Quiz 1 Flashcards
Health promotion vs Health maintenance
Health promotion: increase well-being. Strategies that make POPULATIONS reach higher level of wellness. Looks at strengths & goals of individuals, families, populations. E.g., providing housing, promoting oral health
Health maintenance: preserve INDIVIDUAL’S present state of health, prevent disease recurrence. Focus on known risks. e.g., developmental surveillance, IZs, anticipatory guidance
3 levels of disease prevention
part of health maintenance
Primary: stop dz from occurring. IZs
Secondary: Stop progression. Screening.
Tertiary: Minimize residual dz. Help live w/residual dz.
Pediatric health promotion: First 5 years
focusing HP efforts on first 5 years of life can help reduce incidence of dz in general population
Standard components of pediatric well visit
History (subjective) Physical exam (obj) Screening tests - dvptl & physical Assessment (not just Dx) Plan of care, anticipatory guidance (diet, IZs, safety, growth & dvpt, screening) *F/U* & referral
AAP 2014 periodicity schedule
gives recommendations for pediatric preventative care
Changes to 2014 AAP periodicity schedule
Routine dyslipidemia screening 9-11yo
Depression screening 11-21yo
Screen w/CRAFFT for etoh/drug use
STI & HIV screening 16-18yo
REMOVAL of routing cervical dysplasia screening before 21yo
CHD screening after 24h/age but before hospital discharge
Hgb & Hct at 15 & 30 months (still 12 & 24, but at 15mths they’ve switched to whole milk so can pick up more)
Approaches to health promotion
Medical, behavioral, educational, client-centered, societal change
Medical approach to HP
Goal: keep ppl free of disease & disability. Focus is on sustaining dz-free state, not on enhancing ability
Behavioral change approach to HP
Encourage behaviors that will lead to freedom from dz. “Healthy behavior” is defined by health promoter (disempowering?)
Health Belief Model of HP
Person is convinced of necessity of behavior change
Health Belief Model: stages of change
Pre-contemplation: no perceived need to change
Contemplation: aware of problem but struggles w/energy/cost of change
Preparation: planning for change, small steps made
Action: Concerted effort, at least 6mths
Maintenance: plans to prevent relapse
Educational approach to HP
HCP provides knowledge & understanding. Choice is up to individual.
Client-centered approach to HP
Children & young people identify their own needs. Work on equal plane w/HCP.
Societal change approach to HP
Modifies physical & social environment to make healthier choices easier to make. E.g., sidewalks.
Family Capacities: definition & 4 categories
Definition: resources parents/caregivers bring to tasks of raising kids
4 categories:
Financial resources
Time investments
Psychological resources
Human capital (e.g., level of education, health literacy)
4 core foundations of children’s health
Responsive caregiving
safe & secure environments
adequate & appropriate nutrition
health promoting behaviors
Age Ranges: Early Childhood Middle Childhood Adolescence Young adulthood
Early Childhood: birth - 8yo
Middle Childhood: 6-12yo
Adolescence: 10-19
Young adulthood: 20-24
urination pattern in infants
bladder reflexively empties 20x/day
Volume capacity approx 60 cc
urination pattern in toddlers
can hold urine for 2 hours
voids 7-12x/day
Volume capacity 300ccs
urination pattern in preschoolers
98%+ will have bladder control by 4yo during day
Nighttime control varies. “Accidents” WNL till 6yo for boys & 5yo for girls
Primary enuresis
continued involuntary leakage of urine (have never been fully dry)
Secondary enuresis
Had bladder control for at least 3 mtgs but not currently.
Diurnal: daytime
nocturnal: nighttime
Requires further evaluation - UTI, diabetes, constipation, sickle cell, CRF, psychosocial stressors, abuse
***common
Primary nocturnal enuresis
common (even 1% of 18yo)
more common in boys
family pattern
Why do infants stool after feeding?
Gastrocolic reflex often causes stool after feeding
Stooling: breastfed infants
BF: yellow, seedy, 1-8x/day or 2-4x/week (okay b/c no unbroken down food)
Less than FF, lower percentage of hard stools
Stooling: FF infants
FF: brown/green/soft/formed 1-4x/day (no less than every other day)
Higher percentage green stools
Soy –> highest percentage of hard stools
Straining & hard stools in infants
Normal to strain, cry & grunt - no coordination of muscles
Hard stools abnormal/ Prunes do work!
Stooling: toddlers
Patterns & barriers to toileting
pattern develops w/diet & activity. 1-2x/day or QOD
Increased awareness: may go off alone to poop
Need to learn words to associate w/going
Animation/fear of toilet common
Need to watch others poop (normalize)
Negativism may impede toilet training (if saying “no” to everything - not the right time)
Painful stools will impede toileting process
Stooling: preschoolers, school-age, adolescents
Usually 1 stool/day
Diet & activity important to regularity (no scientific evidence)
Witholding pattern can lead to painful stools (can cause megacolon/lack of signals to brain)
Straining UNCOMMON & may indicate constipation
Constipation
Decrease in child’s normal frequency WITH difficult or incomplete passage of hard dry stools
Encopresis
Stool incontinence after 4yo
usually secondary to constipation (liquid poop around solid poop - so must treat constipation)
Diarrhea
Infection Change in diet (excessive fluids/juices) Protein, lactose, carb intolerance Stress Tx: BRAT (bananas, rice, applesauce, toast) - no evidence it works
Toilet training: child readiness cues
walks well able to sit & play, dress & undress self partially Wants to put toys "where they belong" Likes to imitate Not in period of negativism Takes pride in doing things BM formed at regular time each day Able to remain dry 2hrs at a time Has words for urine & stool
Toilet training: length
Typically takes 2-3 months
Assisted infant toilet training
can begin soon after birth
caregiver recognizes signals that infant is ready & needs assistance to toilet
REM & babies
develops about 29 weeks gestation Rapid, irregular pulse & RR Body twitches active dream state Ends w/brief awakening but they don't know how to go back to sleep yet
NREM & babies
Non-rapid eye movement begins 32-35 weeks gestation HR & RR are lower Restorative functions of sleep 4 Stages: Stage 1: drowsiness, light sleep Stage 2: deeper but easily aroused Stage 3: Deeper, body relaxed, shallow breathing. Develops at 3-4mths Stage 4: Deep sleep. If awakened, confused.
Effect of poor sleep in kids
Poorer health (depression) in parents, esp mothers. Moderate to severe in 17% infants, 14% preschoolers
Infant sleep cycle
50 - 60 min more REM: enter REM shortly after sleep onset Newborns: 50% REM Premature infants: 80% REM Preschoolers: 30% REM
Adult Sleep Cycle
90-100 min
20% REM
First REM 90min after sleep
Sleep cycle
Awake -> Stage 1 NREM -> Stage 2 NREM -> Stage 3 NREM -> Stage 4 NREM -> REM
Newborn pattern of sleep
REM w/frequent arousal. 16-17 hours per 24h. No circadian rhythm.
Infant (3-4mth) sleep pattern
NREM increases. 14-15 hrs sleep. Can fall asleep after REM. Circadian rhythm.
Infants (6-12mth) sleep pattern
Need for feeding at night less acute. Can sleep 12h, 2 naps during day. Separation anxiety starts (change sleep environment before).
Breastfeeding & infant sleep
associated w/increased wakening (sometimes digested faster)
Toddler sleep pattern
11-12h at night
No morning nap, keep afternoon nap
Separation anxiety
Rituals important
Preschool sleep pattern
11-12h at night
Some stop afternoon nap
Fear of monsters
School age sleep pattern
10-11 h at night
sleep problems learned behavior or sign of stress
Adolescent sleep patterns
9 hours/night
irregular sleep schedule
Most don’t sleep enough: ETOH (>0.08 –> less REM, >stage2, >awakening), caffeine
SIDS vs SUID
SIDS: cannot be explained
SUID: explained or unexplained - any sudden death during infancy
3 major causes SUID
suffocation
asphyxia
entrapment
“Back to Sleep” Campaign
AAP - only on back, not side or stomach to avoid SIDS
Up to 1 yo
Appropriate mattress for infants
Firm crib mattress covered by fitted sheet No soft materials Not on shared beds No bedrails Not in sitting devices
Bed sharing & infants
AVOID
room share w/o bedshare –> decrease SIDS by 50%
Soft objects in crib
AVOID - no soft objects or loose bedding, no bumper pads
Prenatal care & SIDS
lower risk for SIDS
Smoking & SIDS
AVOID
2nd hand
sharing bed w/smoker particularly risky
ETOH & illicit drugs & SIDS
increased risk
Breastfeeding & SIDS
Reduced risk of SIDS. Increases w/exclusivity of BFing.
Pacifiers & SIDS
Pacifiers are protective - even if falls out.
Do not hang on neck.
Attach nothing to it
Delay pacifier introduction until BFing firmly established - 3-4weeks
Temperature & SIDS
Avoid overheating (no standard definition)
Babies need only 1 more layer than adults
Avoid covering face & head/overbundling
No evidence for fan
IZs and SIDS
No evidence for causative link between IZs and SIDS, more evidence that it’s protective
Commercial Marketing devices & SIDS
Avoid 0- no evidence
Cardiorespiratory monitors & SIDS
No evidence they decrease SIDS
Awake tummy time & SIDS
if supervised, it’s recommended to facilitate development & minimize developmental plagiocephaly
Populations w/highest rates of SIDS
African-American, American Indian
2 common reasons for sleep problems in infants
Night waking & night feeding
*put to bed awake, reinforce circadian rhythm with quiet dark room, comfort & change in bed, feed only when necessary
Ferber / Controlled Comfort Method
Sleep assist method
Baby in crib awake but drowsy. Make sure dry, fed, well.
Return at progressing intervals to comfort but not pick up - 3min, 5min, 12 min
*for infants 6mths of age (can go whole night w/o feeds)
Camping out method
sit w/infant until falls asleep independently. Parent gradually removes presence from room. First sitting near bed, then door, then outside door.
Night terrors in children
during NREM
Don’t try to wake but keep safe and back to bed
Can try to wake up at point before it usually happens - after few weeks may stop
Sleep disordered breathing
Has health consequences, e.g., ADHD, asthma & allergies
Physical exam: TMs (r/o OM), neuro, nasopharyngeal structures
Possible referral to ENT
“Sexually reactive youth”
better term than “youth sex offenders”
Factors that affect frequency & type of sexual behavior
Childcare- more interaction Preschool age - inquisitive Exposure to nudity Family environment Access to porn Abuse Developmental disabilities
Normal sexual behaviors: common
Transient, few, distractible touching/masturbating in public/private Viewing/touching others' genitals Showing genitals Standing/sitting too close Trying to view adult nudity
*assess situational factors
Normal sexual behaviors: less common
Transient, moderately responsive to distraction
Rubbing body against others
Trying to insert tongue while kissing
touching peer/adult genitals
crude mimicking of sexual acts
sexual behaviors that are occasionally but persistently disruptive
*assess situational factors
Sexual behaviors: uncommon
Persistent & Resistant to parental distraction
Asking peer/adult to engage in specific sexual act
Inserting objects into genitals
Explicitly imitating intercourse
Touching animal genitals
Sexual behaviors that are frequently disruptive
*assess situational factors
Sexual Behaviors: Rarely Normal
Involve children 4+ years apart
Variety displayed on daily basis
results in emotional distress or physical pain
associated w/other physically aggressive behavior
involve coercion
child becomes angry if distracted
*assess situational factors
3 considerations in giving care for adolescents r/t sexuality
Consent (“mature minor doctrine”), Confidentiality, Payment
Adele Hoffman Models of Adolescent Care
Model I: Parent adolescent collaborative
Model II: Patient Primary - Parent Secondary (purpose reviewed together, parent leaves and returns at end, confidentiality w/teen)
Model III: Patient Alone - Parent Optional
When to ask about sex
Bright Futures: 11-14yo
STIs and screening recommendations for adolescents
All sexually active: GCCT
If requesting
HIV/AIDS - if treated for STI, unprotected w/multiple partners, high risk, IVDU, MSM, sex for $, etc
Pregnancy intention & ambivalence
If ambivalent, more likely to get pregnant or STI (less likely to use condom)
Age of Consent
16 years: in general
18 yo: if partner in position of power (NON school teacher, athletic coach)
13-15 yo: can consent to sexual relations w/anyone up to 3y older
12yo and younger: cannot legally consent
NO age of consent if partner is school teacher, psychologist, or therapist
Growth rate of infants
Weight doubles by 5-6 months, Triples by 12 months
Challenges to nutritional needs
small size of stomach
immaturity of digestive system
Nutritional needs of infants from birth to 1year of age
exclusive BFing for 6mths followed by continued BFing as complementary foods are introduced = best
Breast milk as PRIMARY food for first year
Vitamin & mineral supplementation:
400 U oral vit D drops for BF prior to discharge
Iron supplementation may be needed
Fluoride 6mths to 3 years if <0.3 ppm
Solids: begin at 6mo depending on development and interest
How long to breastfeed?
First year of life and as long as mutually desired after that
Advantages of breastfeeding r/t medical conditions
decreased risk of OM, URI, LRI, asthma, RSV bronchiolitis, NEC, atopic dermatitis, gastroenteritis, IBD, obesity, DM, etc
The specificity of human milk
50% of baby’s genetic material
Not static
Virtually every component plays a nutritional role
Anatomy & Physiology: stages of lactation***
Mammogenesis (dvpt of breast tissue): embryogenesis to puberty. estrogen & progesterone: Proliferation of ducts and glands.
Lactogenesis I (initiation of milk production): mid pregnancy to day 2 PP.
Progesterone: Lobular formation
Prolactin: lobular, alveolar dev, colost.
Placental lactogen: Increases prolactin
Estrogen: Ductular sprouting.
Lactogenesis II (onset of copious production of milk). Day 3-8. A switch from endocrine to autocrine (local) control.
Progesterone down: Lactogenic trigger prolactin: supportive/permissive
glucocorticoids: assists in milk production
insulin, cortisol: supports milk production
Galactopoeisis (aka lactogenesis III, maintenance of milk production): Day 9 to beginning of involution.
Prolactin, cortisol, & insulin: Stimulates transcription of genes that encode milk proteins
Oxytocin: Facilitates milk transfer- MER
Thyroid, PTH and GHs (?): increase responsiveness of mammary cells to prolactin
Effect of retained placenta on BFing
can inhibit w/drawal of progesterone & subsequent release of prolactin
Conditions that affect prolactin secretion
hypothyroidism, DI (vasopressin secretion is supressed, impedes prolactin release), PCOS, pituitary surgery
On dopamine agonists: ergot alkaloids (carbergoline, ergotamine
OCPs with estrogen
Human Milk vs cow: protein, fat, carbs
less protein: 1.1g
More fat: 4.2g
More carbs: 7g
*per 100g fresh milk
Infant feeding cues
Early: stirring, mouth opening, turning head & rooting
Mid: stretching, increasing physical movement, hand to mouth
Late: crying, agitated body movements, turning red
C/Is to BFing
PCP, cocaine, connabis
Methadone (unless adequately nourished and in maintenance program)
ETOH: minimize intake < 0.5 g alcohol/kg body weight. Wait 2 hours. Does not increase milk production.
Smoking: strongly discouraged.
Maternal diet & BFing
increased calorie needs 450-500 kcal/day
Risk of mercury in fish - read recs
Breast Milk storage
Room temp 3-4 h (6-8 h if very clean) Refrigerator 72h (5-8 daysif very clean) Freezer 6mths (12 acceptable)
Vitamin D in infancy***
BF & partially BF: 400 IU/day beginning in first few days of life
Continue supplementation unless infant is weaned to 1 L/day or 1 qt/day of bit D fortified formula or whole milk
*if non-BF and receiving less than 1000mL day of vit D supplemented formula/milk, same guidelines.
Iron supplementation in BF infant
High levels of lactose & bit C in breast milk facilitates iron absorption
Reserves laid down in utero - not affected by mom’s iron intake during BFing
Iron supplementation before 6mths may be detrimental
Longer BFing - less likely to be anemic
Gradual introduction of iron rich foods around 6mths - cereals, meats, dark green veggies, oatmeal, grains
Infants who may require early iron supplementation
Preterm
LBW
Hematologic D/Os
Born w/inadequate stores
Fluoride supplementation in BF infant
from 6mo to 3 yo - decision based on fluoride concentration in water supply, food, fluid, and toothpaste sources
Too much fluoride: brown and white spots under enamel. Hard to repair.
B-12 supplementation in BFing
vegetarian mothers and those w/gastric bypass - if mom doesn’t supplement (4mg/day), then infant should
Types of infant formula/concentrations***
Ready to feed
Concentrate (1 can water, 1 can formula)
Powder (1 scoop formula, 2 oz water)
*discard unused after feeding! Refrigerate after mixing
Calorie considerations in infant formula and infant needs***
20kcal/oz in regular calorie formulas
Some specialized brands have 22-24kcal/oz
Babies need minimum 100-115 kcal/kg/day to gain weight
Protein hydrolysate formula
“hypoallergenic formula”
useful for babies w/milk or soy protein allergies
Easier to digest
less likely to cause allergic reactions
Soy infant formula - use
Medical indications: galactosemia & hereditary lactase deficiency (ONLY)
May be used for milk allergy
Vegetarian (not vegan)
Gastroenteritis if secondary lactose intolerance
NOT recommended for preterm
Soy infant formula: controversy
Safety
in vivo & in vitro study raise possibility of estrogenic effects of isoflavones in SIF
Isoflavone levels higher in infants fed SIF
Animal studies show isoflavones decrease fertility
No human studies w/adverse effects
Goat’s milk vs cow’s milk: infant nutrition
similar weight gain
More BMs in GM
Whole cow’s milk: infant nutrition
NOT before 1 yo: can cause anemia by irritating gut and leading to small but consistent blood loss from GI tract (micro bleeds)
Interferes w/absorption of nutrients
High solute load which kidneys have trouble excreting
Rice milk: infant nutrition
insufficient protein for <2yo
hypoalbuminemia & poor weight gain
Increased arsenic levels
Almond milk: infant nutrition
Insufficient protein source for <2yo
No difference ingrowth rate (increment, length, head circumference) as compared to soy or hydrosylate
Formula additives: pre/probiotics
Nothing to say for or against
DHA and ARA
docosahexaenoic acid & arachidonic acid
omega-3 FAs found in breast milk and certain foods, such as fish and eggs
Some studies suggest adding to formula may help infant eyesight and brain development. Some shows no benefit.
Unpasteurized milk: infant nutrition
possible health hazard
pasteurization does not change nutritional value
When to introduce solids
4-6 mths of age (from spoon/bowl, not bottle)
Developmentally, at 4-6mths, extrusion (tongue thrust) reflex diminishes and infant begins to sit well with support
6-12 mths solids are in addition to, not replacing essential nutrients from milk
First complementary food
Often rice cereal
Provides iron when prenatal iron stores are decreasing
Easily digested
rarely causes allergic reaction
1-2 tablespoons of cereal once or twice daily before milk feeding
Introducing finger foods
after 6mths age
avoid hot dogs hard veggies, whole grapes, chunks PB
Supervise eating
Parents should be familiar w/techniques of airway obstruction removal
Introduce meats early (6mths)
Delay introduction of honey until after 1 year (infantile botulism before 1yo)
Effects of delayed introduction of solids
associated w/reduced odds of childhood overweight/obesity
Assoc w/increased risk of allergic sensitization to food and inhalant allergens
Findings support introduction from 4-6mo, no later than 6mo!
Weaning guidelines
Between 8-9mths, offer baby a cup w/assistance (discourage non spill- just like sucking)
By one year, bottles should be slowly withdrawn
BFing can continue, but water/juice from cup
Cup @snack/mealtime to accustom child to drinking when thirsty and not as comfort (will decrease dental caries & caloric intake)
Iron levels in infancy: infant nutrition***
Newborns have maternal stores
iron in breastmilk has high bioavailability
Iron stores decrease by 4-6mo = need more dietary iron
6-12 mo 11 mg/day iron. Formula contains 10-12mg/L of iron
Weight gain/loss in first weeks: newborns
Normal to lose up to 10% weight in first week. Start to gain again around day 4/5. Expect all back in 1-2 weeks (closer to 2 for breastfed).
