Well Child Care - Exam 2 Flashcards
From birth to 36 months, what frequency interval should a child be seen for a well child check? What if the child is breastfed?
Newborn (generally 24-48 hrs after discharge)
Weight check after 1 week (not required)-mostly for breastfed babies
2 weeks (birth weight, jaundice)
1 month
2 month
4 month
6 month
9 month
12 month
15 month
18 month
24 month
30 months
36 months
then start yearly visits until 18 (some office can see up to 21)
How is the physician-patient-parent relationship established? What is it based on?
This relationship develops over time, with regular visits
This relationship is based off of trust
Parents/kiddos can refused to discuss certain topics, this right should be respected in most instances, what 3 instances does this not apply to?
physical/sexual abuse
neglect
suicide/homicide
When are growth parameters taken? What are the 3? The one that is NOT measured in adults, when is the last one needed?
At every well-child visit
height, weight and head circumference
Head circumference is measured up through age 3 years
Which growth parameters are taken at EVERY visit? When is the first BMI measurement?
height and weight
starting at age 2
Why are growth parameters so heavily monitored? They are measured in _______. What do you want to notice about them?
Monitoring is used to help recognize growth deficiencies and abnormalities, proper nutrition, CNS issues, neglect, and other forms of abuse
Measured in percentiles
You want to see a TREND not necessarily what percentile they’re in at that time
Define failure to thrive. What 2 important marks to remember?
growth faltering in infants and young children whose weight curve has fallen by TWO major percentiles in <6 months from a previously established rate of growth, OR whose weight for length decreases below the 5th percentile
T/F: When evaluating growth parameters, it is safe to assume the kiddo will grow similarly to their siblings
NO!! every child is different, don’t compare siblings
What age should you start checking blood pressure? If ____ or ____ present, BP should be checked at every visit regardless of age
Starts at age 3
renal or cardiac abnormalities
What is the criteria to dx HTN in a child? What age can you start using adult guidelines?
systolic or diastolic blood pressure greater than the 95th percentile based on age and height of child or >130/80 on 3 occasions
> age 13 years, use adult guidelines >130/80
How is vision assessed from birth to 3 years old? Also need to check ______
assessed by testing a child’s ability to fixate on and follow an object (ask parents)
symmetric red reflex
In newborn infants, if you shine light on eye, you should get a _______. How old does the kiddo need to be in order to fixate? What age can you start using a formal visual acuity test?
blepharospasm response
At 6 weeks, should begin to fixate
At 3 years, formal visual acuity testing (tumbling E or picture tests)
Visual acuity: when should kiddos 3-4 years old be referred? 5 years? 6 and up? How should you test visual acuity?
Ages 3-4 with vision worse than 20/40 should be referred
5: 20/30 should be referred
6: 20/20 should be referred
Test visual acuity in each eye SEPARATELY!!
What 2 red reflex signs should be referred? _____ should also be tested during each eye visit
Abnormal or asymmetric red reflex should be referred
strabismus
______ in one eye detected during a screening evaluation is often the first indication of amblyopia
Loss of visual acuity
_____ is one of the most common congenital abnormality in newborns. If undetected, what can it lead to?
Hearing loss
substantial impairments in speech, language, and cognitive development. Even a minimal degree of hearing loss may cause speech and language delay and difficulty in social and educational environments
Who is the most at risk of hearing loss? What should you do next?
kiddos with infections, familial disorders or defects with ENT
screen for hearing loss and language development needs to be monitored closely!!
hearing loss interventions should be in place by _____ of age for social/language development
6 months
All infants with or without risk factors for hearing loss should receive ongoing surveillance of ______ development beginning at _____ of age during well-child visits
communicative/language
2 months
What is the primary goal of hearing loss screening in the 2-5 year old period?
detection of medically remediable otopathologic abnormalities, progressive hearing loss, or late-onset acquired hearing loss.
What is the principal cause of hearing loss in 2-5 year old?
recurrent otitis media
**______ are the gold standard of hearing screening for the birth to 3 years old age group. What is it when the kiddo is 4 and older?
Behavioral and language responses
audiometry in office is used
What is the hearing loss screening for a kiddo 5 and older?
Continue to do at WCC
Typically these kids are screened in the school setting and referred to physician only if they fail the screening.
What are the 8 innate reflexes?
sucking
rooting
palmar
moro
tonic neck
traction response
placing
stepping
At what age does the sucking reflex start to become voluntary vs a previous newborn reflex? When does the rooting reflex disappear?
voluntary activity by 4 months
disappears by 4 months
______ placement of the examiner’s finger in the newborn’s palm; develops by _____ gestation and disappears by _____
Palmar grasp:
28 weeks gestation
3-6 months
______ head turns to side of facial stimulation disappears by 4 months
Rooting reflex:
What is the moro reflex? When does this reflect develop? When does it disappear?
hold the infant supine while supporting the head. Allow the head to drop 1-2 cm suddenly. The arms will abduct at the shoulder and extend at the elbow with spreading of the fingers. Adduction with flexion will follow
This reflex develops by 32 weeks and disappears by 3-6 months
Describe the tonic neck reflex. When does it disappear?
turn infant’s head to one side; the arm and leg on that side will extend while the opposite arm and leg flex (“fencing position”).
disappears by 4-6 months
Describe the traction response. When does it disappear?
he infant is pulled by the arms to a sitting position. Initially, the head lags, then with active flexion, comes to the midline briefly before falling forward.
disappears around 6 months-> baby can hold its head up by that point
What is the placing response? When does it disappear?
Hold the infant’s axillae from behind, the dorsum of one foot is allowed to brush against the undersurface of a tabletop edge and is followed normally by simultaneous flexion of the knees and hip and placement of the stimulated foot on the table
disappears at 2 months
What is the stepping response? When does it disappear?
hold the infant’s axillae from behind, the soles of the feet are allowed to touch the surface of the table, which elicits alternating stepping movements with both legs
disappears at 1-2 months
What is the absence of red reflex called? What 3 things can it indicate? What should you do next?
leukocoria
congenital cataracts, retinoblastoma, glaucoma
immediate ophthal referral is needed!!
When should you check for strabismus/amblyopia? ______ is an intermittent phenomenon in newborns/infants up to 6 months
6 months
Strabismus
What am I?
abnormal white reflex
leukocoria
(later the kiddo was diagnosed with retinoblastoma)
What are the 4 major sutures palpable at birth?
frontal, coronal, sagittal, lambdoid
Where is the anterior fontanelle located? When does it usually close?
junction of sagittal and coronal (closes over 9-18mos, can go to 24 months)
Where is the posterior fontanelle located? When does it close?
Posterior fontanelle is located at junction of sagittal and lambdoid (closes around 2-3 months)
What should a normal fontanelle look like/feel like?
Normally flat and soft on palpation and okay to feel pulsing
What is craniosynostosis? What is plagiocephaly? In plagiocephaly, what 2 sutures are usually involved?
craniosynostosis: premature closure of sutures
Plagiocephaly: abnormal shape, resulting in a lopsided appearance
premature closing of coronal or lambdoidal suture
What is anterior plagiocephaly characterized by? What happens to the contralateral forehead? What side will the nose turn towards?
flattening of the forehead and elevation of the eyebrow on the affected side
becomes excessively prominent as a result of compensatory overgrowth
nose will turn towards the affected side
What is scaphocephaly? What is the resulting feature?
Premature closure of sagittal suture
resulting in restricted width of the head so that it is abnormally long and narrow
What is the MC specific head concern to look for during a WCC?
scaphocephaly
can be partial or complete closure
What is acrocephaly? What 3 sutures are involved? What will the kiddos head look like? What is it associated with?
Closure of coronal, lambdoidal, and sagittal sutures
resulting in an upward growth of the head so that it has a pointed, or conical, shape. “Tower skull”
rare syndromes
What am I?
acrocephaly
What suture(s) are involved in trigonocephaly? What is it characterized by?
Premature closure of the frontal (also called metopic) suture
Characterized by a narrow, triangular shaped forehead with a prominent midline ridge
aka only 10%, so not super super common
What is positional plagiocephaly caused by? What are the treatment options?
Mechanical pressure on the malleable skull caused by static supine positioning leads to flattening of the occiput in patients
think supine sleeping position, congenital torticollis, prolonged periods in car seats, and hydrocephalus
Frequent position changes, tummy time, change crib positions, switch arms when feeding/holding baby
What are the 4 mishaped skull types that need to be referred to maxillofacial sx or neurosx? When is imaging needed?
Plagiocephaly
Scaphocephaly
Acrocephaly
Trigonocephaly
imaging held until specialist visit!
What is the imaging that should be ordered once at the specialist’s office for cephaly?
CT can identify sutures more accurately and can be used to assess the extent of fusion
What are the 4 types of mishaped heads that can be corrected with an open surgery approach? What does it involve? How old does the kiddo have to be?
Acro, plagio, and trigonocephaly, scaphocephaly
Involves large incision across scalp to obtain access to cranial vault
Delayed until 9-12 months so bones are strong enough to build enduring construct
What types of mishaped head is a endoscopic surgical approach in option for? What is involved? When is it corrected?
Scaphocephaly
smaller incisions, cranial bone is much easier to remove and has LESS blood loss
corrected at 2-3 months old
What is required postoperatively after a head reshaping surgery?
All approaches require postoperative shaping with a helmet
What is the tx for positional plagiocephaly? How long should the kiddo wear it? What region of the head? How does it work?
Frequent position changes
Skull-molding helmets
until around 12-16 months
occipital region
Works by symmetrically shaping the cranial growth
When should you do starting doing dental screenings on kiddos?
eruption of first tooth generally around 6-8months old
What is the recommendation for the kiddos first dental appointment? What is the rationale behind this decision?
recommend first dental visit at or around 1st birthday
Rationale: early initiation of preventative care and counseling, including evaluation of dental risks and anticipatory guidance regarding dental hygiene, diet, and oral habits
When should you discuss dental care? When does non-nutritive sucking behavior tend to go away by itself?
at every visit!!
4-5 years old due to development of other coping mechanisms
If the kiddo continues to display non-nutritive sucking behavior, what can it cause? What everyday item can you replace to help with this transition?
Can cause malocclusion (imperfect position of teeth) if continue into period of permanent tooth eruption
sippy cups by 12 months (NOT BOTTLES)
How often should kiddos brush their teeth? What age range should the parent continue to supervise kiddo brushing and flossing?
twice daily (even infants can clean with soft toothbrush)
Parents should supervise a child’s brushing/flossing until about 8 years of age
What is the toothpaste recommendation for all children with teeth? How much should the child use based on their age?
infants/toddlers less than 3, 3, older kiddos?
FLUORIDE in toothpaste
Infants and toddlers less than 3: size of a grain of rice
Age 3: pea size
Older children can use size slightly larger than pea size (“load” the toothbrush head across versus linear)
When brushing their teeth, do NOT give _____. Why?
do NOT give water to rinse
increases risk of swallowing
What are the CDC recommendations with regard to “routine” hemoglobin screening? What does this help with?
CDC recommends EVERY child at age 9 - 12 month
helps to r/o MC cause of anemia in kiddos (iron deficiency anemia)
What is the MC cause of anemia in children?
iron deficiency anemia
What 2 age range does iron-deficiency anemia peak? Why does the first one occur? Why does the second one occur?
age 12 to 24 months and then again in adolescence
This peak in childhood corresponds to the transition of children from human milk or iron-containing formula to whole milk
In adolescents it is typically due to a poor dietary intake of iron
What is the screening CBC recommendations for kiddos at HIGH risk for anemia?
at 9-12 months, 15-18 months, and annually 2 - 5 years of age
In adolescents, what is the initial test for anemia?
finger-stick in office and if low, then will repeat lab
**What is the recommendation for UA in a WCC setting?
**Don’t order routine screening urine analyses (UA) in healthy, asymptomatic pediatric patients as part of routine well child care.
When is a UA warranted in the pedriatric population?
Urine examination is usually warranted only in symptomatic patients or those at risk for renal disease
What 4 categories of kiddos should get screened for TB? The amount of TB bacteria needed to infect a kiddo is (small/large)
Kids from country where TB is common
People who have spent time with people with TB
Infants, children, adolescents exposed to adults who are at increased risk of latent TB
Babies/children who have latent TB
Why is confirming TB in a kiddo challenging?
because difficulty of sputum collection in kids AND lab tests used in kids have higher rates of false negatives
T/F: Need to wait until lab confirms dx of TB before starting treatment in kiddos
False! For these reasons, diagnosis of TB in children is often made without lab confirmation and instead on a combination of factors:
What are the combination of factors needed to diagnosis TB in kiddos?
Clinical signs/symptoms; history of contact with a person with infectious TB
Positive tuberculin skin test or positive TB blood test
Chest xray with patterns typically associated with TB disease
What are the recommendations regarding sleep arrangement for kiddos under 1? Why?
NOTHING but a tight fitted sheet in the crib for the first year
no pillows, no mattress cover, no crib bumpers etc
trying to prevent SIDS
What does the HEADSS assessment stand for? When do you use it?
Home
Education
Activities/Employment
Drugs
Suicidality
Sex
risk assessment tool in teenagers
What are the juice limit recommendations?
none or less than 6 oz a day
What are the expectations for the 24-28 hours office visit?
lactation consultant if needed
full PE of baby (check for jaundice)
poop/peeing okay
check circumcision
patency of nose/ear
weight check
umbilical cord care
stress rear facing car seat
How often should a newborn baby feed? give both breastfeeding and formula feeding
Breast feed 8-12 times per day, or every 2-3 hours
formula: feed every 3-4 hours
How much weight is normal for a baby to lose in the first 3-5 days?
Weight check - baby can lose up to 7% of birth weight over first 3-5 days, breast fed up to 8-10%
What is the recommended umbilical cord care?
leave it alone (falls off between 1-2 weeks)
Sponge bath until it falls off
At what age should the baby be back up to their birth weight by?
2 weeks
When should you check and see if the babies newborn screening is back?
check results at 2 week visit
_____ needs to be added if the baby is breastfeeding. When should physiologic jaundice resolve?
vit D
Physiologic jaundice should resolve by 2 weeks
What vaccine is given at 1 month?
Vaccines (none scheduled at 1 month unless Hep B not given at birth)
What vaccines are given at the 2 month appt? What vaccine can cause a slight fever?
Vaccines (DTaP, IPV, Hep B, Hib, Pneumococcal, Rota)
DTaP (PLEASE call doc before giving Tylenol or appropriate guidance in office during visit)
What is the age specific milestone that the kiddo should be able to do at 2 months?
moves head to sound
social smiles
recognize caregiver
What vaccines are given at 4 months? What is the age specific milestone?
DTaP, IPV, Hep B, Hib, Pneumococcal, Rota)
control of head and neck, turn and look at things
When is it okay to drop the middle of night feeding if the baby is feeding well?
4 months
What age is it okay to introduce solid foods? What is the recommended way to introduce things?
6 months
Can now introduce solid foods (iron fortified cereal, baby foods, pureed foods)
Introduce new foods every 3-5 days to make sure there is no reaction
When can introduce water in sippy cup (does not have to be distilled)? When can you introduce puff/cheerios?
6 months for water
6-9 months for puff/cheerios because the baby is developing pinching mechanism
When should the kiddo receive their first flu shot? What is the recommendation?
Schedule 2nd flu shot in one month for the first vaccination under age 9 years, then continue “one and done” yearly after 2 dose season
What are the age appropriate milestones for 6 month old?
6 stunts at 6 months (sit, stand, speak, swipe, slobber, switch)
need to speak with parents about baby becoming mobile
When is it okay to introduce table foods with more than 1 ingredient?
9 months (pasta, baked chicken, bananas, wafers/crackers) but NOTHING that needs to be chewed
What are the age appropriate milestones for 9 months?
“ma & da”, raspberry, pulls to stand, gross pinscer
What age can you introduce whole milk? What vaccines?
12 months
Vaccines (MMR (live), Varicella (live), and Hep A
**What age should you do the lead screening? What additional lab also needs to be checked?
12 months
Hgb
When do kiddos start teething? When should they see the dentist for the first time?
Pediatric dentist at 12 months
Children start teething about 6 months and after
What are the developmental milestones for 12 months?
point
2 words
walking or very close to walking
fine pincer
How old should the kiddo be for 5 words, climbing and body parts?
15 months
What vaccines are needed at 15 months?
(DTaP, Hib, Pneumococcal)
What age do you screen for development and Autism? What are the names of the questionnaires?
18 months or 24 months
ASQ-3 / M-CHAT
What is the final vaccines that is given at 18 months that concludes routine vaccines until school age?
Hep A #2
When is the absolute latest the kiddo should be walking by before you need to refer them out? What is normal walking age range?
18 months-> then PT referral
normal is 9-15 months for walking
What age? colors, 3/4 of speech should be understandable by a stranger by this age
30 months
What age? ride tricycle, count to 10, walk up steps by alternative feet instead of stepping together
36 months
What is the average growth and development parameters for the average 4 year old?
avg. 4 year old about 40” tall & 40 #)
When do kiddos start to become aware of gender difference and checking genital area? What is the pt education?
4 years old
“Only mommy, daddy, and your doctor (or PA) are allowed to do this”
When should you start asking the kiddo about drugs, alcohol, tobacco and bullying?
around age 11
HEADSS assessment
What vaccines are needed at 11?
MCV4 and TdaP
+/- HPV series
What are the HPV series recommendations?
Also start HPV series, approved down to age 9 years and only 2 doses required if started < 15 years (3 doses if later start)
What vaccines are needed at age 16?
MCV4 #2 and Men B recommended; Check HPV series
What age does the kiddo have confidentiality legal rights?
in WV the age is 12
What is the Age and Stages Questionnaire (ASQ)? When is it given? What areas does it address?
19 age-specific surveys asks parents about developmental skills common in daily life
From age one month to 5.5 years
Language, personal-social, fine motor, gross motor, and problem solving
What do the screening item and questionnaire help determine? How many questions in each area?
help determine if the child is on schedule
6 questions in each area
What is the cut off for screening item and questionnaires? When is a referral indicated?
2 standard deviations below the mean
if below cutoff in 1 or more areas, diagnostic referral is indicated
What should you do if your pt is close to the cutoff for screening items and questionnaires?
If close to cutoff, provide follow up activities to practice specific skills, then re-screen in 4-6 months, earlier if needed
What does M-CHAT stand for? What is it screening for?
Modified Checklist for Autism in Toddlers (M-CHAT)
Autism Spectrum Disorder
What is M-CHAT designed to do? When should M-CHAT be administered?
Designed to identify children 18-30 months of age who should receive further assessment for early signs of ASD
The AAP recommends that all children receive autism specific screening at 18 and 30 months
What M-CHAT score equals no follow-up needed?
total score of <3
What M-CHAT score equals M-CHAT-R follow up should be administered? When should you refer out for diagnostic evaluation?
total score 3-7
total score greater or equal to 2 on M-CHAT-R
What M-CHAT score equals refer immediately for diagnostic evaluation and early invervention?
total score greater than or equal to 8
Where are common sources of lead?
homes built before 1950
water, food, soil, toys ceramics
On parents clothes inadvertently from work at battery mills, pottery, painting, printing, demolition sites
When does the CDC recommend lead screening for kiddos?
at 1 and 2 year old WCC
weakness, irritability, weight loss, vomiting
Personality changes, ataxia, constipation, headache, and abd pain
aggression, antisocial behavior
What am I?
What are some late symptoms?
lead poisoning
retarded development, convulsions, coma, language abnormalities, seizures, lower IQ
Which is worse, to ingest small amounts of lead poisoning over time or have 1 larger ingestion at once?
worse to have smaller amounts over time
What is the preferred testing in lead poisoning?
venous blood sampling is preferred but capillary finger stick is okay first option
What lead level does NOT require any further action?
No action required for blood levels less than 10mcg/dl
What is the the tx for lead levels between 10-19mcg/dl? Give some examples. When do you need repeat testing?
counsel parents on ways to diminish ongoing exposure
Replace old windows, cover leaded paint that is chipping, mop floors and clean window sills with high-phosphate detergent, wash hands and pacifiers regularly, use cold water for cooking, remove paint in old homes
retest lead level in 3 months
What should you do if your parents lead level comes back between 20-44mcg? When do you need to repeat tests?
medical evaluation consists of nutritional, developmental, environmental history
Lab evaluation of iron status, abdominal xrays, evironmental eval, public home inspection
aka need to find the source of the lead
Repeat tests weekly to monthly
If a kiddo is low in _______, can cause 2-3x increase in lead absorption
iron-deficient anemia because iron deficient people absorb 2-3 times higher amounts of lead
What is the tx for a lead level that is 45mcg and higher? When should you repeat lead levels?
Treat with Succimer (DMSA dimercaptosuccinic acid), an orally approved chelator, when levels reach 45mcg/dl
45-69mcg/dl repeat within 48 hour
60-69mcg/dl repeat within 24 hours (venous)
need to get abdominal xray!!!
Treat with Succimer (DMSA dimercaptosuccinic acid), an orally approved chelator, when levels reach 45mcg/dl
How can you tell if the lead exposure is acute or chronic? What result indicates acute? What result indicate chronic?
through FEP and ZPP testing
Elevated blood lead and normal FEP/ZPP = Acute exposure
Elevated blood lead and elevated FEP/ZPP = Chronic Exposure ** Chronic is worse in the long run**
What do the FEP and ZPP tests measure?
tests that measure biologic effect of Pb
FEP=free erythrocyte porphyrins
ZPP=Zinc Protoporphyrin
What should you do if the lead level reaches 70mcg or higher? What PE should always be included?
-hospitalize & repeat immediately
-Treat with Succimer (DMSA dimercaptosuccinic acid), an orally approved chelator, when levels reach 45mcg/dl
neurodevelopmental assessment
An increasing lead level shows decreasing _____
cognitive function (IQ)
What are the additional agents used in lead poisoning treatment? Which one is NOT FDA approved
Calcium Disodium EDTA
Dimercaprol
D-penicillamine -> not FDA approved
______ MOA calcium displaces metal (lead), then forms a water soluble complex that is excreted in urine. What drug class?
Calcium Disodium EDTA
chelating agents
When should you begin calcium disodium after succimer? What route? What do you need to monitor?
Begin 2 hours after first dose of succimer
usually given IV
renal function
What are the CI to calcium disodium?
renal dz and hepatitis
_____ is a heavy metal antagonist, chelating agents and reverses metallic binding. When is it used?
Dimercaprol
Used as adjunct to EDTA in lead poisoning
_____ can also be used for mercury, gold, and arsenic as well
Dimercaprol
What are the CI to Dimercaprol?
hypersensitivity to peanuts, lactating, liver failure
______ is a heavy metal antagonist that can also be used in mercury or arsenic. What route?
Succimer
can be given orally
_____ MOA binds with lead ions to form a water soluble complex excreted by kidneys in urine
Succimer
_____ is NOT FDA approved in lead poisoning treatment but CAN be used in copper and mercury poisoning. Is it safe to use while pregnant or breastfeeding?
D-penicillamine
CI in breastfeeding and pregnancy
What does a deficiency of fluoride lead to? What does excess fluoride lead to?
Deficiencies have tendency for dental caries
Excess fluoride can cause mottled teeth (pitted teeth brown in color)
Where is the majority of fluoride found? What is the standard level?
Most fluoride found in community water supply
The standard level for community water fluoridation (0.7 parts per million fluoride)
What are the 3 ways fluoride works to protect the teeth against dental caries? What is the recommendation for kiddos in their toothpaste?
- inhibits bacterial metabolism
- inhibits demineralization of teeth
- promotes remineralization of teeth
all children with teeth should have fluoride containing toothpaste!!
If fluoride is NOT in the community water supply, where can the kiddo gain it? Can also ________ by a dental provider
rinses, toothpastes, or varnishes
be applied professional by dental provider
When is fluoride supplementation recommended?
Fluoride supplementation if fluoride intake is low and caries risk is high
or
when fluoride toothpaste, rinses, gels, have proven inadequate
As long as the water supply is _______, no fluoride supplementation is needed
> 0.6 ppm Fl
What is the fluoride supplement if the water supply is 0.3 to 0.6 ppm Fl?
0.25 mg supplement recommended ages 3 – 6 years
0.5 mg 6 – 16 years
What is the recommended fluoride supplementation level if the water supply is less than 0.3ppm?
0.25 mg supplement ages 6 months to 3 years
0.5 mg supplement ages 3 to 6 years
1 mg supplement ages 6 to 16 years
What does excessive fluoride consumption cause? What does mild vs severe look like?
fluorosis
Starts out mild, which is indicated by white flecked/lacy appearance, to severe, which is indicated by brown discoloration
How can fluorosis be prevented?
Can be prevented by limitation of fluoride consumption
Limitation of swallowing of toothpaste, mouth rinses
What am I?
different levels of fluorosis
