1 / 72

Well child visit preschool age

Well child visit preschool age. Julie M Hurtado, MD 9/10/09. I. Introduction II. Growth and Development 1. Physical development Ht/Wt Vision/ Hearing Muscle/ Neuro Cardio/ Respiratory GI 2. Psychosocial and Cognitive III. History and Physical Exam IV. Screening

Télécharger la présentation

Well child visit preschool age

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Well child visit preschool age Julie M Hurtado, MD 9/10/09

  2. I. Introduction II. Growth and Development 1. Physical development • Ht/Wt • Vision/ Hearing • Muscle/ Neuro • Cardio/ Respiratory • GI 2. Psychosocial and Cognitive III. History and Physical Exam IV. Screening V. Anticipatory Guidance VI. Common Questions VII. Common Concerns • Nutrition • Sleep • TV and Internet VIII. Common Conditions • Febrile Illness • AGE • Constipation • URI IX. PREP questions

  3. I. Introduction • 3-5 y/o • Magical period of curiosity and activity • Enormous amount of attention • Period of physical, psychological, cognitive and emotional changes

  4. II. Growth and Development • Series of tasks to be master within certain stages • Biological changes reflects developmental changes influenced by the environment • Individual variations may be transient • Early clinical intervention is crucial for children with dev. delay

  5. 1. Physical development • Gains in Ht and Wt are constant during this age • Ht ~7cm (2inch)/year • Wt ~2kg (1lb)/year • HC ~ 2cm (1inch)/year • Boys > Girls • Adb flattens and body appears slimmer & face becomes elongated • Legs grow faster than the trunk/head and arms *As the child grows, parents might mistake this for weight loss. Keeping clear records and growth charts can be reassuring

  6. Vision • 3 years ~ 20/40 • 4-5 years ~20/30 • 6-7 years ~20/20 • Teeth: • By 3 all 20 primary teeth have erupted

  7. Muscle: • 3y/o: • Increase strength and refinement • Walk with steady gait • Ride tricycle, walk tiptoe and balance in 1 foot • 4y/o • Skip and hop in one foot • Can catch a ball • 5y/o • Skip on alternate feet • Fine motor: drawing and dressing

  8. Neurologic Development • By age 2, complete brain myelinization finalized • Cognitive, emotional and physical abilities of the preschooler are related to brain maturation • Sensory function becomes more developed, and the awareness of full rectum or bladder accompanies the ability of control the rectal sphincter • As neural growth slowly continues, the child performs more complex tasks

  9. Cardiovascular Development • By the 5th year, the size of the heart has quadrupled since birth • The HR decreases to 70-100/min as the myocardium growths and the energy demand decreases • Adult levels of pulmonary vascular resistance and pulmonary arterial pressure are attained before reaching age 2 years • Innocent murmur possible, as the heart gains size throughout this phase

  10. Respiratory Development • The number of alveoli and its associated structures increases • Conversely, the RR slows from infancy to approx 20-30 beats/min • As the diaphragm matures, abdominal respiratory movements decreases • By the end of the 5th year, respiratory movement becomes more diaphragmatic

  11. Gastrointestinal Development • By age 5, the GI tract is enzymatically mature, enabling the child to eat and digest a wide range of foods • Anatomically, the stomach is relatively small • Healthy snacks should be encouraged between meals to support nutritional requirements

  12. 2. Psychosocial and Cognitive development • Preschool children deal with the word around them • Vocabulary increases from 50-100 words, to >2000 • The use of language as and expressive tool increases • Children understand the inhibitions that surround them and are able to express feelings, anger and frustration without acting out *Language-delay children exhibit higher rates of tantrums and other externalizing behavior

  13. Preschool age corresponds with Piaget’s preoperational stage of thinking and egocentrism • Uses magical thinking to explain the surrounding word (“the sun goes down because is tired and needs to sleep”) • Play activities are increasingly complex and imaginative • Increased cooperative play and play that is governed by rules

  14. III. HYSTORY AND PHYSICAL EXAMINATION • Examination room should be comfortable and safe for children of all ages • Wearing a white lab coat might evoke a fearful response from the pediatric patient *Friendly interaction with the parents decreases the child’s anxiety. Use a calm tone

  15. 1. History Taking • A thorough history is essential • History elements reviewed during annual preschool visit • Family psychosocial status • Milestones: Language, Cognitive, Emotional and Spiritual • Elimination habits • Nutritional habits • Medication intake • Sleep habits • Television habits • Dental hygiene • Immunization status • Tuberculosis risk factors

  16. Preschool child’s need to know continually what is happening explain each step of the examination (“I’m going to talk to your mom about how’re you doing at home. If you have any questions or want to add anything, let us know”) • Child as an active participant • The use of drawing to explain medical problems • Vague complains can be use to provide AG and assure that the child is developing normally

  17. Initial visit  prenatal history, pregnancy illness, medication or drug use, birth history, neonatal and familial genetic history • Child’s environment is very important and should be explained to the caregiver (home environment, people at home, financial structure, occupation of caregivers and marital status) • Each intake of information should be tailored to the individual’s needs and parental concerns • Educational material and resources for reference should be available as well

  18. 2. Physical Examination • General physical appearance • Ht/Wt • Skin (images) • Head • Size/Shape • Fontanelles closed • Eyes • Size/Shape/Equal • Visual acuity • Red Reflex • Ears • Hearing • External Canal • Nose/Throat • Teeth hygiene • Nasal polyps • Neck • Lymph nodes • Respiratory • Inspection • Auscultation • Cardiology • Auscultation • Gastrointestinal • Hernias/Organ size • Rectum • Genitourinary • Females: Vagina • Males: Foreskin/Testicles • Check for Sexual abuse • Neurologic • Motor • Sensory • Musculoskeletal • Exposure • Inspection

  19. General physical appearance • The child should be examined after the interview and most development screen is completed • Ht and wt should be measured appropriately and plotted in the growth chart at each visit • Normal Vs Abnormal variations *Crossing percentile lines on standardized growth charts between the ages of 3-12 for boys and 3-10 in girls is abnormal and requires further evaluation

  20. Inaccurate data may lead to wrong diagnosis of growth abnormality • Weight with no clothes or shoes • >3 years, Ht should be done standing without shoes • HC not done after age 2 years unless there is a medical reason to do it • Staff should be educated about importance of accurate measures, and if possible, the same staff members should do the measurements

  21. Guidelines create impression that child growth is a continuous process. Growth is discontinuous and repeated observations of growth parameters are important • A single value measurement of growth does not reflect a pattern of development • Time is a tool in assessment as both the age of the child and the presence or absence of significant clinical findings can be observed and evaluated over time *Abnormal growth patterns accompanied by abnormal findings necessitate immediate evaluation *Standard Growth curved were developed in 1960’s and 1970’s and deviations does occur depending on the child’s ethnicity

  22. Eyes • Size and shape • Pupils for symmetry and light reflex • Conjunctivae and color of sclera • EOM for any muscle weakness • Visual acuity with appropriate vision screen

  23. ENT • Ears: • Size, shape and asymmetry • Internally for abnormalities, discharge or inflammation • Posterior for skin infection or mastoid tenderness • Hearing using gross and objective measurements • If language development is delayed, further eval should be done • Nose: • Size, shape and patency • Mucosa for dryness and polyps • FB if chronic nasal discharge • Mouth: • Mouth and tongue symmetry • Teeth for caries, color and gum inflammation

  24. Chest and Lungs • Inspection can uncover Pectum excavatum • Might be visually prominent but lung capacity not reduced • Percussion and auscultation • Rales, ronchi, wheezes and rubs should be investigated

  25. Cardiovascular system • Palpation • Point of maximum impact • Thrills or heaves • Auscultation • Murmurs or extra-sounds *Because most congenital heart diseases are discovered before the preschool period, acquired heart diseases account for the greatest morbidity and mortality of conditions related to this system during this period

  26. Gastrointestinal • Abdomen should be check for size, shape and distention • Inguinal, umbilical and femoral hernias • Auscultation for BS • Palpation of organs for size and abnormalities • Liver edge may be palpated which is normal • Palpable spleen is abnormal and should be investigated

  27. Genitalia and Rectum • Female: • Redness, swelling lesions and discharge *Persistent foul smelling vaginal needs gynecologic referral to r/o FB or chronic sexual abuse • Males: • Foreskin should be fully retractile by age 3-4 years • Position of urethral meatus x hypospadias • Scrotal sac x both testicles and hernias • Rectal exam Both sexes: • Fissures, tears, redness and irritation *Perineal irritation and lichenification may indicate the presence of worms

  28. Musculoskeletal and Neurologic Systems • Done throughout the examination, watching child • Neurologic examination includes language, motor and cognitive tasks which are done during the developmental exam. Vision and hearing are also assessed *Socks should be removed to check for feet malformation and hygiene. Problems could be preventing normal gain and posture

  29. IV. SCREENING(Health Promotion/Disease Prevention) • Rhythmicity and daily patterns • Healthy food choices • Family shares meals • Nighttime rituals • Regularly brushes teeth • Cognitive Growth • Limit television to 1-2 hrs/day • Parents talk to child to develop vocabulary • Parents read to child to support language • Parents provide toys that child can use creatively • Parents listen with care and respond actively • Parents allow the child to explore

  30. Emotional growth • Family manages anger and resolves conflicts • Family shows affection • Child makes choices as appropriate • Parents praise good behavior and accomplishments • Family avoids power struggles • Parents set clear and consistent limits • Child has opportunity to play with other children of the same age • Child is provided with transitional objects • Family uses night-light (Unless shadows increase child's fears) • Parents provide reassurance if nightmares occurs

  31. Self-care • Family encourages self-feeding • Parents anticipate child’s interest in genital differences • Parents promote toilet training and hygienic habits • Parents promote physical activities in safe places • Family insists on use of car seat • Strength and coordination • Child can exercise big muscles • Child sings and dances to music • Parents promote outdoor play opportunities in safe areas

  32. V. ANTICIPATORY GUIDANCE • Is interactive and occurs throughout the provider-patient interaction • Safety is always a priority • AAP has the TIPP (The Injury Prevention Program) age-related safety sheets, that can be given to the parents

  33. TIPP 2-4 years Did you know that injuries are the leading cause of death of children younger than 4 years in the United States? Most of these injuries can be prevented. Often, injuries happen because parents are not aware of what their children can do. Children learn fast, and before you know it your child will be jumping, running, ridinga tricycle, and using tools. Your child is at special risk for injuries from falls, drowning, poisons, burns, and car crashes. Your child doesn't understand dangers or remember "no" while playing and exploring. • Falls Because your child's abilities are so great now, he or she will find an endless variety of dangerous situations at home and in the neighborhood. Your child can fall off play equipment, out of windows, down stairs, off a bike or tricycle, and off anything that can be climbed on. Be sure the surface under play equipment is soft enough to absorb a fall. Use safety tested mats or loose-fill materials (shredded rubber, sand, woodchips, or bark) maintained to a depth of at least 9 inches underneath play equipment. Install the protective surface at least 6 feet (more for swings and slides) in all directions from the equipment. Lock the doors to any dangerous areas. Use gates on stairways and install operable window guards above the first floor. Fence in the play yard. If your child has a serious fall or does not act normally after a fall, call your doctor.

  34. Firearm Hazards Children in homes where guns are present are in more danger of being shot by themselves, their friends, or family members than of being injured by an intruder. It is best to keep all guns out of the home. If you choose to keep a gun, keep it unloaded and in a locked place, with ammunition locked separately. Handguns are especially dangerous. Ask if the homes where your child visits or is cared for have guns and how they are stored. • Poisonings Your child will be able to open any drawer and climb anywhere curiosity leads. Your child may swallow anything he or she finds. Use only household products and medicines that are absolutely necessary and keep them safely capped and out of sight and reach. Keep all products in their original containers. If your child does put something poisonous in his or her mouth, call the Poison Help Line immediately. Attach the Poison Help Line number (1-800-222-1222) to your phone. Do not make your child vomit. • Burns The kitchen can be a dangerous place for your child, especially when you are cooking. If your child is underfoot, hot liquids, grease, and hot foods can spill on him or her and cause serious burns. Find something safe for your child to do while you are cooking. Remember that kitchen appliances and other hot surfaces such as irons, ovens, wall heaters, and outdoor grills can burn your child long after you have finished using them. If your child does get burned, immediately put cold water on the burned area. Keep the burned area in cold water for a few minutes to cool it off. Then cover the burn loosely with a dry bandage or clean cloth. Call your doctor for all burns. To protect your child from tap water scalds, the hottest temperature a the faucet should be no more than 120°F.In many cases you can adjust your hot water heater. Make sure you have a working smoke alarm on every level of your home, especially in furnace and sleeping areas. Test the alarms every month. It is best to use smoke alarms with long-life batteries, but if you do not, change the batteries at least once a year.

  35. And Remember Car Safety Car crashes are the greatest danger to your child's life and health. The crushing forces to your child's brain and body in a collision or sudden stop, even at low speeds, can cause injuries or death. To prevent these injuries, correctly USE a car safety seat EVERY TIMEyour child is in the car. If your child weighs more than the highest weight allowed by the seat or if his or her ears come to the top of the car safety seat, use a belt positioning booster seat. The safest place for all children to ride is in the back seat. In an emergency, if a child must ride in the front seat, move the vehicle seat back as far as it can go, away from the air bag. Do not allow your child to play or ride a tricycle in the street. Your child should play in a fenced yard or playground. Driveways are also dangerous. Walk behind your car before you back out of your driveway to be sure your child is not behind your car. You may not see your child through the rear view mirror. Remember, the biggest threat to your child's life and health is an injury.

  36. VI. COMMON QUESTIONS • 1. My child is inventing imaginary friends and talking to them. Is this normal?

  37. VI. COMMON QUESTIONS • 1. My child is inventing imaginary friends and talking to them. Is this normal? • Yes, magical thinking accelerates during preschool years, which allows the child to role play, develop sexual identity, and growth emotionally. • Nightmares and fears of monsters are common. Calm reassurance that monsters and dreams are not real usually is adequate to treat these sleep disturbances

  38. 2. My child is “showing off” his or her genitalia and is curious about sex. Is this normal?

  39. 2. My child is “showing off” his or her genitalia and is curious about sex. Is this normal? • Yes, The preschool’s mind is ablaze with fantasy and this is a normal manifestation • Children should be told that others are not to touch them in their private areas

  40. 3. My child doesn’t understand limits to activities. Does he overstep these limits just to anger me? • Caregivers must agree and be united in decision making concerning their child. The rules must be consistently enforced. If expectations are made clear, the child will strive to achieve them • When reprimanding the child, it’s most important that parents criticize the deed, but never the child • The child is not trying to anger the parents, he’s testing the parent’s limits • Preschoolers are learning the boundaries of their new and challenging word

  41. 4. When my child misbehaves, should I punish him? • When dealing with preschoolers it is especially important not to delay the consequences of inappropriate behavior. • Punishment should be weighed carefully and with reason. A child should never be spanked or hit. • Instead, restrictions of privileges often create positive effects • Encouraging and rewarding positive behavior can provide a mechanism to communicate with love. *The action should be punished, not the child

  42. 5. My child occasionally wets the bed after he witnesses a fight between my husband and me. Is this normal? Should I punish him for these accidents? • Family counseling should be part of all plans for anticipatory guidance • Children should be never punished for accidents. Rather, children should learn to understand the consequences of bed wetting by assisting parents with the removal of soiled bedding • Children should be rewarded for dry nights

  43. VII. COMMON CONCERNS • Nutrition • The nutritional goal is the child’s satisfactory growth • From age 2 throughout adolescent only 2% of energy expenditure is directed toward growth (from ~40% during infancy) • Calorie requirements are 70-90 cal/kg/day, including 1.5 gr/kg/day of protein • Fluid requirements are 100 ml/kg/day for average activity • Children are more likely to eat foods they have helped to prepare • Important to encourage healthy foods *Common concern is that the children are not eating enough. If they are following a steady growth pattern and are eating a healthy diet, they’re doing OK

  44. Serving size ~ ½ of adult’s portion • Child should never be forced to eat • Mealtime should be in relaxant and pleasant atmosphere *Children will eat when they’re hungry. • 12 million Americans are vegetarians • Lacto-ova vegetarians consume eggs and dairy products • Vegans exclude all animal products • With proper AG, children can achieve good protein intake (soybeans, fortified soy milk, tofu, legumes, nuts, seeds and peanut butter) • Vit B12 supplementation • Calcium: dark leafy greens, tofu, and beans

  45. Sleep • Essential for child’s healthy growth and development • Amount of overall sleep and REM sleep decreases while quiet sleep increases • By age 4, daytime sleep is not longer needed, and the child should have a sleep routine • Nightmares and night terrors can be addressed by reassuring the child • New disturbances (frequent night awaking or bedtime difficulties) Look for cause (pinworms, hypothyroidism, colic, infections) • Discourage co-sleeping (X 2-3 more times of night awakening) *Explore cultural practices and economic situation before

  46. Television and internet • Often takes place of imaginative playing • The amount of TV time peaks during preschool years (21-30 hrs/week) • Prosocial TV and Moderate amount of TV viewing appropriate for age level can be positive impact (~ 80% of TV is developmentally inappropriate with ~ 5 acts of violence/hr)

  47. Violent TV increase aggression in children • > 5hrs TV/day is associated with obesity and hypercholesterolemia • Electronic media may serve as educational tools, but need to be supervised • Parents should set limits on television and electronic media • In general 2 hrs or less of responsible TV viewing is acceptable

  48. VIII. COMMON CONDITIONS • Febrile illness • Acute viral infections cause most febrile illness. • Unless extremely high (>41.1 or 106) fever doesn’t specifically harm the child • Hydration and antipyretics • Vomiting and diarrhea (together) • Usually self-limited AGE • Assure hydration *Increase ICP, intestinal obstruction and toxic ingestion should be suspected if sudden vomiting with no diarrhea

  49. Constipation • Cause most of the times is inadequate water intake, not enough high-residue foods, disruption of daily habits or painful anal fissures • URI’s • Usually viral • Symptomatic relief

  50. IX. PREP QUESTIONS

More Related