Ambulatory Office Pediatrics

What are some things we do at a WCC?

- review interval history (acute problems with pertinent ROS)

- chronic problems (w/ pertinent ROS)

- perform physical exam & developmental assessmnet

- order age-approrpiate screening tests

- administer immunizations if due

- provide anticipatory guidance

What is observed with gentials/anus on PE?

- Tanner staging

- rarely pelvic exam, but possible

What's an important MSK aspect of the PE to look out for?

scoliosis checks

What is the expected growth from birth to 6 months?

- should be back to birth weight by 2 weeks (normal for newborns to lose up to 10% of birth weight the first few days after birth)

- grow 1/2-1 in per month

- gain 5-7 oz per week

- should double birth weight by 4-6 months

What is the recommended feeding for the first 6 months of life?

breastfeeding (or at least milk) should be the only food the first 6 months

When are solids added?

solids are added after 6 months, but breastfeeding should continue until 12 months

Why is breastfeeding so important?

contains antibodies that provide protection against GI and URIs

What happens in newborns can't handle CMPA?

can't tolerate cow's milk, so if a breastfeeding mom is having any type of cow's product in diet, we'll see poor wieght gain and blood in the stool for the baby

What are pros of bottle feeding?

more maternal freedom, no worries about moms' diet, intake or medications

What are the cons of bottle feeding?

antibodies cannot be replicated, costly

True or false: a baby drinking only cows milk (before a year) can cause renal issues

true

How do we diagnose a baby who isn’t tolerating CMPA?

test stool and if it comes back for occult blood, stop mom from having diary or only give hypoallergenic formula

What is baby-led weaning?

- a feeding approach that emphasizes self-feeding and infant control of how much they consume

- offer a variety of foods that the family is already eating

- might lead to potentially less picky eating during early childhood

What to avoid in infant feeding and anticipatory guidance?

- choking hazards (nuts, grapes, popcorn, raw carrots)

- honey - associate with infant botulism

- fruit juice and cow's milk (when under 12 months)

What is failure to thrive?

failure to gain weight appropriately, especially in children younger than 3

What happens in failure to thrive?

- weight <2nd % and decreased velocity of weight gain

- "falling off the curve"

- bascially poor weight gain happens first, eventually fall off in length too

Possible etiologies of failure to thrive?

psychosocial factors, organic causes, improper formula preperation, breast feeding problems

What is the diagnostic workup when failure to thrive is suspected?

initial lab tests: CBC, BMP, UA and culture, tTG-IgA (for celiacs)

Additional testing is based on symptoms (amylase/lipase, stool studies, CXR/echo, thyroid testing)

How is failure to thrive managed?

- hospitalization

- nutrition education, high calorie formula

- frequent follow up appointments

When does BP evaluation begin?

at 3 y/o unless risk factors exist

What can a too small cuff and too large cuff cause?

too small: falsely high BP

too large: falsely low BP

What is the best way to assess BP in peds?

Auscultation, automated BP monitors are an okay alternative, but aren't always great for peds because can cause falsely high results

What are the 5 stages of Tanner staging (female breast)?

1. prepubertal

2. breast buds

3. growth of breast and areola

4. seperation of nipple and areola from mound of breast aka "secondary mound"

5. areola rejoins breast (complete development)

What are the 5 stages of Tanner staging (female genitalia)?

1. prepubertal

2. straight/fine pubic hair initially on mons pubis; sparse

3. hair increases in amount and is darker, curlier, more coarse and spreads to labia

4. adult type hair but limited in amount, no hair on the thighs

5. complete development (adult genitalia)

What are the 5 stages of Tanner staging (male genitalia)?

1. prepubertal

2. sparse growth of straight long, slightly pigmented hair at the base of the penis; testes increase in size, scrotal skin reddens

3. hair becomes curly, coarse and dark; penis grows in length

4. hair is full, limited in area; penis grows in width, scrotal skin darkens

5. completel development (adult genitalia)

When do most active developmental changes occur?

0-3 y/o

True or false: delays are uncommon

false; they can be common and occur in about 18% of kids

What should we be screening for as far as developmental assessment at each WCC?

- parental concerns

- developmental history

- observe the child

- identify RFs for possible delays

- accurately track findings and progress

True or False: no screening tool is universally deemed appropriate for all populations and all ages

true

What are some means of developmental assessment?

- grades and standardized testing

- performance in athletics/extracurriculars - art/music

- learning to drive a motor vehicle

When is ages and stages questionnaire 3rd edition (ASQ-3) used?

birth to age 5

What 5 domains are assessed in the ASQ-3?

1. communication

2. gross motor

3. fine motor

4. problem solving

5. personal-social

When can Denver II be administered?

0-6 y/o

What does the Denver II consist of?

consists of 125 taks-items across 4 domains

What are the 4 domains in the Denver II?

1. personal-social

2. fine motor-adaptive

3. language

4. gross motor skill

What are the scoring categories in the Denver II?

- pass

- fail

- no opportunity (NO)

- refrusal

What does pass mean in Denver II scoring?

child successfully performs item (observed/reported)

What does fail mean in Denver II scoring?

child does NOT successfully perofm item (observed/reported)

What does no opportunity mean in Denver II scoring?

used on reported items only, child has not had had the chance to perform the item due to restrictions from the caregiver or for other reasons

What does refusal mean in Denver II scoring?

child refuses to attempt the item

What are milestones for 1-2 months

- holds head erect and lifts head

- regards faces and follows objects through visual field drops

- becomes alert in response to voice

- smiles spontaneously

What are milestones for 3-5 months?

- sits with support

- turns from back to side (pushes up to elbows or forearms when on tummy)

What are the milestones for 6-8 months?

- sits alone for a short period

- imitates bye-bye

- passes object from hand to hand in midline

- rolls from back to stomach

What are the milestones for 9-11 months?

- stands alone

- uses thumb and index finger to pick things up

- walks by supporting self on furniture

What are the milestones for 1 year?

- walks independently

- says "mama" and "dada" with meaning

- can use a neat pincer grasp to pick things up

- tries to build a tower of 2 cubes

- says 1 or 2 other words

What are the milestones for 18 months?

- builds a tower of 3-4 cubes

- walks up and down stairs with help

- says 4-20 words

- feeds self

What are the milestones for 24 months?

- builds a tower of 6-7 cubes

- jump off floor with both feet

- stands on either foot alone

What are the milestones for 30 months?

- walks backward

- begins to hop on 1 foot

- copies a crude circle

- holds crayon in fist

- caries on a conversation

encopresis

severe stool blockage, but there's diarrhea leaking out because of it, so it gives the impression that the child is going

What are the milestones for 3 years?

- holds crayon with fingers

- builds tower of 9-10 cubes

- copies circle

- gives first and last name

- rides tricycle using pedals

What are the milestones for 3-4 years?

- climbs stairs with alternating feet

- begins to button and unbutton

- gives full name

- feeds self at mealtime

- takes off shoes and jacket

What are the milestones for 4-5 years?

- runs and turns without losing balance

- may stand on 1 leg for at least 10 seconds

- buttons clothes and laces shoes (does not tie)

- self-care at toliet (may need help with wiping)

- dresses self except for tying

What do abnormal developmental results require?

comprehensive, developmental, and medical evaluation, which assesses for hearing loss, metabolic d/o, lead poisoning, autism screen, and genetic disorders

What referrals should be made when there are abnormal developmental results?

- early intervention (EI) services

- PT, OT, SLP

- neurodevelopmental pediatrician/geneticist

- pediatric psychiatrist/behavioral specialist

What is the most common nutritional deficiency in children?

iron defiicency anemia

What are RFs for iron deficiency anemia?

- prematurity, breastfeeding

- early introduction of cow's milk (earlier than 12 months) and/or excess intake of cows milk (more than >24 oz/day)

Why can excessive cow's milk intake cause iron defciency anemia?

it decreases iron absorption

When do we do lead poisoning screening?

12 months and 24 months, but if high risk start at 6 months

What are RFs for lead poisoning?

home built before 1978, chipped/peeling paint, home in industrial setting, high levels in other kids in area

What are the screening options for lead poisoning?

- Risks can be assessed via a questionnaire

- capillary heel-stick (if increased, confirm with venous specimen)

- venous sample

When do we start assessing visual acuity?

perform at 3-6, 8, 10, 12, & 15 years

How is visual acuity assessed?

picture identification, tumbling E

What is considered full credit for the VA assessment?

>50% of line correct

What is the rule of 8s for VA asssessment?

patients age + the 10s digit of the denominator should be < 8? (ex. 3 y/o 20/50 = 3+5 = 8)

Who gets referral after a VA assessment?

- abnormal VA for age

- 2-line discrepnacny between the eyes

- high risk - down syndrome, preterm

What is visual screening?

instrument based screening (photoscreening and autorefraction)

What is the purpose of visual screeninga and when can it start?

does not directly assess VA, but can identify ocular RFs like strabismus, cataracts, and ptosis; can begin at 6 months

What is the most common chronic disease in childhood?

dental caries

When do we start assessing cavity risk?

6 monhts & 9 months

When should a kid start seeing the dentist?

at 12 months (or within 6 months of first tooth)

What dental supplement is needed if water source is deficient?

fluoride supplementation from 6 months - 16 y/o

What families need fluoride supplementation?

if they have well-water, they'll need supplements, even some people with city water (if levels are low) will need it

What is fluoride varnish application?

application q 3-6 months age 6 months-5 y/o, done by dentist or PCP/pediatrician; good for kids with lots of cavities

When does anxiety screening begin, and what can be used to screen

starts by 8; can use SCARED, CATS

When does depression screening begin, and what can be used to screen?

starting at 12 y/o; PHQ-2, PHQ-9

When do you screen for lipids?

9-11 y/o and then 17-21 y/o, but start earlier/repeat periodically if obesity or other CV RFs

At what age do we begin screening for PAP/HPV testing?

21

At what age do we begin screening for CG & CT?

anually if sexually active <25 y/o

At what age do we begin screening for HIV?

once between 15-21 years, anually if high risk

What amount of new HIV cases occur in pts 13-24, and what amount occur in males?

1 in 4 (26%) occuring in pts 13-24; 4 in 5 occur in males

At what age do we begin screening for hepatitis C?

> 18 y/o

At what age do we begin screening for TB?

only if high risk

What is considered infancy?

< 12 months

What is considered early childhood?

1-4 years

What is considered middle childhood?

5-10 y/o

What is considered adolescence?

anually

What are the most important aspects of medical history in comprehensive pediatric history?

- birth history

- developmental history

According to WHO, what are the percentile ranges for 0-24 months?

2nd to 98th percentile

According to the CDC, what are the percentile ranges for 0-36 months and 2-21 years?

3rd to 97th percentile OR 5th to 95th percentile

What is the expected growth in infancy at 6-12 months?

- grow 3/8 in (1 cm) per month

- gain 3-5 oz per week (0.5 oz/day)

- should triple birth weight by 1 yr (12 months)

How much milk is the baby fed at birth (0-24 hrs), and what is the expected number of feedings per day?

up to 1/2 ounce; 8 to 12 feedings

How much milk is the baby fed at birth (24-48 hrs), and what is the expected number of feedings per day?

1/2 to 1 ounce; 8 to 12 feedings

How much milk is the baby fed at birth (48-72 hrs), and what is the expected number of feedings per day?

up tp 1 ounce; 8 to 12 feedings

How much milk is the baby fed at 1 week, and what is the expected number of feedings per day?

1 to 2 ounces; 8 to 12 feedings

How much milk is the baby fed at 2 to 3 weeks, and what is the expected number of feedings per day?

2 to 3 ounces; 8 to 12 feedings

How much milk is the baby fed at 1 month, and what is the expected number of feedings per day?

3 to 4 ounces; 8 to 10 feedings

How much milk is the baby fed at 2 months, and what is the expected number of feedings per day?

4 to 5 ounces; 6 to 8 feedings

How much milk is the baby fed at 4 months, and what is the expected number of feedings per day?

4 to 6 ounces; 6 to 8 feedings

How much milk is the baby fed at 6-12 months, and what is the expected number of feedings per day?

7 to 8 ounces; 4 to 6 feedings

When is it recommended to start solids?

6 months, but continue with breast milk or formula until at least a year