Fluent Essays

Week 6 Discussion For this assignment, you will review the latest evidence-based guidelines in the links provided below. Please make sure you are using scholarly references and they should not be older than 5 years. The posts/references must be in APA format.  Apply the information from the Aquifer case study to answer the following questions:  1: Which essential questions will you ask this pediatric patient or his/her caregiver during this well-child check? Why are these questions important? What lab tests or diagnostic studies will you order and why? 2: What diagnoses would you give the patient in this case? Include the findings that support the diagnoses. 3: What is your treatment recommendation and education for the patient and family? Why? Include anticipatory guidance. Pediatrics 03: 3-year-old male well-child visit User: Elizabeth Hernandez Email: [email protected] Date: September 20, 2021 12:00AM Learning Objectives Upon completion of the case, the student should be able to: Discuss the importance of identifying parent concerns in order to set priorities for a well-child visit. Describe the components of a preschool health supervision visit, including common concerns, key elements of health promotion, recommended screening, and immunizations. Demonstrate ability to measure and assess growth, including height/length, weight, and body mass index using standard growth charts. List normal developmental milestones at 3, 4, and 5 years of age. Identify eczema and discuss principles of management. Describe key elements of the physical exam for a well-child visit in early childhood, including tests to identify strabismus. Discuss strategies for modifying the elements of the well-child visit to match the child's level of comfort and cooperation. List common causes of injury in early childhood. Discuss age-appropriate anticipatory guidance about safety in preschoolers, including recommendations for addressing firearms in the home. Summarize risk factors and screening for tuberculosis, lead poisoning, anemia. List potential causes of anemia in a preschool aged child. Outline an approach to the assessment of anemia in children Describe an initial approach to the management of suspected iron deficiency anemia. List common dietary issues in early childhood. Discuss strategies for counseling parents on making dietary changes in preschoolers. Knowledge Vision and Hearing Screening Hearing is initially evaluated in the newborn period. Between birth and age 3, children are evaluated by asking the parent if they have concerns about vision or hearing. Instrument based vision screening, with a photoscreener, should start at 1 year Vision screening using a chart begins at age 3 years. Hearing evaluation through audiometry begins at age 4 years. Children who cannot cooperate with testing by age 4 are more likely to have developmental delays. (For these children, you may need to refer for formal audiology and/or ophthalmology for screening, especially if developmental delays are suspected.) Important Review Topics for a 3-Year-Old's Health Maintenance Visit Social The social environment plays a major part in how children develop. It is necessary to understand the family context before giving advice. To enter this arena, ask about changes and family stressors in a non-threatening way. Nutrition Preschoolers can suffer from poor nutrition. Inadequate fruit, vegetable, and iron intake is quite common. Calcium and vitamin D deficiencies are also common, and should be supplemented if patients are at risk for deficiencies. Exercise According to the American Academy of Pediatrics (AAP) guidelines, "Active Healthy Living: Prevention of Childhood Obesity through Increased Physical Activity": "Toddlers should be allowed to develop enjoyment of outdoor physical activity and unstructured exploration under the supervision of a responsible adult caregiver. Such activities include walking in the neighborhood, unorganized free play outdoors, and walking through a park or zoo." Having quality play environments is optimal at this age. Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity. Toilet Training Toddlers at age 3 may not have achieved full toilet "independence" - especially toddlers with intense, willful temperaments. Requiring assistance toileting is not a clear sign of developmental delay at this age, but may preclude attendance at child care or preschool. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 1/11 Dental The American Association of Pediatric Dentists (AAPD) and the AAP both state that all children should be seen within six months of the first tooth eruption or by 1 year of age. Additionally, the AAP states that all children should be screened by 6 months old to see if they are at a higher risk of developing caries. Your community, however, may not have a pediatric dentist. Also, many general dentists feel that the first visit should be at age 3 years. This is an unresolved issue between general and pediatric dentists. It is recommended that children have fluoride varnish applied after tooth eruption, every 3-6 months, until 6 years. See the AAPD policy statement about "early childhood caries," the diagnostic term that has replaced "baby bottle tooth decay" or "milk bottle caries." Also see the AAPD policy statement about "the dental home," advocated for children at higher risk of dental caries. Safety Car seats are often used inappropriately; toddlers are moved too soon to booster seats. The AAP recommends that "children remain in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat." Most car seats allow for rear caing until 2 years or older. Older children should stay in a booster seat until they reach a height of 4' 9" (142 cm). In the toddler years, overall safety issues become increasingly important because of the increased independence, inquisitiveness, and motor skills of preschoolers. Injuries are a major morbidity in the preschool years and safety information should include water safety and avoiding hazardous household chemicals. Early Childhood Developmental Assessment Developmental assessment of most preschoolers is a process of both observing the child and taking a history from the parent. The American Academy of Pediatrics guidelines for developmental assessment draws distinctions between (1) surveillance, the process of recognizing children who may be at risk of developmental delays, (2) screening, the use of standardized tools to identify and refine that recognized risk, and (3) evaluation, the process of identifying specific developmental disorders that are affecting a child. Developmental Surveillance A form of developmental assessment - often in the form of play activities - incorporated into the exam. Helps to determine areas of concern, prompting further evaluation, if necessary. Performed at every encounter with the family. Evidence continues to mount that developmental surveillance alone inadequately identifies developmental delays. One standard, recognized source for health maintenance information for children is Bright Futures from the American Academy of Pediatrics. This comprehensive document provides an evidence-based synthesis of the best available information on what to expect at each age. Remember, the behaviors identified for each age in Bright Futures are what MOST kids at that particular age will do; these are simply descriptions of expected behaviors, not a developmental screening test. Developmental Milestones for 3-, 4-, and 5-Year-olds by Domain Developmental monitoring involves a careful review of progress in each of several different developmental domains. There are several different screening tools, and you may note slight variations in the delineation of the domains and tasks depending on the tool used. Additionally, some tables present milestones that 50% of children can perform at each specified age, while others present milestones that 75% or 90% of children can perform. The table below is based on Bright Futures Surveillance of Development - these milestones generally represent the mean or average age of performance of these skills, when available. 3-year-old 4-year-old 5-year-old Socio- emotional Brushes teeth (with assistance) Feeds self Knows gender and age Friendly to other children Plays with toys/engages in fantasy play Listens and attends Can tell the difference between real and make-believe Shows sympathy/concern for others Communication Speaks in two– to three–word sentences Speech is 75% understandable States first and last name Sings a song Most speech clearly understandable Articulates well Tells a simple story using full sentences Uses appropriate tenses and pronouns Counts to 10 Follows simple directions © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 2/11 http://www.aapd.org/media/Policies_Guidelines/P_ECCUniqueChallenges.pdf http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx Cognitive Knows name and use of "cup, ball, spoon, crayon" Names colors Aware of gender Plays board games Draws person with 3 parts Copies a cross As children get ready for school, the developmental milestones shift to more cognitive processes. Asking the parents about school performance is as important as the following milestones: Draws a person with more than six body parts Prints some letters and numbers Copies squares and triangles Physical Builds tower of six to eight cubes Throws a ball overhand Rides a tricycle Copies a circle Hops on one foot Balances for two seconds Pours, cuts, and mashes own food Brushes teeth Balances on one foot Hops and skips Ties a knot Has mature pencil grasp Undresses/dresses with minimal assistance Aquifer's tool for learning the milestones includes videos demonstrating expected milestones in all four domains at each recommended well-visit age (2 months old, 4 months old, 6 months old, etc.) from birth to 5 years. Developmental Screenings Pediatricians do not, in general, perform definitive developmental evaluations, but do perform screening tests to determine which children must be fully assessed. The AAP recommends routine developmental screening through a validated tool at 9, 18 and 30 months. They recommend routine screening for autism at 18 and 24 months. Developmental Evaluations Less than 3 years old: Children of this age with suspected developmental problems should be evaluated by one or more of the following (the choice may be determined by which specialists are available in the community): Early Childhood Intervention (ECI) – each state is mandated to provide developmental assessments and services for those children at risk for or determined to have developmental delays A developmental-behavioral pediatrician A child psychiatrist or child psychologist Early childhood learning specialists Ages 3 to 5 years: If problems are detected early, services provided by the school system for 3- to 5-year-olds can often help these children catch up to their peers. Eczema (Atopic Dermatitis) Eczema has been called "the itch that rashes," because there is a cycle of irritation leading to scratching, leading to the rash. Educate parents that anything leading to itching (even a child's rubbing his face on Mom's sweater) can exacerbate eczema. Eczema and Allergies Although eczema often occurs without a history of allergies, such a history would support an atopic diathesis and should prompt you to ask additional questions about allergic triggers and asthma symptoms. Family History While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear environmental (allergic) triggers. Differential Diagnosis Sometimes eczema may be confused with the other common inflammatory rashes: Contact Dermatitis: This is very common in children and can be the result of any irritants including new products that they are using or something they came in contact with while playing. Scabies: This is an infection from mites that presents with a non-specific rash that is extremely itchy. Multiple family members may have similar rashes. Psoriasis: Although psoriasis can occasionally first look like eczema, it is rare in young children. When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection. Seborrhea: This should also be part of the differential diagnosis, especially in early infancy (e.g., cradle cap). It is unusual to have a new case of seborrheic dermatitis at age 3. Treatment The basic tenets of the treatment of eczema are: Protecting skin by performing frequent daily moisturizing © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 3/11 file:///documents/803 Using topical anti-inflammatories in short bursts Treating associated skin infections aggressively Pharmacological Treatment In developing an effective treatment plan, it is important to understand what treatment has been used already and with what results. Topical steroids Prescribe topical steroid, alternating a higher potency for severe flares with a lower potency for minor bouts. Often over-the-counter hydrocortisone is inadequate. Topical calcineurin inhibitors Calcineurin inhibitors are considered second-line therapy. Although effective, safety concerns remain for long term use. Antihistamines Remember that sometimes simply prescribing antihistamines can help with the itch, which in turn can prevent scratching and worsening of the rash. The non-sedating antihistamines approved for children – loratadine, fexofenadine, and cetirizine – may be effective. Traditional antihistamines (with sedative side effects) such as diphenhydramine and hydroxyzine are often used at bedtime to decrease itch. Common Dietary Issues in Early Childhood Inadequate nutrition One study of preschool-aged children 2 to 3 years old found that these children consumed, on average, about 80% of the recommended fruit servings/day, but only 30% of the recommended vegetable servings/day. Iron is of crucial importance to normal development in this age group due to its role as a CNS co-catalyst. Iron intake in toddlers occurs predominantly from meat, legumes, and iron-fortified cereals. Milk and juice intake Recent studies suggest that milk may be deficient in many preschoolers diets, with substitution of fruit drinks or other high-fructose corn syrup-sweetened beverages. Juice drinks with sweetened high-fructose corn syrup can especially add substantial calories to a child's diet and contribute to the development of early obesity. The AAP recommends no introduction of juice before one year and in older children no more than 4-6 ounces of juice per day. Early childhood caries Bathing teeth throughout the day with milk or juice from a bottle can result in early dental caries. Early childhood caries typically have a lag time before visible decay. Thus the patterns established when a child is 1 to 3 years old may result in caries when the child is 3 to 5 years old. Although constant use is most damaging, even routine bedtime use of the bottle can lead to cavities. It is recommended that parents discontinue the bottle by the time the child is 12 to 15 months old. In older toddlers, it becomes more difficult if the bottle has become their transition object or "lovey." Control battles about food It is important to avoid the evolution of a pattern of negative interactions about eating between a toddler and her/his caregiver. Once a toddler has been given control over what s/he eats, it is difficult to promote healthy food habits. Food rewards and punishment in preschoolers may promote obesity by interfering with children's ability to regulate their own food intake. Injuries in Childhood Important causes of injury in a toddler include: Car accidents Swimming pools Falls Firearms Poisonings Fires At every opportunity, parents should be counseled about avoidance of accidents. The Injury Prevention Program (TIPP) was started in 1983 by the AAP to help pediatricians prevent injuries in their patients. "TIPP is © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 4/11 designed to provide a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries-behaviors that are effective and capable of being accomplished by most families." The program includes an AAP policy statement, safety surveys for parents to complete, age-appropriate safety information for parents, and a schedule of safety counseling for pediatricians. View the TIPP information for a 3-year-old. Children and Gun Safety The most effective strategy for discussing gun safety with families is “gun-neutral,” meaning to present the facts on how to be safest without having an opinion on if families should have a gun at home. It is important to discuss that children are not able to appropriately reason or understand guns from a developmental standpoint and that increases the risk of injuries. In a study from 2003, the authors found that 52% of parents who owned guns thought that their children were "too smart" or "knew better," even though only 40% had given specific instructions to their children regarding guns. In this survey only 12% of parents who owned guns locked them. Another study from 2001 found that, when given the opportunity, boys ages 8 to 12 would handle a gun (76%) and pull the trigger (48%). Parents' opinions about whether or not their child would handle a gun were not predictive of which boys would handle the gun. Lead Screening No level of lead exposure is considered safe. Lead exposure, even at low levels, is a causal risk factor for cognitive impairment and behavioral difficulties in children. Children living in lead-contaminated environments are at greatest risk for having elevated blood lead levels between 6 and 36 months, largely because of the normal mouthing behavior and increasing mobility that occur during this developmental stage. In addition, lead absorption is higher in younger children than in older children and adults. Iron deficiency, which is common in toddlers, increases lead absorption. Common sources of lead exposure include: House paint used before 1978 - and particularly before 1960. Deteriorating paint produces lead-containing dust, particularly during renovation. Soil Plumbing, pipes Hobbies, occupational exposures Imported toys, ceramics, candy, cosmetics Folk remedies The American Academy of Pediatrics emphasizes that primary prevention (removal of environmental sources of lead) should be the focus of policies and physician advocacy to protect children from lead toxicity. At an individual level, current AAP policy recommends blood lead testing for All children 12 to 24 months of age in areas where more than 25% of housing was built before 1960 or where the prevalence of blood lead levels higher than 5 μg/dL in children is 5% or greater. Individual children who live in or regularly visit homes/facilities built before 1960 that are in poor repair or have been renovated within the past six months. All recent immigrants to the country because of the increased risk. Screening based on local guidelines. Screening for Tuberculosis TB risk factors: Spending time with an individual known or suspected to have TB disease Being infected with HIV or another condition that weakens the immune system Having symptoms of TB disease Living in (or coming from) a country where TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia) Living somewhere in the U.S. where TB disease is more common (e.g., a homeless shelter, migrant farm camp, prison or jail, and some nursing homes) Use of injected illegal drugs. If an individual has any of the above risk factors, a PPD should be placed and read by a medical professional in 48 to 72 hours for children under 2. Children older than 2 can be tested with an IGRA test (quantiferon) Iron Deficiency Anemia Epidemiology Nationally among preschoolers, deficient iron stores may occur in up to 35% of low-income children (versus only 7% in other preschoolers), with up to 10% having iron-deficiency anemia. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 5/11 http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-2-to-4-Years.aspx Association with Cognitive Difficulty Studies have shown an association between iron deficiency in infancy and later cognitive deficits. It is unclear whether cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk for iron deficiency. Causes Lack of iron intake is the most likely acquired cause of iron-deficiency anemia. Excessive ingestion of cow's milk (drinking more than 24 oz of milk daily) in young children is an important risk factor for iron deficiency due to the low concentration and bioavailability of iron in cow's milk. Children with excessive milk intake are also at risk for occult intestinal blood loss. In rare cases, iron stores are decreased from chronic GI blood loss (e.g., food allergies and gluten enteropathy). Therapy In children whose anemia is mild, many providers will provide a trial of iron rather than do any further workup at this point. If the hemoglobin recovers to the normal range after a trial period, that is sufficient evidence of iron-deficiency anemia. Other Causes of Anemia In children of Mediterranean, Asian, or African descent, hemoglobinopathies should be considered, including: alpha thalassemia sickle cell disease In these cases, the child's newborn screening hemoglobin electrophoresis would have been abnormal. Other causes are rare in children and present with a more severe anemia (Hgb less than 9 g/dL (90 g/L)): Decreased marrow production (e.g., aplastic anemia) Hemolytic anemia Vitamin deficiencies (e.g., folate and B6) Unusual acquired causes of anemia include chronic or severe illnesses: Collagen vascular disease Malignancy Other chronic illnesses Evaluation of Anemia Two classification schemes are frequently employed to narrow down the differential diagnosis in anemia: Size Classification: The first uses the MCV and/or the peripheral blood smear to classify the size of the red blood cell as microcytic, normocytic, or macrocytic. Although it can be quite helpful, the system is imperfect. Since MCV values in children vary with age, the age-specific MCV values must be used. Even so, certain conditions do not fit neatly into one category. (For example, the anemia of inflammation/chronic disease and of lead poisoning can be microcytic or normocytic, and the anemia seen with liver failure can be normocytic or macrocytic.) Microcytic Normocytic Macrocytic Iron deficiency Thalassemia Chronic inflammation Lead poisoning Sideroblastic anemia Acute blood loss Immune hemolytic anemia Hereditary spherocytosis Sickle cell anemia Renal disease Transient erythroblastopenia of childhood (TEC) Folate deficiency B12 deficiency Liver disease Hypothyroidism Neoplasms Bone marrow failure syndromes (aplastic anemia, Diamond-Blackfan anemia (DBA), and congenital dyserythropoietic anemia (CDEA) Mechanism Classification: The second categorizes anemia by its mechanism. In this system, if a patient's hemoglobin is low, it is due to one of three basic reasons: He/she is either not making adequate amounts (decreased production) . It is being destroyed (increased destruction). The body is losing it from somewhere (blood loss). This system is intuitive and reliable, but more difficult to categorize: Reticulocyte count Mechanism Possible causes © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 6/11 Low Decreased production Iron, folate, or B12 deficiency Lead toxicity Thalassemia Aplastic anemia Chronic inflammation Neoplasms TEC DBA Renal disease Hypothyroidism CDEA (congenital dyserythropoietic anemia) Sideroblastic anemia High A high reticulocyte count indicates that the patient is able to adequately make red cells and is trying to compensate for the anemia, suggesting the cause to be either blood loss or destruction Increased destruction Jaundice Elevated bilirubin Dark urine Splenomegaly Schistocytes and microspherocytes on peripheral blood smear Low serum haptoglobin Immune hemolytic disease Hereditary spherocytosis Sickle cell disease Thalassemia DIC (disseminated intravascular coagulation) Mechanical heart valves Burns PNH (paroxysmal nocturnal hemoglobinuria) Hypersplenism High A high reticulocyte count indicates that the patient is able to adequately make red cells and is trying to compensate for the anemia, suggesting the cause to be either blood loss or destruction. Blood loss Acute hemorrhage Dysfunctional uterine bleeding (heavy and/or prolonged menstrual periods) Pulmonary hemosiderosis (pulmonary hemorrhage) Goodpasture's disease Gastrointestinal blood loss (peptic ulcer disease, other GI conditions) Clinical Skills Interacting With a Preschool Age Child At 3 years of age, some children can be cooperative at the pediatrician's office, some are wary still, and some still need a lot of parental reassurance. Smiling and talking with the child in a pleasant, reassuring, calm voice is an outstanding strategy, rather than just talking and interacting with his mother. Giving the preschooler a fun activity to do while obtaining a medical history is effective; just giving a couple of crayons and drawing on the table exam paper can engage the child so that he is cooperative. In order to avoid scaring a toddler, it is important to give them time to warm up and feel comfortable before getting too close to them or examining them. Many parents are embarrassed when their children act up at the office, but reassuring that it is normal childhood behavior will allow the parent to relax more. Physical Exam of the Toddler and Preschooler General Tips Listen with your stethoscope first in case he/she starts crying. If the exam needs to be truncated due to the child's behavior, then © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 7/11 you should focus on: Neurodevelopment Monitoring previously recognized findings New findings identified by parents, and Physical problems common in preschoolers for which intervention may be helpful Exam Area Possible Findings General Appearance Look for any dysmorphisms Assess whether well or ill-appearing HEENT Mouth: Caries Ears: Middle ear effusions that may persist after earlier URI and affect hearing. Click here to link to video demonstrating proper otoscope technique (with a notably cooperative patient): https://www.youtube.com/watch?v=b80LyZRZOFY&sns=em Eyes Strabismus (Discussed further below) Neck An enlarged thyroid is rare in children. Many children have "shotty" nodes (pea or marble-sized, nontender, easily mobile lymph nodes that are not fixed to surrounding structures) in the anterior and occasionally posterior cervical chain. These are normal in the cervical and inguinal chains in children and may persist for years. Cardiac Most murmurs will be functional. New murmurs of congenital heart disease are unlikely, but signs of atrial septal defect sometimes are appreciated better in older children. Lungs Yield likely to be low in a healthy child. May hear subtle wheezing in a child with a history of allergies or asthma. Abdomen Palpation for organomegaly and masses is appropriate. While the most common mass will be stool, children this age occasionally have an enlarged kidney or, very rarely, an abdominal tumor such as Wilms' or neuroblastoma. Skin Observe for rash, nevi, cafe-au-lait spots, birthmarks, or bruising Musculoskeletal Several gait variants occur at this age. The most common is intoeing. Intoeing in toddlers is usually caused by tibial torsion. In tibial torsion, when the patella faces straight ahead, the foot turns inward. Tibial torsion resolves naturally with weight bearing – usually by 4 years of age. Intoeing in preschool- and school-aged children is usually caused by femoral anteversion. In femoral anteversion both the feet and knees turn inward. Femoral anteversion usually resolves spontaneously by 8 to 12 years of age. Link to more information about intoeing: http://www.massgeneral.org/ortho-childrens/conditions-treatments/intoeing.aspx Genitals Hernias are sometimes seen. This segment of the exam also provides the opportunity to teach about who can appropriately examine the child. Some girls show nonspecific vulvar erythema due to poor hygiene once they are toilet trained and caring for themselves in the bathroom. Neurologic Assessment of overall muscle tone, strength, and coordination is appropriate. In general, the neuro exam at this age is more focused on assessing a child's achievement of overall neurodevelopmental status, including gross and fine motor, along with language and social-skills milestones. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-09-19 20:00 EDT 8/11 https://www.youtube.com/watch?v=b80LyZRZOFY&sns=em http://www.massgeneral.org/ortho-childrens/conditions-treatments/intoeing.aspx Examining for Strabismus Strabismus refers to misalignment of the eyes. Strabismus can lead to amblyopia, or poor visual development if not managed. Two methods of assessing presence and degree of strabismus: The Hirschberg light reflex (corneal light reflex) Hirschberg simulator The cover/uncover test Abnormal cover test Neurodevelopmental Exam of a 3-Year-Old A neurodevelopmental exam should include assessment of the following developmental domains: Language (speaks in short sentences; 75% of language is intelligible to a stranger) Fine motor (holds a …