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WELL CHILD CARE

General Rules. Get a good FHx for congenital problemsPerinatal hx ie substance abuseExamine each part of the babyDevelop a routine or system. Developmental Dysplasia of the Hip (DDH, formerly CHD). 1 in 100 unstable hip, only 1 in 1000 true dislocation.Types: a) Typical

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WELL CHILD CARE

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    1. WELL CHILD CARE The Newborn Exam and General Pediatric Screening. By Dr Chi Jokonya

    2. General Rules Get a good FHx for congenital problems Perinatal hx ie substance abuse Examine each part of the baby Develop a routine or system

    3. Developmental Dysplasia of the Hip (DDH, formerly CHD) 1 in 100 unstable hip, only 1 in 1000 true dislocation. Types: a) Typical normal child b) Teratological syndrome or abnormal bone FHx (20%), firstborn, female (F:M 9:1), breech (40%) Associations: congenital muscular torticollis; metatarsus adductus

    4. DDH contd. Audible click means nothing. Dx: highest yield at 1 month newborn screeing maybe ineffective and perhaps harmful. Dynamic uss screen breech babies at 4wks X-rays: AP and frog Other: CT, MRI, arthrography

    5. Treatment DDH Double/triple diaper for 2-3wks: probably ineffective in true DDH Pavlik harness, Frejka splint, van Rosen splint 95% successful in dysplastic hips, 80% in DDH Surgery at 6-12mths; cast and traction 3% recurrence

    6. Fingers and Toes Extra digit: 2 in 1000 births, 30% FHx, usually 5th toe or finger: tie off EMLA or lidocaine anesthesia Syndactyly: x-ray to be certain bones present. Think of syndrome (toes Smith-Lemli-Opitz) Polydactyly: may need x-ray to preclude presence of bone in digit

    7. Funny Looking Kids FAS Downs/Edwards/Pataus trisomy syndromes Cornelia de Lange

    8. Umbilical Problems Single umbilical artery: 0.55% deliveries, 27% associated malformations. Umbilical hernia: 35% African American babies, 4% white babies, increased in LBW. Association: trisomy 18, 21 and hypothyroidism. Usually close spontaneously if not surgery at 3 to 5yrs

    9. Umbilical Problems contd Gastrochisis Omphalocoele Omphalitis Umbilical granuloma rx with AgNO3

    10. Birth Injuries Cephalohematoma Brachial nerve injury: -90% Erbs palsy C5,C6,C7 -1% Klumpkes palsy C8,T1 Facial nerve palsy 0.5%, forceps/syndrome Clavicular fracture may occur in utero

    11. Nose Disorders Hemangioma Choanal atresia Cleft lip/palate/nose Tilted, flattened or deviated -oligohydramnios: renal agenesis, Potters syndrome -think syndrome

    12. Eyes NB Check red reflex!! - retinoblastoma Cataracts: numerous causes. 50% missed at birth Glaucoma: 50% primary infantile glaucoma, remainder familial so get FHx

    13. Ears Low set many syndromes Abnormal pinna: -large flabby urogenital malformations -flat pressed against head Potters syndrome -pits Beckwith Weidemann (BWS) -tags (BWS)

    14. Screening in Pediatrics

    15. When Should PE Be Done Birth 1mo, 6mo, 1yr 1, 2, 5, 10 and 14yrs Both of above for screening purposes and neither conforms with recommendations of various primary care specialty groups.

    16. The Physical Exam A composite of screens, most effective when purpose is health maintenance. Yield of new abnormalities LOW Hx defines most abnormal findings NB need to be using BMI to identify obesity, chart and review growth curves.

    17. Genetic and Metabolic Screens Newborn: PKU, tyrosinemia, galactosemia, hypothyroidsim, SCD. Potential future screens: -CAH in boys, some states already doing -biotinidase deficiency (1 in 70 000) 9 states decided yes: cheap and easy to treat -cholesterol in late childhood and adolescence? Insufficient evidence

    18. Tuberculin Testing PPD preferred (most standardized) Low risk: screen at 12-15mths, before school and at 14-16yrs High risk: screen annually 15mm always +ve, 10-14mm +ve in high risk gps, 5-9mm doubtful unless immunosuppressed.

    19. Anemia Screen at 6 and 18mths Hct more reliable than Hb If positive MCV will distinguish IDA from thalassemia trait (smaller rbcs in TT)

    20. Lead Poisoning Screen all children at 1yr? All abnormal levels interview, educate, give questionnaire Levels 10-14mcg/dl repeat in 1yr; 15-20mcg/dl repeat in 3mths; 20-30mcg/dl consider EDTA; >30mcg/dl requires intervention www.ahrg.gov/clinic/uspstf/uspslead.htm

    21. Scoliosis Late childhood/early adolescent mild types rarely progress and almost never cause significant disability. Evidence show screening not cost effective and harm exceeds benefits. Routine screening NOT recommended www.ahrg.gov/clinic/uspstf/uspsaisc.htm

    22. Urinalysis Screening NOT recommended: -proteinuria FP common: fever, exercise -orthostatic proteinuria transient and harmless -bacteria: non treatment of asymptomatic bacteruria does NOT increase freq of pyelo or cause renal insufficiency. Rx may INCREASE freq of pyelo Screening NOT recommended but high index of suspicion in febrile illness

    23. Auditory Screening 1 in 2000 severely hearing impaired Healthy Newborns, screening safe insufficient evidence to recommend routine screening Older children: gross assessment at all CV. Test in kindergarten grades 1,3,5,7 Pure tone audimetry at 4yrs refer if fails to hear 2 frequencies at 25db (NB r/o OM)

    24. Visual Screening During each health maintenance visit, <5yrs look for strabismus, ambylopia and as soon as possible visual acuity (USPSTF 2004) Use fixation pattern in <3yrs. Cover one eye, encourage fixation. Child will not like having good eye covered. School checks generally suffice in older children

    25. Developmental Screening Must be in contesxt of H&P, vision and hearing screens. Know normal developmental stages. Major focus first year of life then preschool years. Newer instruments such as ASQ (The Ages and Stages Questionnaires) are easier to use and more accurate than the DDST (Denver Developmental Screening Test) Journal of FP May 2006 Vol:55; No.5 415-421

    26. Sickle Cell Conditions Screen at birth: HB electrophoresis Imperative to start penicillin prophylaxis once diagnosis is made CT until 10yrs 2-16yrs transcranial doppler screening: inc BF >/=1 major blood vessel inc reisk of stroke, 2 +ve screens institute chronic transfusion therapy to keep HbS <30%

    27. Gyn Screening Annual pap once sexually active Routine chlamydia screen all sexually active adolescent females. Testicular cancer: USPSTF recommends against routine screening, however, encourage regular self examination and examine at every visit.

    28. Short List Birth to 10yrs Ht, wt, BMI BP Vision (3-4yrs) Hemoglobinopathy at birth PKU, T4 and or TSH at birth

    29. Short List 11 to 24yrs Ht, wt and BMI BP Pap test Chlamydia screen (females >20yrs) Rubella serology or vaccination Assess for substance abuse

    30. Case Scenarios Cases Questions Discussion Children are not little adults Know age specific milestones Monitor growth charts/BMI !

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