Well Child Care - Developmental assessment Flashcards
1
Q
relationship b/t circumcision and UTIs? STIs?
A
- research suggests that there MIGHT be a lower risk fo UTIs and pyelonephritis in circumcised infant until 9 months old
- Recent data shows that risk of acquiring STD is higher in uncircumcised male, also cervical CA may be more common in partners of uncircumcised males
- no definite literature to indicate clear medical recommendation to circumcise every male infant.
2
Q
Most beneficial thing about well child care?
A
- it allows you to pick up on things in a child that you might otherwise not pick up if he/she only came in when sick
3
Q
Frequency of well child care visits?
A
- 5-7 days, 2 weeks
- 2, 4, 6, 9, 12, 15, 18, and 24 mos
- then yearly until 6
- then every 2 years till age 12
- yearly ages 13-18
- do best you can to encourage parents to bring their kids in even when shots aren’t due
4
Q
approach to well child visit?
A
- have laid back attitude
- speak directly to child
- compliment child in some way
- smile and be non-threatening
5
Q
Main pts of well child exam?
A
- growth measurements
- interval Hx (assess family)
- PE (abnormalities?)
- developmental assessment
- anticipatory guidance: prevention and nutrition
- immunizations
- answer questions
6
Q
Growth measurements?
A
- ht, wt, and head circumference
- normal? compare with family background
- when to worry:
when wt falls 2 percentiles
wt below 5%, head size passing 2 percentiles - always remember to mark and refer to growth charts along with the parents and explain where this child is in relationship to his/her peer group
7
Q
Interval hx?
A
- use open ended ?s
- how are you feeling (include mother/father/sibs/relatives)
- how is baby/child doing?
- how have things gone since our last visit?
- ask appropriate f/u ?s to explore leads
8
Q
PE?
A
- be thorough
- have parent help with exam
- don’t forget all of unique elements that are particularly impt for ped pt
9
Q
Developmental assessment?
A
- much of this will be done through observation during interview and PE
- may also include specific developmental tests such as Denver II or Ages and Stages Questionnaire
- areas to be assessed:
gross motor
fine motor
language
personal-social
vision
hearing
10
Q
Developmental delays? When do they manifest themselves?
A
- age related manner
- motor delays tend to manifest in 1st year of life
- language delays tend to manifest in the toddler and preschool years of life
- learning disabilities manifest during school years
- parents tend to be good at recognizing if their child is developmentally delayed, so listen to them!
11
Q
What may motor delays signify?
A
- neuromuscular, genetic/metabolic, infectious, or other abnormality and warrants thorough eval
12
Q
What should be tested if there is a language delay?
A
- hearing assessment (any child at high risk for hearing loss should undergo screening to ID them b/f language delay)
- once it is determined that hearing is normal, assessment aimed at whether there is global problem (cognitive delay), or whether it is isolated in domain of speech and language
- language delay in preschool years is classic manifestation of mental retardation, but many kids do appear to exhibit delays that are limited to language
13
Q
Purpose of developmental assessment?
A
- can realy help ID problems early, increasing chance for more successful prognosis
- a child may be advanced in one area and delayed in another
- much of the assessment is done by H&P
- many times a standardized instrument isn’t used (may lead to delayed dx)
14
Q
Why is early detection of developmental problems so critical?
A
- children involved in early intervention programs are more likely to:
- live independently
- graduate from high school
- productively contribute to society
- save society 30,000-$100,000/child
15
Q
Types of std instruments that are used?
A
- Denver II
- ASQ (ages and stages)
- Brigance screening
- PEDS (parents’ eval of developmental status)
16
Q
Main pts of Denver II?
A
- for ages 0-6
- objective measure: ID children that may have developmental delay, and thus would benefit from further eval
- 4 areas screened include: gross motor, fine motor, personal-social, and language
- children born b/f 38 weeks gestation must have their age corrected for prematurity, up to 2 years of age
- some items can be passed by report of caregiver, others must be done by child
- first thing - take childs age and draw straight vertical line, each item that intersects or is just adjacent to age line should be scored
- items should be scored as: pass, fail, no opportunity or refused to cooperate
17
Q
Denver II scores?
A
- advanced: child passes item that falls completely to right of age line
- normal: child passes, fails or refuses item on which age line falls b/t 25th and 75th percentile
caution: child fails or refuses item on which age line falls b/t 75th and 90th percentile - delayed: child fails or refuses item that falls completely left of age line
- pass: no delays and maximum of one caution
- failure: needs referral to developmental specialist, 2 or more delays
- re-evaluate in 3 months: one delay and/or 2 or more cautions
- untestable: significant number of refusal or no opportunity test items (if untestable on 2 consecutive screenings - refer)
18
Q
Criticisms of Denver II?
A
- can take awhile to admin test
- norms established not necessarily representative of population as a whole, may not compare appropriately with other populations
- some items are difficult to test
- requires a number of items to admin test thoroughly
- high over-referral rate
- if using this test - use with discretion, see the big picture
- understand that this is a screening tool, not a test to make a final dx
- Denver II is starting to fall out of favor
19
Q
Main pts of ASQ?
A
- relies on info from parents
- screens for developmental problems
- takes 10-15 minutes to complete (done at home)
- can be used in pts 4 months - 5 years
- separate 3-4 page form for each well-child visit (age-specific)
- available in English, Spanish, Korean, and French
- std scoring procedures
- can be photocopied
- This forces parents to go through the testing with their child, good for several reasons:
gets parents involved in child’s care, helps them to become more aware of child’s abilities/limitations, saves a ton of time as test is already complete by time they come into the office
20
Q
main pts of Brigance screening?
A
- relies primarily on observation and elicitation of skills (0-2 yr age range can be administered by parent report)
- can be used in pts 0-90 months
- 9 separate forms based on age
- takes 10-15 minutes
21
Q
PEDs? (parents’ eval of developmental status)?
A
- relies solely on info from parents
- can be used in ptients birth to 8 years
- involves 10 ?s to parents (4th-5th grade reading level reqd)
- available in English, spanish, and Vietnamese
- parents can compete in waiting room or can be admin in interview format in 2 minutes
- standardized scoring procedures
22
Q
High impact anticipatory guidance for parents?
A
- NO SMOKING!!!!
this increases risk of SIDs, AOM, asthma, cough, URI, and children of smokers smoke - reading to child: proven to increase school performance, helps with bonding b/t parents and child
23
Q
What kind of guidance should you give parents with newborn?
A
- review feeding method
- proper sleep position, and environment
- care of skin, cord, circumcision
- breast engorgement, vaginal d/c
- jaundice
- injury prevention: microwave safety (check temp of bottle), car seat safety, crib safety, sibs, pets, smoke detectors, hot water heater temp setting, UV protection, smoke free home
- When and why to call Dr
- individuality of infant
24
Q
2 week visit – what should you cover with parents?
A
- answer ?s about breast or formula feeding
- sleep patterns (encourage mom to sleep when baby sleeps)
- social interaction with family
- injury prevention - education about colic, educate about shaken baby syndrome, smoke free home!!
25
Q
Why shouldn’t you give a little child honey?
A
- b/c of risk of contracting clostridium botulinum
26
Q
What should you cover at 2 month visit?
A
- nutrition: Vit D, Fe, fluoride as indicated, no honey or corn syrup
- defer solids until 4-6 months
- sleeping issues
- play with, talk to, cuddle, never to early to read to child, educate about time with siblings
- signs of maternal depression -screen for this
- injury prevention: gun safety, smoke free home
27
Q
4 month visit?
A
- expect about 6 URIs/year, more if in daycare, most will not need abx, unnecessary abx may be harmful
- elimination
- nutrition: introduce solids one at a time, use Fe fortified cereal
- avoid honey or corn syrup until 12 months
- injury prevention:
smoke free home, safe toys, no small objects, UV protection
28
Q
6 month visit?
A
- nutrition: offer sips from cup, start solids if haven’t yet
- discuss sleep patterns
- development - stranger danger, read
- injury prevention: childproof home, poison control telephone number, no infant walkers, never leave infant alone in bathtub (2 secs is too long)
29
Q
9 month visit?
A
- nutrition: regular mealtimes, soft table foods, use of cup
- educate about waiting until 1 year before using cow’s whole milk
- sleep patterns (regular bedtime)
- interaction with kid
- injury prevention - avoid foods like peanuts, popcorn kernels that can be aspirated
30
Q
12 month visit?
A
- nutrition: appetite may be decreased, don’t force feed (growth velocity slows at this time, don’t be concerned)
- wean to cup, transition from baby footd to all table foods
- educate about limiting use of cows whole milk
- behavioral development:
infant will seek increased autonomy over next several months, interact heavily with child, show mutual interest in enviro - injury prevention:
window and stair safety, childproof home, never leave kid in bathtub, use of appropriate car seat, hot stoves, heaters, irons, UV protection
31
Q
15 month visit?
A
- nutrition: regular meals, sits still to eat (attempts)
- don’t expect to potty train until past 18 months
- behavioral:
drive for autonomy is normal, don’t punish exploration - state no clearly with emotional congruence
- more yes than no messages
- use lots of distraction
- participate in games such as hide and go seek
- temper tantrum management
- little amt of TV
- injury prevention: car seat, door, window, stairwell safety, hot stoves, pots, pans, water safety, UV protection
32
Q
18 month visit?
A
- nutrition: balanced diet, allow toddler to decide how much to eat, encourage cup, discourage bottles
- toilet training techniques
- behavioral: parallel play, not interactive, self comforting behaviors, time-out, allow decision making
- injury prevention: durable toys w/o small parts, reinforce others
33
Q
2 year visit?
A
- nutrition: d/c bottle feeding (if not done yet)
- balanced diet
- note signs of toilet training readiness
- behavioral: offer choices b/t acceptable alternatives, read to child, limit tv, positive outcomes for desired behaviors
- injury prevention: reinforce all other teachings, gun safety
34
Q
3 year visit?
A
- nutrition: encourage self feeding with utensils, dental referral
- support toilet training
- may d/c naps
- interact appropriately with child give honest answers
- injury prevention
35
Q
4 year visit?
A
- regular dental care
- nocturnal enuresis
- opportunities to play with peers
- chores
- clear limits and consequences
- praise desired behavior
- injury prevention: bike helmets, stranger and animal danger, water safety
36
Q
5 year visit?
A
- regular physical activity
- increasoing autonomy
- praise liberally
- injury prevention: pedestrian, bike safety, poisons, tools, guns
37
Q
How should you close a WCC appt?
A
- schedule next WCC appt
- never appear hurried
- never check your watch
- don’t cut off parent’s sentences
- last door handle ?: have I answered all your concerns?
38
Q
Norm HR in children?
A
- newborn: 120-160
- 2 weeks to 6 mo: 145
- 6-12 mo: 135
- 1- 3 yr: 120
- 4-5 yr: 110
- 6-8: 100
- 9-16: 85
- older than 16: 80
39
Q
RR in children?
A
- 0-1: 24-38
- 1-3: 22-30
- 4-6: 20-24
- 7-9: 18-24
- 10-14: 16-22
- 14-18: 14-20
- slightly higher respiratory rates in neonatal period (40-50) may be normal in absence of other signs or sxs
40
Q
BP norms?
A
- one year: 85/40
- incrementally increases to about 100/60 at age 8 and then to 110/65 as 17 yo
- ht will change norms: shorter kids: lower BPs, and taller: higher
41
Q
High impact anticipatory guidelines: the big ones?
A
- no smoking
- read to child
- as well as several others that are age specific: never leave child alone in bathtub, childproofing home when child becomes mobile
42
Q
Can asthma affect growth of a child?
chronic daily steroid use?
A
- only if it is poorly controlled
- if well controlled - won’t have an affect
- steroid use: probably not
43
Q
Normal causes of short stature?
A
- 80% of causes
- familial short stature
- constitutional delay
44
Q
Pathologic causes of short stature?
A
- 20% of causes
- x’somal abnormality (Turners, trisomy 21)
- chronic disease
- malnutrition
- psychosocial deprivation
- endocrine disorders (cushings, hypothyroidism)
- meds/drugs
45
Q
How can you determine if cause of short stature a consitutional delay?
A
- order a radiograph of the wrist for bone age
- typical pattern for constitutional delay: normal size at birth, followed by decrease in both ht and wt velocity in first few years of life, and then by normal velocity following lower percentile
- familial short stature: similar pattern - will show bone age same as actual age, parents likely to be short
46
Q
Do kids with familial short stature have delayed puberty?
A
- no they wouldn’t
- if child has constitutional delay - most likely have delayed puberty
47
Q
What would you expect if child was in 50th percentil in ht and wt until age 4 and then ht velocity decreased to less than 3rd percentile and wt velocity increased to 90th percentile? (hint: on exam - round face and purplish bands of rough skin along abdomen)
A
- cushings
48
Q
5 critical areas of normal development?
A
- physical growth
- gross motor control
- fine motor control
- language
- personal-social
49
Q
Normal development in the first year?
A
- physical growth: avg child triples in birth wt by 1
- gross motor control: 6 months: sit independently, by 9 - crawl, 12 - walk
- fine motor control: 12 months: fine pincer grasp
- language: 2 months - smiles socially, 6 - babbles, 9 - says mama/dad, waves
- 12: uses 2 words other than mama and dada
- personal social: 2 months - recognize parent, 12 months: imitates actions, comes when called
50
Q
Normal development in 2nd year?
A
- gross motor: 18 months: throw objects, 24 months: walks up and down steps without help
- fine motor: 18 months - scribbles spontaneously, 3 block tower, 24 monthsL imitates stroke with pencil, 7 block tower, remove clothes
- language: 15 months - 4-6 words
18 months: 7-10 word vocab
24 months: use pronouns inappropriately, uses two word sentences - personal social: 15-18 months: uses spoon and cup, 18 months: copies parent in tasks, plays with other children, 24 months - parallel play
51
Q
Normal development in 3 year old?
A
- gross motor: can alt feet when going up steps, pedals trike
- fine motor: copies circle, undresses completely, unbutton
- language: 250 word minimum, 3 word sentences, uses plurals, knows all pronouns
- personal-social: group play, shares toys, takes turns, plays well with others, knows full name, age, gender
52
Q
Normal development in 4 year old?
A
- gross motor: hops, skips, alternates feet going down steps
- fine motor: copies a square, buttons clothing, catches ball
- language: knows color, says song or poem from memory, asks ?s
- personal-social: tells tall tales, plays cooperatively with group of kids
53
Q
Normal development in 5 year old?
A
- gross motor: skips alt feet, jumps over low obstacles
- fine motor: copies triangle, ties shoes, spreads with knife
- language: prints first name, asks what a word means
- personal-social: plays competitive games, abides by rules, likes helping in household tasks
54
Q
development b/t 5-7 years?
A
- acceleration of separation-individuation them initiated in preschool years
- go from being able to deal with one variable cognitively to dealing with more than one
- magical thinking diminishes
- reality of cause-effect relationship better understood
55
Q
Development b/t 7-11 years?
A
- devotion of energy to school and peers
- progressive interaction with opposite sex
- expectations for behavior and academics intensifies: this is where children with learning disabilities and attention deficit problems can really begin to struggle
56
Q
Determining cause of short stature? Define it!
A
- majority of time - short stature (defined as being 2 std deviations below the mean, has normal cause)
- in those incidences where there isn’t a normal cause, there is usually a hint with H&P as to likely etiology
- radiograph of wrist for bone age helps to differentiate child with constitutional delay from child with familial short stature (also take into account parent’s ht and hx into account)
