TCP Week 3 - The Pediatric Examination

What is the general approach to a pediatric examination?

Build rapport; use creativity and flexibility; adapt the encounter for autism spectrum disorder, developmental delay, or anxiety; remember that children are not simply tiny adults.

Why is rapport especially important in pediatric care?

A cooperative examination often depends on establishing trust with both the child and caregiver.

Why must the pediatric examiner be creative and flexible?

The sequence and technique of the examination may need to change based on the child's age, developmental level, behavior, anxiety, or special needs.

Which patient factors may require modification of the pediatric examination?

Autism spectrum disorder, developmental delay, and anxiety.

What are the three major goals of a well-child examination?

Maximize development; detect treatable disease early; prevent injury and disease through education.

What clothing requirement is emphasized for the comprehensive pediatric examination?

The patient should be in a gown.

When is the first well-child examination scheduled?

The first day of life.

When is the early newborn follow-up visit scheduled?

At 2-5 days of life.

At which months are routine well-child visits scheduled during the first 3 years?

1, 2, 4, 6, 9, 12, 15, 18, 24, 30, and 36 months.

How often are well-child visits scheduled after 36 months?

Annually.

What major history and physical components should be included in a pediatric visit?

Growth and development; nutrition; sleep; elimination; safety; hygiene; social history; review of systems; comprehensive examination.

What is growth?

The process of increasing physical size.

Which growth measurements should be routinely obtained in children?

Height or length and weight.

Until what age should head circumference be measured?

In children younger than 3 years.

Beginning at what age should BMI be calculated?

After age 2 years.

Why are serial growth measurements important?

They allow the clinician to identify trends or deviations over time rather than relying on one isolated measurement.

What developmental screening test is identified in the presentation?

The Denver Developmental Screening Test.

What age range does the Denver Developmental Screening Test cover?

Birth through age 6 years.

What four developmental domains are assessed by the Denver Developmental Screening Test?

Gross motor, fine motor, social, and language.

What should be assessed in the gross motor developmental domain?

Age-appropriate large-muscle movement and motor milestones.

What should be assessed in the fine motor developmental domain?

Age-appropriate small-muscle and hand-use milestones.

What should be assessed in the social developmental domain?

Age-appropriate social interaction and adaptive behavior.

What should be assessed in the language developmental domain?

Age-appropriate receptive and expressive language milestones.

What nutrition questions should be asked for a newborn or infant?

Breast milk, formula, or both; type of formula; ounces per feed; timing and frequency of feeds.

Which medical conditions may require specific dietary restrictions in children?

Galactosemia, food allergies, and celiac disease.

When may solid foods be introduced?

At approximately 4-6 months.

When should whole milk be introduced?

At 12 months.

By what age should a child be off the bottle?

By 18 months.

What meal pattern is recommended for toddlers and school-age children?

Three balanced meals with two healthy snacks.

How much juice should toddlers and school-age children receive?

Less than 4 ounces.

What nutritional approach is emphasized for pediatric obesity?

Weight maintenance, provision of healthy foods, and caregiver role-modeling of healthy eating.

What activity counseling is included in pediatric obesity prevention?

Encourage sports and outside play and limit screen time.

How many hours of sleep are recommended for infants and toddlers?

11-15 hours.

How many hours of sleep are recommended for school-age children?

10-13 hours.

How many hours of sleep are recommended for teenagers?

8-10 hours.

What sleep topics should be reviewed in a pediatric history?

Amount of sleep, sleep arrangement, safety, and sleep hygiene.

What is the safest basic crib setup described in the study guide?

A bare crib with a firm, flat sleep surface and fitted sheet, without loose bedding or objects.

Which objects should be kept out of an infant crib?

Loose blankets, pillows, stuffed animals, crib bumpers, and other loose objects.

What stool characteristics should be reviewed during the pediatric history?

Character, frequency, and amount.

Why should feeding method be considered when assessing infant stool?

Breastfed and formula-fed infants may have different stool patterns.

Which history findings suggest constipation?

Straining, infrequent stools, and painful stooling.

What urinary topics should be assessed?

Urinary frequency and urinary symptoms.

When should toilet training begin?

When the child demonstrates readiness.

What safety topics are emphasized for infants?

Safe sleep, fall avoidance, ingestion prevention, and car-seat safety.

What safety topics are emphasized for toddlers?

Baby-proofing the home, car-seat safety, swimming safety, poison prevention, and gun safety.

What safety topics are emphasized for preschool and school-age children?

Booster-seat use, swimming safety, street crossing, and gun safety.

What safety topics are emphasized for high-school students?

Mental-health screening, risky behavior, cyber or other bullying, online safety, driving safety, and gun safety.

How long should a child remain in a rear-facing car seat?

Until the child reaches the maximum height or weight allowed by the seat, generally through approximately age 2-4 years.

Where should a rear-facing car seat be placed?

In the back seat, never in front of an active passenger airbag.

When should a child transition to a forward-facing car seat?

After outgrowing the rear-facing seat.

What restraint features should be used with a forward-facing car seat?

A harness and top tether.

How long should a child remain in a forward-facing car seat?

Until the child reaches the maximum height or weight allowed by that seat, at least through approximately age 5.

When is a booster seat used?

After the child outgrows the forward-facing seat and until the vehicle seat belt fits correctly.

At approximately what age does a vehicle seat belt usually fit correctly without a booster?

Around ages 9-12 years.

How should the lap portion of a seat belt fit a child?

Across the upper thighs, not the abdomen.

How should the shoulder portion of a seat belt fit a child?

Across the center of the shoulder and chest, not the neck or face.

Until what age should children ride in the back seat?

Until age 13.

By what age should a child have a dental home?

By 12 months.

What dental hygiene practices should be reviewed?

Brushing, flossing, and use of fluoride toothpaste.

What amount of fluoride toothpaste should be used before age 3?

A smear covering less than half of the bristles.

What amount of fluoride toothpaste should be used beginning at age 3?

A pea-sized amount.

What personal hygiene topics should be reviewed?

Bathing and washing.

Which laboratory screenings are recommended at 12 months?

CBC and lead screening.

At what ages should M-CHAT screening be performed?

18 months and 24 months.

What does M-CHAT stand for?

Modified Checklist for Autism in Toddlers.

Beginning at what age should vision and blood pressure be checked at each visit?

After age 3 years.

At what ages should a lipid panel be obtained according to the presentation?

At ages 10 and 18 years.

At what ages should girls be screened for scoliosis?

At ages 11 and 13 years.

At what age should boys be screened for scoliosis?

At age 12 years.

What major prenatal history areas should be reviewed before examining a newborn?

Prenatal care; infections or illness; substance or medication use; prenatal screening results; previous pregnancies; congenital or genetic syndromes; maternal complications.

Which maternal complications are specifically listed in the prenatal history?

Preeclampsia, gestational diabetes mellitus, and placental abnormalities.

What birth-history elements should be reviewed?

Gestational age, birth weight or size, delivery type, assistance during delivery, special care, NICU stay, and interventions.

What gestational-age range is considered full term?

37-42 weeks.

How is small for gestational age defined in the presentation?

Birth size below the 10th percentile.

How is large for gestational age defined in the presentation?

Birth size above the 90th percentile.

What is low birth weight?

Birth weight less than 2,500 g.

What is very low birth weight?

Birth weight less than 1,500 g.

What is extremely low birth weight?

Birth weight less than 1,000 g.

Which delivery types should be documented?

Normal spontaneous vaginal delivery, induced delivery, or cesarean delivery.

What additional detail should be documented for a cesarean delivery?

Whether it was emergent or scheduled.

Which assisted-delivery methods should be documented?

Forceps and vacuum extraction.

What forms of special newborn care should be included in the birth history?

Extended hospital stay, NICU admission, and interventions.

Which conditions are included in the mandatory heel-stick neonatal screening listed in the presentation?

Phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell disease, congenital adrenal hyperplasia, maple syrup urine disease, cystic fibrosis, and toxoplasmosis.

What method is listed for newborn hearing screening?

Otoacoustic emissions.

What is the purpose of the Apgar score?

To assess newborn health and determine the need for immediate intervention based on physical findings and vital signs.

When is the Apgar score first assessed?

At 1 minute after birth.

When is the Apgar score reassessed routinely?

At 5 minutes after birth.

How often is the Apgar score repeated if it remains abnormal?

Every 5 minutes thereafter.

What are the five Apgar components?

Appearance, pulse, grimace, activity, and respirations.

What does an Apgar appearance score of 0 indicate?

The newborn is blue or pale all over.

What does an Apgar appearance score of 1 indicate?

Blue extremities with a pink torso.

What does an Apgar appearance score of 2 indicate?

Pink color all over.

What does an Apgar pulse score of 0 indicate?

No pulse.

What does an Apgar pulse score of 1 indicate?

Heart rate less than 100 beats/min.

What does an Apgar pulse score of 2 indicate?

Heart rate at least 100 beats/min.

What does an Apgar grimace score of 0 indicate?

No response to stimulation.

What does an Apgar grimace score of 1 indicate?

Weak grimace with stimulation.

What does an Apgar grimace score of 2 indicate?

The newborn cries or pulls away with stimulation.

What does an Apgar activity score of 0 indicate?

No muscle tone or movement.

What does an Apgar activity score of 1 indicate?

Some flexion of the arms.