Prevention, Health Promotion, Nutrition, and Health Maintenance Visits

10-14 days

neonates should regain their birth weight by

Weight: Doubles by 5 months, triples by 12 months.

Length: Increases by ~50% by 12 months.

Head circumference: Rapid growth, increases ~1 cm/month for first 6 months.

how does an infant's growth change over the first year?

familial short stature

Child is short but following a consistent growth curve.

Normal bone age, normal puberty timing.

Family history of short stature.

Final adult height is shorter but appropriate for parental heights.

constitutional delay of growth and puberty

"Late bloomer" pattern.

Normal birth length/weight, but slows during early childhood.

Delayed bone age and puberty onset.

Family history often positive for delayed growth/puberty.

Ultimately achieve normal adult height.

Diagnosis of exclusion; reassurance and monitoring typically sufficient.

-Weight < 5th percentile for age and sex

-Crossing two major percentile lines downward on the growth chart

-Weight-for-length or BMI < 5th percentile

criteria to meet failure to thrive

-organic: caused by an underlying medical condition

-inorganic: due to environmental , psychosocial, or behavioral issues (no medical illness)

organic vs inorganic failure to thrive

marasmus

Deficiency of total calories, especially protein and energy.

Often occurs in infants <1 year of age.

Due to chronic starvation or severe malnutrition (e.g., poverty, neglect, famine).

-Severe wasting of muscle and subcutaneous fat ("skin and bones")

-No edema

-Weight-for-age <60% of expected

-Thin, emaciated appearance

-Alert and hungry (initially)

clinical presentation of marasmus

-stabilization phase: treat/prevent hypoglycemia, hypothermia, dehydration

-nutritional rehabilitation: start low volume, low protein feeds

-micronutrient supplementation

-monitor for refeeding syndrome

management of marasmus

Refeeding syndrome

what happens after a starved and severely malnourished person finally gets fed via any of the routes. electrolytes distubrnaces happen and declines in phosphorus, potassium, and magnesium happen

kwashiorkor

Adequate caloric intake but severe protein deficiency

Often seen in children >1 year old after weaning to a carbohydrate-rich, protein-poor diet

Bilateral pitting edema (hallmark)

Distended abdomen (hepatomegaly due to fatty liver)

Thin limbs with retained subcutaneous fat

Apathy, irritability

Dermatitis with hyperpigmented, flaky ("flaky paint") skin

Hair changes: sparse, brittle, reddish or hypopigmented

clinical presentation of kwashiorkor

1.Careful fluid management (due to risk of heart failure with edema)

Correcting protein deficiency gradually

Nutritional rehab with complete protein sources (e.g., milk-based formulas)

management of kwashsiorkor

18.5

anorexia is defined by a BMI less than

Multidisciplinary approach: medical, nutritional, psychological

Nutritional rehabilitation (start low to avoid refeeding syndrome)

Cognitive Behavioral Therapy (CBT)

SSRIs (e.g., fluoxetine) for comorbid depression/anxiety, but not effective for weight gain

Hospitalization if severe (e.g., HR <40, BP <80/50, weight <75% ideal)

management of anorexia nervosa

russell's sign

calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time

CBT (first-line)

SSRIs (fluoxetine is FDA-approved)

Nutritional rehabilitation

Hospitalization if electrolyte abnormalities or suicidality

management of bullimia

When refeeding begins (especially with carbs), insulin surges → drives glucose, phosphate, K⁺, Mg²⁺ into cells.

This leads to dangerous electrolyte shifts and increased cellular ATP production demand → hypophosphatemia and complications.

describe the pathophys of refeeding syndrome

hypophosphatemia---> weakness, arrhythmias, resp failure

-others: hypokalemia, hypomagnesemia, thiamine def

hallmark electrolyte deranement of refeeding syndrome

Slipped Capital Femoral Epiphysis

seen in children during growth-spurt years. the proximal epiphysis slips from its normal position on the femoral head

-more common in obese ptss

blount disease

Acquired tibia vara deformity, a growth disorder of the tibia that causes the lower leg to angle inward, resembling a bowleg

-more common in obese pts

-leptin stimulates the hypothalamic-pituitary-gonadal axis

-adipose tissue expresses aromatase which converts androgens to estrogens

-precocious puberty in nfemales, late puberty in males

describe the effect of obesity on puberty

400 IU/day within the first few days of life

-Breast milk typically contains <40 IU/L of vitamin D—insufficient without supplementation

vit D recommendation for breast fed infants

Dental caries

Weak enamel

signs of flluoride deficiency

Breastfed infants: supplement with 1 mg/kg/day starting at 4 months

Iron-fortified formula/cereals

Screen at 12 months

recommended iron supplementation in newnbborns

beriberi

the thiamin-deficiency disease; characterized by loss of sensation in the hands and feet, muscular weakness, advancing paralysis, and abnormal heart action (cardiomyopathy)

Cheilitis, glossitis, eye irritation

signs of vitamin B2 (riboflavin) deficiency

Irritability, seizures, anemia

signs of vitamin B6 deficiency

Bleeding gums

Petechiae, bruising

Bone pain, pseudoparalysis

Irritability, poor wound healing

signs of vitamin C deficiency

Delayed closure of fontanelles

Bowed legs, wrist widening

Rachitic rosary (costochondral thickening)

Hypocalcemic seizures or tetany

signs of vitamin D def (rickets

Protein-rich diets (meat, peanuts, grains)

niacin rick foods

3 D’s: Dermatitis, Diarrhea, Dementia

Photosensitive rash

Neurologic changes

signs of niacin deficiency (pellagra)

Poor growth (failure to thrive)

Delayed wound healing

Diarrhea

Dermatitis (especially around mouth and anus)

Impaired immunity

signs of zinc deficiency

Mechanism: ↑ energy expenditure due to work of breathing and poor perfusion

Needs: High-calorie feeds (e.g., 24–30 kcal/oz formula), frequent feeds

how do congenital heart diseases change nutrition requirements?

drowning

#1 cause of injury-related death in 1–4 year olds

tip 1-2 cm above carina

Too low → right mainstem bronchus intubation → left lung collapse

Too high → risk of extubation

Esophageal placement → gastric distention, absent lung inflation

ideal positioning of a endotracheal tube

Ideal Position: Tip at IVC–right atrium junction (T8–T9 vertebral level)

Malposition Signs:

High → in right atrium → arrhythmia/perforation

Low → in liver/portal vein → hepatic injury, thrombosis

ideal position of umbilical venous catheter

Ideal Position: Tip in SVC–RA junction

Malposition Signs:

Into jugular or azygos vein

Coiling or perforation

Thrombosis or arrhythmia from improper placement

ideal position of central venous line (PICC)

12 months

universall screenning of CBC takes place at

Ages and Stages Questionnaire

Indication: General developmental screen

Age range: 1–66 months

Domains: Gross/fine motor, communication, problem-solving, social

Use: Parent-completed questionnaire

Limitation: May miss mild delays; depends on parent insight

constitutional delay

Transient state of hypogonadotropic hypogonadism associated with prolongation of childhood phase of growth, delayed skeletal maturation, delayed and attenuated pubertal growth spurt, and relatively low insulin-like growth factor-1 secretion.

familial short stature

A condition in which the final adult height achieved is less than the third percentile for the patient's age, gender, and population. Nevertheless, it is consistent with parental height in the absence of nutritional, hormonal, acquired, genetic, and iatrogenic causes

Hypophosphatemia, hypokalemia, ad hypomagnesemia

electrolyte derangement associated with refeeding syndrome

-infants screened at birth and again at 4 months if documented risk

-ALL screened at 12 months of age with a hemoglobin test

anemia screening recommendation

ASQ-3

parent completed questionnaire from birth to age 5 to assess development

Denver Developmental Screening Test (DDST)

Provides a simple method of screening for evidences of slow development in infants and preschool children

Covers 4 functions: gross motor, language, fine motor adaptive and personal social

MCHAT

Intended for toddlers between 16 and 30 months to see if further evaluation for autism is needed

Asks 20 qs about child's behavior

-Live or spend time in a house or building built before 1978

-Are from low-income households

-Are immigrants, refugees, or recently adopted from less developed countries

-Live or spend time with someone who works with lead or has hobbies that expose them to lead

children at increased risk of lead poisoning

Because of the significant association of lead intoxication with poverty, the CDC recommends routine blood lead screening at 12 and 24 months. In addition, standardized screening questions for risk of lead intoxication should be asked for all children between 6 months and 6 years of age

CDC recommendation for screening for lead poisoning

-once 0-6 months

-6 months-3 years

-at 4, 6, 8, and 10 years old well visits

screening recommendations for hearing

All children should be assessed for risk of tuberculosis at health maintenance visits at 1 month, 6 months, 12 months, and then annually

recommendation for tuberculosis screening

-Vision screening should be a routine part of every primary care visit, with physical examination from birth and formal acuity testing from 3 years on.

-Elements of the physical examination include inspection, red reflex evaluation, corneal light reflection, cover-uncover test.

Instrument-based testing can begin at 1 year of age until chart-based acuity testing is possible from 3 years on.

recommendations for vision screening

hx of intussusception

contraindication to rotavirus vaccination

Encephalopathy not due to another identifiable cause and occurring within 7 days of pertussis vaccination is a CI to subsequent doses of pertussis containing vaccine

contraindication to pertussis vaccination

hx of thrombocytopenia or thrombocytopenic purpura

relative contraindication to MMR vaccination

History of Arthus-type hypersensitivity reaction after a previous dose of diphtheria toxoid or tetanus toxoid vaccine is a precaution to these vaccines

-progressive neurologic disorder

relative contraindication for dTAP and Tdap

infantile colic

episodes of uncontrollable crying or fussing in an otherwise healthy infant

1. Age <5 months when the symptoms start and stop

2. Recurrent and prolonged periods of crying, fussing, or irritability that start and stop without obvious cause and cannot be prevented or resolved by caregivers

3. No evidence of poor weight gain, fever, or illness

4. Caregiver reports of crying/fussing for ≥3 hours per day on ≥3 days/week in a telephone or face-to-face interview

5. Total daily crying confirmed to be ≥3 hours when measured by at least one prospectively kept 24-hour diary

ROME IV criteria of infantile colic

swaddling, side or stomach holding, soothing noises, swinging, and sucking on a pacifier

the 5 Ss of calming a colicky infant

stage N3

sleepwalking and sleep terrors are associated with what stage of sleep

between 2-4

-bowel movement before bladder

age at which child should be ready to begin toilet training

developmentally inappropriate, and the onset of these symptoms should be before the age of 12.

criteria for ADHD diagnosiss

encopresis

-Intentional or involuntary passage of feces into clothing in children with a developmental age of 4 years of more. This condition should be also be considered in a 3-year-old who still is not potty-trained with respect to bowel movements.

-Children often leak stool due to underlying constipation or a fecal impaction

-behavioral training and use of stool-softening therapy to prevent wittholding

treatmennt of encopresis

primary (incontinence in a child who has never achieved a period of nighttime dryness) or secondary (incontinence in a child who has been dry for at least 6 months)

primary vs secondary nocturnal enuresis

First-line therapy consists of either enuresis alarm conditioning therapy or desmopressin pharmacotherapy . Enuresis alarms consist of a sensor in the undergarment or bed pad and an arousal device worn on the wrist or waist.

first line therapy of enuresis

Dyscalculia

Also known as developmental arithmetic disorder; a learning disability that involves difficulty in math computation.

dysgraphia

A learning disability that involves difficulty in handwriting, typing, andd spelling

auditory processing disorder

difficulty processing and interpreting auditory language symbols; a dyslexia of the ears

-hear sounds but have trouble making sense of them

language processing disorder

A specific type of Auditory Processing Disorder (APD) in which there is difficulty attaching meaning to sound groups that form words, sentences and stories.

-difficulty attaching meaning to sound groups that form words, sentences, and stories

non-verbal learning disorder

-affects a person's ability to decode nonverbal behaviors and social cues

visual perceptual/visual motor deficit

A disorder that affects the understanding of information that a person sees, or the ability to draw or copy.

Oppositional Defiant Disorder (ODD)

-Child displays a pattern of uncooperative, defiant and angry behavior toward people in authority

-They may lose their temper easily, have frequent outbursts of anger or resentment, be touchy and/or easily annoyed by others, frequently angry and/or disrespectful, excessively argue with adults, actively refuse to comply with requests and rules, blame others for their own mistakes, deliberately try to annoy or upset others, be spiteful and seeking revenge, or say mean and hateful things when angry or upset

transient tic disorder

Single or multiple motor and vocal tics that occur many times a day nearly every day for more than four months but no longer than twelve consecutive months

chronic motor or phonic tic isorder

Single or multiple motor or vocal tics, but not both

Tics will appear frequently on most days, for more than a year, during which no period of time was tic free for more than three consecutive months

Tourette Synrome

Persistent motor tics (lasting >12 months) combined with vocal tics

-begins before age 12

persistent depressive disorer

a chronic form of depression characterized by a depressed or irritable mood present for at least 1 year. Two of the following symptoms are also required: changes in appetite, sleep difficulty, fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.

disruptive mood disregulation disorder

includes children ages 6-18 years who present with a chronic (≥12 months) pattern of severe irritability and behavioral dysregulation.

bipolar I dissorder

consists of distinct periods of mania (elevated, expansive, or irritable moods and distractibility) and persistent goal-directed activity or energy that may alternate with periods of severe depression

bipolar II disorder

at least one current or past full major depressive episode and at least one period of current or past hypomania

cyclothymic disorder

a chronic (>1 year) mood disorder characterized by several periods of hypomanic symptoms and depressive symptoms (which do not have to meet the full diagnostic criteria for hypomania or a depressive episode, respectively).

-emergency

-diagnosis and treatment of sexuality related care

-diagnosis and treatment of drug-related care

-emancipated minors

-mature minors

exceptions in which health care services can be provided to a minor

HEADDSS

-home, education, alcohol, activities, drugs, diet, sex, suicide/depresssion, seslf

mnemonic of a social history in an adolescent