Pediatrics Lecture 4 - Pediatric Growth & Development/Documentation in Peds

WCC Schedule

1. Newborn

2. 2 weeks

3. 1 mo, 2 mo , 4 mo

4. 6 mo, 9 mo, 12 mo

5. 15 mo, 18 mo

6. 2 yr, 2.5 yr, 3 yr

7. Annually

AAP Bright Futures (Guide for Preventive Care and WCCs)

1. Pre-visit screening from parents

2. Documentation guiding questions and issues

3. Hx

4. Developmental surveillance

5. Physical exam

6. Screening

7. Immunizations

8. Anticipatory guidance

Early and Periodic Screening, Diagnosis and Treatment Program

1. Child health component of Medicaid

2. Mandated components of pediatric preventive care visits

WCC Components

1. Screening tools

2. Developmental assessment

3. Risk factor identification

4. Growth measurements

5. Physical Examinations

6. Immunizations

7. Safety and anticipatory guidance

What maternal depression screening is used?

Edinburgh Postnatal Depression Scale

When should maternal depression screening be done?

1. 1 mo

2. 2 mo

3. 4 mo

4. 6 mo

Postpartum blues

1. Sxs begin few days after birth, up to two weeks

2. Doesn't impair function

What are the sxs of postpartum blues?

1. Crying

2. Depressed mood

3. Irritable

4. Anxiety/confusion

Postpartum Depression

1. PPD last longer and interfere with activity

2. Intense sxs of sadness, anxiety, and hopelessness that last up to one yr

Postpartum Psychosis

1. First four weeks after birth

2. Paranoia, mood shift, hallucinations/delusions, suicidal/homicidal

If a parent mentions thoughts of suicide on a screening form or conversation, what is the next step?

Receive immediate, emergency mental health services

Depression Screening

1. Universal screening for depression starting @12yo

2. PHQ-2 then PHQ-9

3. If anxiety too, GAD-7 (13+or Scared (8+)

Food Insecurity at WCC

1. Within the past 12 mo, we worried whether our food would run out before we got money to buy more.

2. Within the past 12 mo, the food we bought just didn't last and we didn't have money ot get more

3. Yes or no answer

Ages & Stages Questionnaires Third Edition

1. Age 0-5.5yo

2. Based on answers from parents

3. Communication, gross motor, fine motor, problem solving, personal-social

ASQ Scoring

1. 10 - yes

2. 5 - sometimes

3. 0 - never

4. Shows if development is WNL or delayed

How do we assess development in a preemie?

Appropriate ASQ

MCHAT is

1. The Modified Checklist for Autism in Toddlers

2. Based on parental answers

3. Given at 18mo and 2 yr WCC

If the MCHAT is positive?

Refer for autism evaluation

Low-Risk (0-2) MCHAT Score

1. Younger than 24mo, screen again after 2yo

2. No further action required unless surveillance indicates risk for ASD

Medium-Risk (3-7) MCHAT Score

1. Administer the follow up to get additional info

2. If remains positive, refer for dx eval and eligibility eval for early intervention

High-Risk (8-20) MCHAT Score

Acceptable to bypass the Follow-Up and refer immediately

Age 1 mo Milestones

1. GM - lifts chin up in prone position, turns head up when prone

2. FM - hands fisted

3. Language- throaty noises, startles to sound

4. SE - discriminates parents' voice, follows face

Age 4 mo Milestones

1. GM - sits with support, rolls from front to back

2. FM - hands open, reaches for objects

3. Language - LOL, stops crying to soothing voice

4. SE - social smile

Age 6-7 Mo Milestones

1. GM - sits propped on hands, lateral protection, bounces when held

2. FM - moves objects from hand to hand, reaches out with one hand, feed cracker

3. L - babbles, understands no

4. SE - reflection in mirror, looks at object and parent and back

Age 9 Mo Milestones

1. GM - pulls to stand, bear walks, creeping

2. FM - pincer graps, bang two things together

3. L - mama, imitates sounds, orient to name

4. SE - follows a point, peekaboo, stranger anxiety

Age 12 Mo Milestones

1. GM - stands, starts taking first steps

2. FM - scribbles, hold crayon, tower with two cubes

3. L - one word with meaning, points to objects, one step commands with gestures

4. SE - shows objects to parents to share

Age 15 Mo Milestones

1. GM - stoops to pick up toys, climbs furniture, run stiff legged

2. FM - uses spoon with some spilling, 10 cubes in cup, turn pages

3. L - 3-5 words, jargon speech, points to body part

4. SE - empathy & hugs on request

Age 18 Mo Milestones

1. GM - creeps down stairs, runs well

2. FM - makes 4-cube tower, imitates vertical stroke

3. L - 10-25 words, 3 body parts, points to self/familiar people

4. SE - engages in pretend play

2yo Milestones

1. GM - walks downstairs holding rail both feet, kicks ball

2. FM - imitates horizontal line, opens door knob, sucks through straw

3. L - 2 word sentences, 50+ words, 50% intelligibility, self by name

4. SE - parallel play

30 Mo Milestones

1. GM - walk up stairs holding on alt feet, jump in place

2. FM - tower with 8 cubes, wash hands, brush teeth with help

3. L - self with correct pronoun, understand action words, prepositions

4. SE - imitates adult actions

3 Yo Milestones

1. GM - goes upstairs without holding on, alt ft, pedals tricycle

2. FM - copies circle, strings small beads, 2-3 part person drawing

3. L - 3 word sentences, 75% understood, understands negatives, knows gender

4. SE - sharing, imaginative play, fears imaginary things

4 Yo Milestones

1. GM - balances on one foot for 8 sec, throws overhand, catches bounced ball

2. FM - copies square, toilet alone, 4-6 part person drawing

3. L - speaks 100% intelligibility, 3 step commands, understand adjectives

4. SE - preferred friend labels feelings, group play

5 Yo Milestones

1. GM - walks downstairs alt feet, hops on one foot, skips

2. FM - copies triangle, cut with scissors, writes first name

3. L - 6-8 word sentences, count to 10, knows colors, phone number, tells story, rhyming

4. SE - group of friends, apologizes for mistakes

Physical Developmental Task (Characteristic) (Age 5-10yo)

1. Enhanced strength and coordination

2. Competence in various tasks and activities

Healthcare Needs for Physical Developmental Task (Age 5-10yo)

1. Screen for strengths, assess problems

2. Involve parents

3. Support for disabilities

4. Anticipatory guidance: safety, exercise, nutrition, sleep

Characteristic of Cognitive Developmental Tasks (Age 5-10yo)

1. Concrete operational - focus on the present

2. Achievement of knowledge and skills; self-efficacy

Healthcare Needs for Cognitive Developmental Task (Age 5-10yo)

1. Emphasis on short-term consequences

2. Support; screening for skills and school performance

Characteristic of Social Developmental Tasks (Age 5-10yo)

1. Achieving good "fit" with family, friends, school

2. Sustained self-esteem

3. Evolving self-identity

Healthcare Needs for Social Developmental Task (Age 5-10yo)

1. Assessment, support, advices about interactions including peer relationships

2. Support, emphasis on strengths

3. Understanding, advice, support

Early Adolescence Developmental Task (10-14yo)

1. Physical (puberty)

2. Cognitive (concrete operational)

3. Social identity

4. Independence

How do we approach early adolescence developmental tasks?

1. Confidentiality; privacy

2. Emphasis on short-term

3. Reassurance and positive attitude

4. Support for growing autonomy

Middle School Adolescence Developmental Tasks (age 15-16)

1. Physical (females more comfy than males)

2. Cognitive (transition to higher emotional thinking)

3. Social identity ( introspection)

4. Independence (limit testing, experimental behavior)

How do we approach Middle adolescence developmental tasks?

1. Support if patient varies from normal for physical

2. Problem solving, decision making, increased responsibility for cognition

3. Nonjudgmental acceptance (social identity)

4. Consistency; limit setting

Late School Adolescence Developmental Tasks (age 17-20yo)

1. Physical (adult appearance)

2. Cognitive (formal operational)

3. Social identity (role with respect to others, sexuality, future)

4. Independence (separation from family)

How do we approach late adolescence developmental tasks?

1. Minimal physical unless chronic illness

2. Approach cognitive as an adult

3. Encourage identity and healthy-decision making

4. Support and anticipatory guidance about independence

If a child fails to meet developmental milestones at the appropriate age or suspicion of developmental delay, what do we do?

Formal developmental testing

Depending on the developmental delay who do we involve?

1. Pediatric subspecialties: neuro, ortho, psych, developmental/behavioral

2. Under the age of 3 - early intervention with Child Developmental Services Agency

What does referral to developmental center provide?

1. Physical therapy

2. Speech therapy

3. Feeding and swallowing program

4. Occupational therapy

Once school aged what can be done regarding developmental delays?

Individual educational plan to address any deficiencies

Risk Factor Identification for Infants and Younger children

Related to the mother's health during pregnancy, so maternal hx needs to be documented

Adolescent Risk Factor Identification

1. HEEADSSS Assessment

2. CRAFFT Screening

What does bright futures recommend screening for (risk factor identification)?

1. Lead

2. TB

3. Anemia

4. Cholesterol

5. STIs

Lead Screening

1. Routine @ 12mo and 24mo

2. capillary blood sample

3. Repeat with venous sample if elevated

4. Hemoglobin is also checked around this time

TB Testing

1. 1mo

2. 6mo

3. 12mo

4. Annually

5. PPD used

Anemia Testing

1. Screen at 4mo if infant was low birth weight, premature

2. Screen at 12mo, high incidence of iron deficiency

3. Capillary blood sample

Lipid Screening

1. Age 2,4, 6, 8, 10 and annually in adolescence if famhx or unk famhx or RF

2. Universal @ 9-11yo and 18-20yo

Fasting Lipid Panel (Total Cholesterol)

1. /= 200 mg/dL is elevated

What age do you start pap smears regardless of sexual activity?

21yo

What should all sexually active females <25yo be screened for annually?

1. Chlamydia trachomatis

2. Neisseria gonorrhea

When is weight checked at WCC?

Each visit

When is length checked at WCC?

<24 mo

When is height checked at WCC?

>24 mo

When is head circumference checked at WCC?

Plotting Growth Charts

1. Measuring growth in comparison to same age same gender kids

2. Discussed as percentile

3. Trends are important as ABSOLUTE measurement

Remember to (Growth Charts)

1. Always recheck abnormal data on growth chart

2. Always use the correct age adjusted chart

When do you do BMI? And what is the alternative?

1. > 2yo

2. weight for length percentile for under 2yo

BMI

1. Weight/height^2

2. Pediatric BMI charts are age and sex specific

What does childhood obesity lead to?

1. HTN

2. DM

3. Metabolic syndrome

4. Poor self-esteem

5. Adult obesity

6. Shortened life-span

Underweight for BMI for Age

<5th percentile

Healthy Weight for BMI for Age

5th-85th percentile

Overweight for BMI for Age

85th-95th percentile

Obese for BMI for Age

>/= 95th percentile

Rules of Thumb for Growth (Infant)

1. Weight loss in first few days (5-10% of BW)

2. Return to BW at 7-10 days

3. Double BW in 4-5 mo

4. Tripe BW @ 1yo

What vitals are checked at each visit?

1. Weight

2. Height (or length)

3. Head circumference (through age 2)

4. Temp

5. HR/RR

6. BP @ age 3

Hearing and Vision

1. Early eval - observe and parent report

2. Formal in-office screening before elementary school

When is vision test done?

1. Age 3

2. Snellen chart with shapes

When is hearing test done?

1. Age 4

2. Full-scare acoustic screening test using standardized equipment

When is dental varnish applied?

every 3-6 mo between 9mo-5yo

When do you begin dental visits?

After first tooth eruption

Oral Health Recommendations

1. Dental exam annually

2. Cleaning by dentist ever 6mo

3. Instructions on preventative care (brushing/flossing)

Birth to 6yo CDC Recommended Vaccinations

1. RSV

2. HepB

3. Rotavirus

4. DTaP

5. Hib

6. Pneumococcal

7. Polio

8. COVID-19

9. Flu

10. MMR

11. Chickenpox

12. Hepatitis A

RSV Vaccine (Birth-6yo)

1. Depends on mother's vaccine status from birth to 7mo

2. Depends on child's health status

Hepatitis B Vaccine (Birth-6yo)

1. Dose 1 @ birth

2. Dose 2 @ 1-2mo

3. Dose 3 @ 6mo-18mo

Rotavirus (Birth-6yo)

1. Dose 1 @2mo

2. Dose 2 @4mo

3. Dose 3 @6mo

DTaP Vaccine (Birth-6yo)

1. Dose 1 @2mo

2. Dose 2 @4mo

3. Dose 3 @6mo

4. Dose 4 @15-18mo

5. Dose 5 @4-6yo

Hib Vaccine (Birth-6yo)

1. Dose 1 @2mo

2. Dose 2 @4mo

3. Dose 3 @6mo

4. Dose 4 @12-15mo

Pneumococcal Vaccine (Birth-6yo)

1. Dose 1 @2mo

2. Dose 2 @4mo

3. Dose 3 @6mo

4. Dose 4 @12-15mo

What pneumococcal is preferred?

PCV20

Polio Vaccine (Birth-6yo)

1. Dose 1 @2mo

2. Dose 2 @4mo

3. Dose 3 @6-18mo

COVID Vaccine (Birth-6yo)

1. 6mo-6yo

2. At least 1 dose of updated formula

Flu Vaccine (Birth-6yo)

1. Every year, starting at 6mo

2. Two doses for some kids

MMR Vaccine (Birth-6yo)

1. Dose 1 @12-15mo

2. Dose 2 @4-6yo

Chicken Pox Vaccine (Birth-6yo)

1. Dose 1 @12-15mo

2. Dose 2 @4-6yo

Hepatitis A Vaccine (Birth-6yo)

1. Starting at 12mo

2. 2 doses separated by 6mo

Where are IM vaccines done for children <2yo?

Anterolateral thigh

Where are IM vaccines done for children >/= 3yo?

Deltoid

7-18yo CDC Recommended Vaccinations

1. HPV

2. Tdap

3. Meningococcal ACWY

4. Meningococcal B

5. Flu

6. COVID-19

7. RSV

8. Mpox

9. Dengue

HPV Vaccine (7-18yo)

1. 9-10yo can get the vaccine

2. 11-12yo should get the vaccine

Tdap Vaccine (7-18yo)

age 11-12yo

Meningococcal ACWY Vaccine (7-18yo)

1. Age 11-12

2. age 16