg peek a boo), recite baby’s day
  • You can start outside of the baby’s room, but the routine should end with baby being alone in the bed when drowsy (not falling asleep in your arms)
• Pick a consistent bedtime
  
  • BUT if your baby is not ready to sleep until after your set bedtime, go with their rhythm and slowly advance to desired time
• Follow a predictable daytime schedule (avoid naps late in day, routine food times, babies like patterns etc)
• Be consistent
• Choose what works for your family*
  
  • *Some families choose to co-sleep or live in a small space which makes it very difficult to sleep train.
• Expect relapses
• Co-sleeping / smaller spacers make it very difficult to sleep train

Question 14

What to do when your child doesn’t want to sleep: baby

Answer 14

• Unmodified extinction (“cry it out” with no relief)
• “Ferber method” (“cry it out” with relief)
  
  • Proven to be highly Effective, although some perceive it as cruel
  • Theory: children need to learn to self soothe
  • Set amount of time where you will allow baby to cry before soothing, increase duration day by day
• Graduated extinction (“fading”)
  
  • Sit with your chair next to where baby is sleeping, then slowly but surely move the chair away
  • “Be baby’s coach, not crutch”
• No Tears
  
  • Promptly respond to crying baby with comfort measures (ie 5Ss: swaddling, side/stomach, shooshing, swinging, sucking, feeding, etc)
  • Can lead to parental fatigue

Question 15

what to do when your child doesn’t want to sleep: toddler/child

Answer 15

• Positive reinforcement
  
  • Sticker charts with rewards for good sleep behavior
  • Toddlers will often ask for many things to soothe themselves / keep you in the room, set a limit
  • No electronics in the bedroom
• Reinforce all the general sleep training behaviors (regular schedule, etc)

Question 16

what to do when your child doesn’t want to sleep: older children/adolescents

Answer 16

• ***Focus more on sleep hygiene***
• Dark, quiet, cool environment
• No screen time up to 4 hours before bed, no electronics in room (ideal)*
• Apps that eliminate your phone’s blue wavelength (reality)
• Avoid caffeine in afternoon/night
• No daytime naps
• Regular bedtime
• No scary or intense movies/shows before bed
• No invigorating physical activity 1 hour before bed
• Sleep diaries
• Bed is for SLEEPING (nothing else)
• No screen up to 4 hours before bedtime. This effects kids with visual acuity or brain damage too-a TV left on can effect sleep for a child with blindness.

Question 17

with concerns around sleep

Answer 17

• … it’s not all behavioral. Rule out:
  
  • OSA
  • Medical interventions (ie medication timing, scheduled feeds, breathing treatments that can interrupt sleep architecture)
  • Medications (stimulants for ADHD, SSRIs, caffeine, etc)
  • GER
  • Psychiatric disorders (anxiety, depression, psychosocial stress)
  • Substance use
  • Chronic pain
  • Autism Spectrum Disorder
  • Epilepsy

Question 18

sleep parasomnias

Answer 18

• “episodic behaviors that intrude onto sleep”
  
  • Fairly complex movements (vs “sleep related movement disorders” like bruxism, restless leg, etc)

Question 19

non REM

Answer 19

• Usually occur within first third of night, children are unresponsive to parental calming, rapid return to sleep, no recollection of events
  
  • Confusional arousals: Prevalence of ~17% in 3-13 year old. Child sits up in bed and cries, moans, whimpers, yells “no”. Lasts 5-30 minutes
  • Sleep terrors: typically 4-12 year old. Child abruptly awakes from sleep with a loud scream, is agitated, and has a flushed face, sweating, and tachycardia
  • Sleep walking: peaks 8-12 year old, most likely to persist into adolescence
• Management:
  
  • If happening infrequently, reassure parents, environmental safety (locked doors and windows for sleep walkers, ground floor room if possible, etc)
  • Ensure no sleep deprivation as this can be a trigger.
  • Unless posing a threat to safety, avoid restraining or awakening the child as this can lead to enhanced disturbance

Question 20

REM

Answer 20

• Children will have recollection, occur later in the night
• Nightmare disorders: “an internally generated conscious experience or dream sequence that seems vivid and real. They have a tendency to become increasingly more disturbing as they unfold”
• Sleep Behavior Disorder: aggressive motor behavior as part of dream reenactment. Followed by awakening and recollection of dream
• Management: Reassurance, Rescripting, Desensitization.
  
  • Recurrent and problematic à Psychological evaluation (for hypnogogic therapies or CBT, evaluation for concurrent anxiety disorders)
• Usually start to occur >3 year olds when fantasy and pretend play part of developmental milestones and >4 year old when more fears about parent separation and concept of death comes into play

Question 21

resources for parents

Answer 21

• www.babysleep.com
  
  • Outlines sleep behavior and expectations month by month, website run by MDs and pediatric sleep experts
• “SLEEP: What Every Parent Needs to Know” (Dr. Moon)
• https://www.chop.edu/conditions-diseases/parasomnias

Question 22

elimination

Answer 22

• Issues of Elimination should be raised at each well child check
• Anticipate Issues of Elimination
  
  • Food Transitions
  • Allergies
  • Picky Eating Behavior
  • Environmental Factors
    
    • Who are the caretakers and where is the caretaking occurring?
    • What is the routine for eating, elimination?
    • What is the diet?

Question 23

potty training

Answer 23

• Our approach to toilet training is culturally dictated.
• Different cultures and societies have different approaches and expectations of what it means to be “potty trained.”
  
  • In the US in 1929, “Parents” magazine stated that children should be toilet trained by 8 weeks of age.
  • In the 1940s Dr. Spock introduced the idea of assessing for child readiness.
  • The Digo people of East Africa start toilet training in the first weeks of life and supposedly have full control by 5 mo of age.
• Current Practice in the US is to start the conversation with parents at 12 mo.
• The AAP promotes a child-centered approach that relies on a child demonstrating physiologic and developmental readiness in order to ensure a successful and positive experience.
  
  • Physiologic criteria- sphincter control is generally achieved by 9-12 months.
  • Developmental criteria- both developmental and behavioral.
    
    • Walk to toilet
    • Indicate they need to use the bathroom
    • Able to follow commands
    • Able to take off their clothes and clean themselves (these are not absolutely necessary such as in the case of a child with physical disabilities)
• Parents become very emotionally invested in potty training and can associate their own or their child’s intelligence or character with success or failure in potty training.
• Accidents will happen in even the best of cases and even children who are dry during the day can have bed wetting episodes.
• During times of stress children will often regress which can exacerbate already stressful situations for a family.
• Children are vulnerable to child abuse during potty training due to the increased stress by care givers.

Question 24

techniques for potty training

Answer 24

• Techniques:
  
  • Parents should familiarize themselves with their child’s toileting habits.
  • Discussions should be had with the child about toilet training.
  • Children should be brought to the toilet with parents and parents or older siblings can model proper behavior.
  • Rewards such as a sticker chart can be given for success in toilet training.
  • Punishment should not be inflicted on a child for failures in potty training as this can lead to pathologic behavior such as stool withholding.
  • Potty training should not be delayed for children with disabilities. However, modifications may need to be made.
• How can a provider help?
  
  • Have a discussion with parents at well child visits discussing toilet training.
  • Understand their approach and offer advice if needed.
  • Assess for constipation. Constipation is a common problem and any barrier to stooling will make this even more difficult. If constipation is an issue you can advise:
    
    • Increased hydration
    • Increased fiber
    • Laxatives such as polyethylene glycol (Miralax) can be prescribed.
    • Accidents happen
      
      • Bedwetting- frequent until age 6-7 years in boys

Question 25

normal development: autonomy and impulse control

Answer 25

• Autonomy
  
  • A toddler has new physical abilities that give them independence.
  • Testing their abilities is a normal part of development.
• Impulse Control
  
  • Babies and toddlers have poor impulse control. (Ex. If they see a toy they will immediately grab it even if they have been instructed not to.)
  • By around 3 yo children develop improved impulse control. They are beginning to understand delayed gratification. (Ex. Experiments where they tell children if they do not eat a cookie for 5 min they will get 2 cookies at the end.)

Question 26

normal development: terrible twos

Answer 26

• The struggle between their new autonomy and parental authority results in the Terrible Twos.
  
  • Limit-setting becomes crucial to the parent-as-authority role
    
    • consequences must be clear and enforcement should be consistent
    • consequences must be brief and linked directly to behavior
    • Link praise for intended behavior (star chart)
  • Replace parent-child bargaining with provision of options by the parent
  • Consistency and Routine will slowly allow behavior modification over time

Question 27

temperament

Answer 27

• The child’s behavioral “style”. Chess and Thomas followed 100 children from birth to adulthood.
  
  • easy child-outgoing and easily adapts to new situations
  • difficult child- does not adapt well to new situations and is very resistant
  • “slow to warm up” children- need more time to adapt to new situations. In between an ”easy” and “difficult” child
• Modifying Behaviors
  
  • Environment- parent has some control
  • Learning- parent can adjust how child learns and can adjust according to child’s ability
  • Temperament- parent does not have control of temperament but important to recognize a child’s temperament for a situation. Important to realize the differences in temperament between parent and child.

Question 28

behavior modification

Answer 28

• positive reinforcement
  
  • Increases frequency of behavior by following behavior with a positive consequence (reward). (Ex. If child finished their vegetables they get praise.)
  • Rewards do not have to be elaborate.
• negative reinforcement
  
  • Increases frequency of behavior by following behavior with removal of unpleasant event. (Ex. If child is upset he has vegetables his parents take them away to make the child happy again)
• Negative reinforcements are often performed unintentionally by parents and reinforce undesired behaviors (e.g., attention to tantrums)
• extinction
  
  • ignoring a behavior to avoid reinforcement
• punishment
  
  • negative consequence for unwanted behavior
  • less effective than positive reinforcement
  • more effective if used with positive reinforcement

Question 29

discipline guidelines

Answer 29

• • Can begin discipline after 6 months of age
    
    • Must be tailored to developmental age
    • express each misbehavior as a clear and concrete rule
      
      • “Don’t hit your brother.”
      • “No yelling when a parent is inside the house.”
    • state the acceptable behavior or alternative
    • ignore unimportant or irrelevant behavior
    • use rules that are fair and attainable
    • consider developmental level
    • Take advantage of desire to imitate
    • Be the role model (reading, cleaning, organizing)
• • concentrate on one rule at a time and add rules slowly
    * safety
    * relating to others
    * biting, kicking, screaming
    * damaging property
• ​​​
  
  • avoid trying to change “no-win” behavior through punishment
    
    • e.g., bed-time, homework refusal, masturbation
  • positive reinforcement for target behavior
  • apply the rules consistently
    
    • write the rules down, if necessary
    • Star Chart so that good behavior can be recognized and rewarded

Question 30

discipline: the timeout

Answer 30

• simple punishment/reset button
  
  • lack of abstract thinking obviates child’s consideration of how bad the behavior was
• unavoidable and unpleasant consequence provides motivation to learn and avoid the misbehavior
• one minute per year of age
• no response from parent during timeout
  
  • no expression of anger from parent
  • avoid a battle of wills: use child’s frustration with imposition of parental will to redirect child to desired behavior
• portable kitchen timers help

Question 31

physical punishment

Answer 31

• Physical punishment is not recommended by the AAP.
• It can make children more violent later on in life.
• It is legal to spank a child as punishment.
• Some Guidelines:
  
  • A parent should always give themselves time to cool off before spanking a child.
  • The punishment must be “reasonable.”
  • Should be with open hand on an area that is well protected ex. bottom

Question 32

tantrums

Answer 32

• Common in 18 month to 4-year-old children
  
  • peaking late in third year of life (before age 3)
• Normal when brief and not accompanied by manipulative behaviors.
• Typically 2 to 5 minutes.
• History can elicit recurrent problems causing frustration, anger, or inability to cope, but also unmet real needs
  
  • hunger
  • fatigue
  • overstimulation
  • inadequate physical activity
  • domestic violence

Question 33

solving tantrums

Answer 33

• Goal is self-regulation of anger & frustration
  
  • assess for normal unmet need
  • remove unnecessary triggers
  • distraction
  • removal from environment
  • positive reinforcement for good behavior
  • adhere to routines
• Interventions usually cause problems to worsen for 1-2 weeks before improvement

Question 34

sexual identity

Answer 34

• Normal Behavior
  
  • Gender self-identification typically occurs around age 2 or 3 yo but possibly can be evolving topic for some. Acknowledge gender fluidity.
  • This is an age of curiosity and poor understanding of personal boundaries and social norms. Normal behavior generally supports this outlook:
    
    • Children will touch their own genitalia both in public and in private
    • They are interested in showing their genitalia to others
    • They may attempt to touch other’s genitalia particularly of the opposite sex due to its novelty
    • They may stare at other people’s naked bodies.
  • By 5 yo children start to understand what is socially acceptable and become more modest.

Question 35

mastrubation/exploration

Answer 35

• Masturbation at this time is typically not a sexualized behavior.
• Instruction about appropriate time and place is typically the only necessary intervention.
• Can be more common in children with intellectual disability.

Question 36

concerning behaviors

Answer 36

• Behavior that is concerning for abuse:
  
  • Any behavior that imitates adult sexual acts
  • Coercion of other children to participate in sexual behavior
  • Insertion of objects
  • Behavior that is intrusive or harmful
• If you have concern, as a medical provider you are a mandated reporter and should discuss this with a social worker and file a report.