Well Child Visits Flashcards
What is the difference between a screening and a diagnositic test?
Screening test: test designed for mass application to an asymptomatic population
Diagnostic Test: evaluates a diagnostic possibility in patients with significant history, symptoms, physical findings, and positive screening test
When should I newborn screening be done?
draw blood before discharge, after 24 hrs but no later than 7 days of age.
Vision Screening
Visual fixation occurs in the newborn and achieves accuracy by 6-9 weeks
Infants have the ability to follow an object by 3 months of age
Most term infants are far sighted, hyperopic at birth while premature infants are near sighted, myopic
Children reach 20/20 vision by 5 years
Ability to match colors is present by 2 years of age
Test visual acuity starting at age 3
Refer preschoolers with acuity worse than 20/40 in either eye
Refer children 5 years of age with 20/30 or if there is a difference between >1 line between the left and right eyes
Optic Nerve Hypoplasia
nonspecific finding due to damage of the visual system before it is fully developed
It is associated with
- maternal diabetes
- alcohol abuse
- maternal exposure to toxins
- hypothyroidism
- growth hormone deficiency
- neonatal hypoglycemia
- midline facial defect such as hypopituitarism
Retinoblastoma
leading malignant ocular tumor of childhood
associated with 13 q deletion
white pupil
(Congenitial cataracts also may present with a white pupil)
Strabismus
Amblyopia
Strabismus: misalignment of eyes
Amblyopia: loss of vision secondary to disuse or misuse of visual pathways during critical periods of visual development
Treatment: occlusive patch on the strong eye
Unilateral cover test
Cover and uncover each eye while child is looking straight ahead at an object 10 feet away.
Movement in the uncovered eye when the opposite is covered or uncovered suggests potential ocular misalignment or strabismus.
Corneal Abrasions
Pain, tearing, photophobia, decreased vision
Diagnose with fluorescein dye and slit lamp
Treatment: topical antibiotic
Hyphema
Presence of blood in the anterior chamber of the eye
after blunt or perforating injury
Eye pain
Immediate ophthalmologic consult
Treatment:
topical steroid and cycloplegia drops
protective eye shield
bed rest
head elevated to 30-45 degrees with close monitoring of intraocular pressure
Conductive hearing loss
disruption of mechanical components required for transduction of sound wave energy
generally caused by ear wax impaction and fluid in the middle ear
Hearing
Hearing loss is deficiency in hearing >90dB
Severe or profound hearing loss is always sensorineural and most often affects high frequencies
Deafness is inherited in 50% of all cases as autosomal recessive pattern
Prolonged exposure to loud noises is a common cause of high pitched hearing loss in adolescents
Hearing Screen
Screening is done with Evoked Otoacoustic emissions initially, then with auditory brainstem response systems if baby less than 6 months fails the initial hearing test
Auditory brainstem response testing measures how CN 8 responds to sound. Hearing loss of 35 dB or greater in the 500 Hz to 4,000 Hz range requires a referral.
Formal hearing screen for all children at 3, 4, 5 years of age and every 2 years after until adolescence
Jervell and Lange-Nielsen syndrome
Autosomal recessive disorder
prolonged Q-T syndrome and hearing loss
Causes of acquired hearing loss
number one cause of hearing loss is otitis media effusion
CMV and Toxoplasmosis account for majority of infectious causes of hearing loss
Rubella can also be a rare cause of deafness
10% of bacterial meningitis causes deafness
Prolonged exposure to loud noises is a common cause of high pitched hearing loss in adolescents
Acute otitis media
test with pneumatic otoscopy
patients must have symptoms
Treatment: No antibiotics at diagnosis in uncomplicated acute otitis media. Give antibiotics if there is an underlying chronic otitis media with effusion
Otitis media with effusion
most common between 6 months- 4 years
Fluid in the middle ear
Most resolve within 3 months
Tympanograms
measures volume of air in the external cavity of the ear
Maximum compliance: vertical peak on the y-axis: 1cm
Peak pressure: point of greatest mobility: x axis: 0
Obesity
Measure BMI in children > 2years of age
BMI= (weight in Kg)/ (height in meters) ^2
Overweight is BMI of 85-95th percentile
Obesity is BMI > 95%
Severe obesity is BMI > 35
No TV for children < 2years of age
Less than 2 hrs of TV for children >2 years of age
Treatment of obesity is family support and involvement
Blood Pressure Screening
Blood Pressure Measurements for children every year starting at 3 years of age
Normal Blood Pressure is BP less than 90th percentile for age and sex
High normal 90-95% for age and sex
Hypertension >95% for age and sex
Cholesterol and Lipid Screening
Only screen children and adolescents with a positive family history of cardiovascular disease or unknown family history
For patients 8 years or older with LDL >190 mg/dL, consider pharmacological intervention to get LDL below 130mg/dl
Metabolic Syndrome
Cluster of related diseases that increases cardiovascular and other health risk
- BMI>97%
- Triglycerides >110mg/dL
- HDL cholesterol: <40mg/dL
- Blood pressure: >90th percentile
- Glucose abnormalities: fasting glucose >110mg/dL, oral glucose tolerance test >140mg/dL
- Waist circumference: >90% percentile
Lead Screening
Universal blood lead screening for all children 1 year and 2 year olds
Consider Lead screening in children with inattentive and hyperactive behaviors
Normal values of lead levels < 10 ug/dL
Hypochromic microcytic anemia and basophilic stippling
See lead lines in chronic lead toxicity which are dense bands in the metaphysis from incorporation of lead in the bone, can find in wrists, other long bones, and axial skeleton
Lines disappear with growth
Iron Deficiency Screening
Is the #1 nutrition deficiency and the number one cause of anemia
Deficiency between 6 and 20 months, may affect development and cognitive abilities
Hematocrit/Hemoglobin screening at 1 year of age
Anemia is defined as hemoglobin that is 2 standard deviations below the mean for age and sex
Urinanalysis
Annual dipstick urine testing for leukocytes to look for Chlamydia and gonorrhea in sexually active males and females between 11-21 years old
Only perform urinalysis screen if there is a family history of inheritable renal disease
Oral Health Screening
Referral to dentist at 12 months of age, then every 6 months after
When a tooth erupts, child’s teeth should be brushed twice daily with plain water
From 2-6 years old, brush teeth twice a day with a pea-sized amount of fluoride toothpaste
Dental Care
First tooth erupts by 6 months with 6 teeth present by the 1st year
Delays in tooth eruption beyond 1 year require investigation
Topical local anesthetics for teething have been associated with methemoglobinemia
Breast Feeding
Initial few days postpartum: mothers can attempt 10-15 mins per breast with each feed. The infant should take from both breasts at each feeding. Newborns should not go longer than 4 hrs between feedings.
At 2 months of age, most infants will stop one of the middle of night feedings
Formula Feedings
Soy based formulas have high aluminum levels, do not recommend soy-protein formulas to infants weighting < 1,800 grams
For newborns: 2 ounces every 2 hrs
At 2months: 4 ounces every 4 hrs
At 6 months: < 30 ounces a day
Most babies can be weaned from bottle to cup at 9 months
If there is a documented cows milk protein allergy, switch to hydrolyzed formula
Advancement of Diet
Introduce solids prior to milk before a meal
At 4-6 moths of age, infants can start with iron-fortified cereals, then strained vegetables, followed by meats and poultry products.
Introduce only one new food at a time and observe for any adverse effects over the next week before adding another item.
At 1 year old: Whole milk
At 2 year old: 2% skim milk
Vitamin and Mineral Supplementation
Vitamin D supplementation 400 IU/day for exclusively and partially breastfed infants
Cow milk should be used after 12 months of age
Folate deficiency in infants fed with goat’s milk
Vitamin B12 deficiency in breastfed infants whose mothers are strict vegetarians
Iron
Always recommend iron-fortified formulations if using formula
Breastfed babies should begin daily supplementation of 1mg/kg of elemental iron at 4 months of age
Fluoride
No Fluoride supplementation to any child under 6 months of age
Sleep
Newborns: 18 hours a day
6-15 month olds: 10-12 hours a night with 2 naps during the day
15 months: 1 nap per day
By 3-4 months of age, infants can put themselves back to sleep, parents must put the child down drowsy and not yet asleep in their own cribs
Stop middle of the night feedings at 6 months of age
Encourage a regular daily sleep routine
Nightmares
occurs during REM sleep
peak age of onset is 3-5 years old
occurs several hours after onset of sleep
Night terrors
occurs during non REM sleep
occurs in the first third of the night
The child appears to be awake but is unresponsive and unaware of the parent’s presence, difficult to arouse, cries intensely, is diaphoretic, and appears disoriented.
The child has no recollection of the episode the next morning
Night terrors peak at 5-7 years old
Parents should observe night terrors without awaking the child
Sleep walking
occurs during stage 4 non REM sleep
occurs in children between 4 and 8 years old
Encourage parents to ensure the environment is safe, to observe the child and to gently lead the child back to bed
Crying
On average, 2 week old infant cries on average 2 hours a day
6 week old infants cries 3 hours a day
3 month old infants cry 1 hour a day
Most crying occurs during the evening hours
Colic
Colic is excessive unexplained crying greater than 3 hours a day and more than 3 days a week for greater than 3 weeks
30-50% of children have colic, generally cries during the same time during the day, generally starts in the first week of life and goes away by 3 months of age
Differential Diagnosis of Colic
1) Anomalous left coronary artery: poor feeder who cries excessively and becomes diaphoretic during feeds
2) Pseudoparalysis of a limb associated with congenital syphilis
3) Caffey disease: infantile cortical hyperostosis
Discipline
Time out at 12 months of age until 5 years of age
Length of time is 1 minute per year of age
No discussion during time out
After 5 years old, children understand loss of privileges
Child Safety Restraints
Infants to 2 year olds: Rear facing car seat
2 year old until school age: Front facing car seat
School age children until 8 years old: booster seat
8 years old to 13 years old: back seat
What temperature should the hot water heater be set to?
Hot water heater temperature should be 120 degrees F or less
