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Exam # EXAM 25, 15, 16, 17, 8 Chapter 25-PEDIATRICS-PG 935-1082, TEXT Pediatric groups Neonates 0-30 days (Also 0- 28 days) Infants 1 month -1 year (also Post Neonates 29days to 1yr) Preschool children 1-5 years School aged 6- Adolescent 12- General Principles of Child Development Tips perform less invasive maneuvers early in the assessment and potential distressing maneuvers near the end. Childhood is a period of remarkable physical, cognitive and social growth by far the greatest in a person’s lifetime. Wgt increases 20x fold Language becomes sophisticated and reasoning Develop complex social interactions Progress toward mature adults. Development should be predictable Governed by maturing brain Measure age specific milestones (compare normal/abnormal) Milestone are achieved in predictable order Normal development range is wide Mature at different rates physical, social and environmental factors as well as diseases (dz.) effect development and health Adverse Childhood experiences (ACEs) impact development Whether abuse or chronic illness, ACEs can impact the rate of development. Children with Physical or cognitive disabilities may not follow the expected age-specific developmental trajectory. Developmental level affects how providers conduct history and physical exams. Ex. if a 15yo is developmentally 5yo then you speak to them as such. Surveillance of Development 5 critical domains of development. Physical (Gross & Fine motor) Gross motor skills-Large muscle groups-Walking, sitting, transferring objects. Fine motor Skills-Digits/hands muscles and eyes-Using hands to eat, draw or play. Parental concerns will prompt visits when children don't meet expected milestones. Cognitive-ability to problem solve through intuition, verbal and non verbal reasoning, retain information and recall.
Language-ability to articulation, receive and express language, non- verbal communication e.g. nodding and waving. Can be influenced by the environment and the way they string words together. Social Emotional-Ability to form and maintain relationships, their responsiveness to the presence of others, the formation of self-help skills of adults e.g., feeding, dressing, & toileting. The American Academy of Pediatrics (AAP) recommends standardized testing for developmental delays screening. Ages & stages Questionnaire (ASQ) Early Language Milestone Scale (ELM Scale-2) Modified Checklist for Autism in Toddlers (MCHAT) Parents Evaluation of Developmental Status (PEDS) Survey of Well Being of Young Children (SWYC) Use PERIODICALLY during routine health visits Cooperative Child fails on testing, requires further investigation Developmental Quotient Normal Measure of development expressed as number is development quotient. Developmental Quotient = Dev. Age/Chronological Age x 100 Example: 12 mo meeting milestones of 10mo 10/12*100=83 (Possible delay) Normal > Possible delay; requires follow-up 70-85; Delayed < SURVEILLANCE OF DEVELOPMENT PHYSICAL DEVELOPMENT (Newborns are born able to fixate on one person and track/follow-This is bc Neuro dev. Progresses centrally to peripherally. Newborn growth fastest development Birth wgt should 3x, height increase 50%
******************************* INSERT BIRTH TO 12 MONTH DEVELOPMENTAL MILESTONE BIRTH TO 12 MONTHS PG 944 Age Gross Motor Fine Motor Language Social- Emotional 1 month Lifts chin up in prone position turns head up When prone Hands fisted Makes throaty noises startles to sound Discriminat es parents voice follows face 4 months Sits with Hands Laughs out Social smile
EVERY INTERACTION WITH CHILD AND FAMILY IS AN OPPORTUNITY FOR
HEALTH PROMOTION.
Main tasks: detect clinical problems & promote health Parents/Caregivers are the major agents of health promotion for children and your advice is implemented through them AAP has recommended number of healthy visits for children base on age Children in high risk environments or chronically ill need more visits. Integrate Physical exam findings with health promotion eg. BMI with exercise & healthy eating guide Vaccines schedule. Age specific screening Anticipatory guidance at every pediatric visit. (INSERT BOX 25-3 Key Components of Pediatric Health Promotion PG941)
- Age-appropriate developmental achievements of the child
- Physical (maturation, growth, puberty)
- Motor (gross and fine motor skills)
- Cognitive (developmental milestones, language, school performance)
- Emotional (self-regulation, mood, self-efficacy, self- esteem, independence)
- Social (social competence, self-responsibility, integration with family and community, peer interactions) 2. Health Supervision visits 1. Periodic assessment of physical, developmental, socio-emotional, and oral health 2. More frequent visits for children with special **health care needs
- Integration of physical examination findings with health promotion
- immunization
- Screening procedures 6. Oral health
- Anticipatory Guidance**
- Healthy habits
- Nutrition and healthy eating
- **Safety and prevention of injury
- Partnership among health care provider, child/adolescent, and family**
- Physical activity
- Sexual development and sexuality
- Self-responsibility, efficacy, and healthy self-esteem
- Family relationships (interactions, strengths, supports)
- Positive parenting strategies
- Reading aloud with the child
- Emotional and mental health
- Oral health
- Recognition of illness
- Sleep
- Screen time
- Prevention of risky behaviors
- School and vocation
- Peer relationships
- Community interactions PHYSICAL EXAM-NEWBORN Examine infant in front of parents-This allows for education and health promotion (INSERT TIPS FOR EXAMINING NEWBORNS 25-6 PG 946)
- Examine the newborn in the presence of the parents.
- Swaddle and then undress the newborn as the examination proceeds.
- Dim the lights and rock the newborn to encourage the eyes to open.
- Observe feeding, if possible, particularly breastfeeding.
- Demonstrate calming maneuvers to parents (e.g., swaddling).
- Observe and teach parents about transitions as the newborn arouses.
- A typical sequence for the examination of the newborn:
- Careful observation before (and during) the examination
- Heart
- Lungs
- Head, neck, and clavicles
- Ears and mouth
- Hips Abdomen and genitourinary system
- Lower extremities, upper extremities, back
- Eyes, whenever they are spontaneously open or at end of examination
- Skin, as you go along
- Neurologic system
CHILDHOOD DEVELOPMENT
Proceeds along a predictable pathway The range of normal development is wide Age specific milestones that guide you as normal/abnormal Numerous factors (physical, psychosocial, environmental, disease) can affect childhood development and health The developmental level guides your history and exam LECTURE KEY POINTS: Childhood is a period of remarkable physical, cognitive, and social growth, by far the greatest in a person's lifetime. Within a few short years, children's weight will increase 20 fold, they will acquire sophisticated language and reasoning, develop complex social interactions, and progress towards mature adults. Child development should proceed along a predictable pathway governed by the maturing brain. You can measure age specific milestones and use them to characterize development as normal or abnormal. Because your health care visit and physical examination take place at one point in time, you need to determine where the child fits along a developmental trajectory (ie. Developmental Quotient) The range of normal typical developmental developments is wide. Children mature at different rates and each child's physical, cognitive, and social development should fall within a broad developmental range. Chronic illnesses, child abuse, and adverse childhood experiences can all cause detectable physical abnormalities or alter the rate and course of development. Additionally children with physical or cognitive disabilities may follow a different age specific developmental trajectory. NEONATES Comprehensive exam usually in office within 24 hours Gestational age risks Key history questions PE: trauma, symmetry, jaundice Behaviors: Prefer humans(look at faces, turn to voice) Ability to regulate state(calm themselves) Reflexes, spine, hips, fontanelles, and so on LECTURE KEY POINTS: The APGAR score is an assessment of the newborn immediately after birth. It is five components that classify the newborns' neurologic or recovery from the stress of birth and immediate cardiopulmonary adaptation to extrauterine life. Score each newborn at one and five minutes after birth. The first year of life, or infancy is divided into neonates. The 1st 28 days any post neonatal. 29 days to one year.
The newborn visit, which is generally performed not more than the first child for 24 hours after delivery, is a critical opportunity for the health care provider to engage with the family, learn about the newborn family and environment, understand key aspects of the pregnancy, bond with the family and observe the families interactions with the newborn. Key components to a health history for the newborn is on page 942(INSERT) in the 13th edition of Bates
- Questions and concerns by parents
- Questions about the newborn, home, prenatal course or delivery
- Concerns about newborn’s physical features
- Concerns and questions about newborn care
- Prenatal history, labor, and delivery
- Pregnancy history, complications, prenatal diagnosis Maternal and paternal physical and mental health Maternal use of tobacco, alcohol, drugs Labor and delivery experience or complications Prior pregnancies and siblings
- Neonatal course prior to the visit
- Health and well-being of mother, other family members
- Plans for breastfeeding or bottle feeding (or both)
- Neonatal history
- How it is going overall, specific issues of concern
- Cultural beliefs
- Family history
- Comprehensive history if time permits
- Social history
- Social determinants (living situation, concerns about food, housing, utilities, parental relationship, adults caring for the newborn, family support, family violence, concerns about finances)
- Alcohol, tobacco, drug use (even if not during pregnancy)
- Any social concerns by parents
- Siblings, other family members, babysitter
- Parents observation of their newborns behavior and activity
- What the newborn has been able to do so far
- Level of activity, attachment
- Feeding and nutrition
- Type of feeding, how feeding is going
- Details of feeding (breast or bottle)
- Sleeping, stooling, urination
- Frequency and color of stools and urine
- Sleeping duration, falling asleep
- safety Newborn examination is performed immediately after delivery by Obstetrics and pediatric clinicians. INFANTS By 1 yr, weight triples, height increases 50%
Barlow provocative maneuvers attempt to identify a dislocatable hip adduction of the flexed hip with gentle posterior force while Ortolani maneuvers attempt to relocate a dislocated hip by abduction of the flexed hip with gentle anterior force (Insert Video) +Bow legged- Bow-legs (genu varum) Normal until age 2, degree?, ortho referral after 2? If the bow is greater than? and knock-knees (genu valgum) are common. Severe bowing of the legs (genu varum) may still be physiologic bowing that will spontaneously resolve. Extreme bowing or unilateral bowing may be from pathologic causes such as rickets or tibia vara (Blount disease). During early infancy, there is a common and normal progression from bowleggedness (Fig. 25-87) that begins to disappear at about 18 months of age, often followed by transition toward knock-knees. +Neuro (reflexes) see below LECTURE KEY POINTS: Start with the infant lying or sitting in the parent's lap, if the infant is tired, hungry or ill ask the parent to hold the baby against their chest. Approach the infant gradually, commonly using a toy or object for distraction. Perform as much of the examination as possible with the infant in the parents lab. Speak softly to the infant or mimic the infant sounds to attract their attention. If the infant is cranky, make sure that they are well fed prior to proceeding. Ask the parent about the infant strength to list useful development and parenting information. Don't expect to do the examination in specific order. Close observation of an awakened infant in the parents lap. can reveal potential abnormalities of tone, conditions with abnormal skin color, jaundice or cyanosis, jitteriness or respiratory problems. Note the parents' manner of holding, moving, dressing and Comforting the infant. use developmentally appropriate methods such as distraction and play to examine the infant. Because infants pay attention to one thing at a time it is relatively easy to distract the infant from the examination as it is performed. Primitive reflexes evaluate the newborn and infants developing central nervous system by assessing these infantile automatisms called primitive reflexes. These developed during gestation, are generally demonstrated at birth, and disappear as defined ages. Abnormalities in these primitive reflexes suggest neurological disease and merit more intensive investigation. Main INFANT reflexes: Palmar grasp plantar grasp rooting reflex -indication of hunger, sucking head turned inward Moro reflex asymmetric tonic neck reflex trunk incurvation
Landau parachute positive support and placing stepping reflex primitive reflex chart is on page 990 ( see below) in the 13th edition Primitive Reflex Maneuver Ages Palmar Grasp reflex Place your fingers into the infant’s hands and press against the palmar surfaces. The infant will flex all fingers to grasp your fingers. Birth to 3-4 months Plantar Grasp Reflex Touch the sole at the base of the toes. The toes will curl. Birth to 6–8 months Rooting Reflex Stroke the perioral skin at the corners of the mouth. The mouth will open and the infant will turn the head toward the stimulated side and suck. Birth to 3-4 months Moro Reflex (Startle Reflex) Hold the infant supine , supporting the head, back, and legs. Abruptly lower the entire body about 1 foot. The arms will abduct and extend, hands will open, and legs will flex. The infant may cry. Birth to 4 months Asymmetric Tonic Neck Reflex With the infant supine , turn head to one side, holding jaw over shoulder. The arms/legs on the side Birth to 2-3 months
stepping will occur. PRESCHOOL & SCHOOL AGE: +Start as clumsy, become more muscular +Speech – 2yrs +Tantrums due to impulse control, poor self-regulation LECTURE KEY POINTS: Preschool and school age children Children are usually accompanied by the parent or caregiver, when interviewing a child you need to consider the needs and perspectives of both the child and the caregiver. Begin the interview by greeting and establishing a rapport with each person present. Referring to the child by the name rather than his or her period families come in many varieties; comedies include traditional families, single parents, separated and divorced parents, blended, same-sex parents, kinship families, foster families and adoptive families so clarify the role and relationship. The developmental milestones chart is listed on page 999 in the 13th edition of Bates. It includes the age, gross motor, fine motor, language and social emotional aspects. Age Gross Motor Fine Motor Language Social Emotional Aspects 12 months Stands independentl y Starts taking first steps Scribbles, hold crayon, makes tower with 2 cubes Says one word with meaning points to get objects follows one step commands with gestures Shows objects to parent to share 15 month Stops to pick up toys, climbs on furniture, runs stiff legged Uses spoon with some spilling, places 10 cubes in cup, turns pages in book Uses 3- words mature jargon speech points to one body part Shows empathy, give hugs on request 18 months Creeps down Makes 4 Uses 10-25 Engages in
stairs, run well cube tower, imitates vertical stroke words points to three body parts, points to self, familiar people pretend play 24 months Walks down stairs holding rail, with both feet on one step kicks ball Imitates horizontal line opens door knob sucks through straw Uses 2 word sentence, uses 50+ words, has 50% intelligibility, refers to self by name Parallel play 30 months Walk up stairs holding on, alternating feet jumps in place Makes tower with 8 cubes can wash hands brush teeth with help Refers to self with correct pronoun understand action words (sleeping eating playing) understand prepositions Imitates adult actions (cooking, taking on phone, cleaning) 3 years Goes up stairs without holding on alternating feet pedals tricycle Copies circle string small beads draws a 2- part person Uses 3 words sentences has 75% intelligibility understand negative know own gender Starts to share imaginative play fears imaginary things 4 years Balances on one foot for 8 seconds, throws ball overhand ,ca tches bounce ball Copies square goes to the toilet alone draws a 4-6 part person Speaks with 100% intelligibility follows three step commands understand adjectives Has a preferred friend labels feelings group play
on short-term consequences Achievement of knowledge and skills, self-efficacy skills and school performance. Social Achieving good “fit” with family, friends, school Sustained self esteem Evolving self identify Assessment, support, advice about interact including peer relationships Support, emphasis on strengths Understanding, advice, support LECTURE KEY POINTS: Middle childhood is an active period of growth and development. Goal directed exploration increased physical and cognitive abilities and achievements by trial and error marked the stage. Children grow steadily but more slowly. Strength and coordination improve dramatically and with more participation in activities. This is also when children with physical disabilities or chronic illnesses become more aware of their limitations. Children become concrete operational, capable of limited logic and more complex learning. Children become more progressively independent, initiating activities and enjoying accomplishments. The physical exam includes examining children whose parents are usually watching and taking part in the interaction, providing you the opportunity to observe the parent child interaction. Your job is to note whether the child displays age appropriate behaviors. You will be assessing the goodness of fit between the parent and child. Normal toddlers are occasionally alarmed by the examiner. Some will be uncooperative but most will eventually warm up with you. If the behavior continues or is not developmentally appropriate, there may be an underlying behavioral or developmental abnormality. Older school age children have more self control and prior experience with clinicians and are generally cooperative with the examination. For your exam, gain the child's confidence and allay the child's fears from the start of the encounter. Your approach will vary with the circumstance of the visit. The child should remain dressed for the duration of the interview, to minimize the child's apprehension. It also allows you to interact more naturally with observing the child playing, interacting with the parents, and undressing and dressing. Toddlers who are 9 to 15 months old may have stranger anxiety, fear of strangers that is developmentally normal.
Engage children and age appropriate conversation. Plan the examination to start with the least distressing procedures and end with the most distressing ones, usually involving the throat and ears. Begin with parts that can be done with the child sitting such as examining the eyes or palpating the neck Tips to examining young children (page 1003)
- Useful Strategies for Examination
- Have the parent help you facilitate the examination (e.g., removing clothing, holding child on lap). Try to be at the child’s eye level.
- Use a reassuring voice throughout the examination.
- Let the child see and touch the examination tools you will be using.
- First examine the child’s toy or teddy bear, or even the parent, then the child. Let the child do some of the examination (e.g., move the stethoscope). Then go back and “get the places we missed”
- Ask the toddler who keeps pushing you away to “hold your hand.” Then have the toddler “help you” with the examination.
- Avoid asking permission to examine a body part because you will do the examination anyway. Instead, ask the child which ear or which part of the body he or she would like you to examine first.
- Make a game out of the examination! For example, “Let’s see how big your tongue is!” or “Is Elmo in your ear? Let’s see!”
- Some toddlers believe that if they can’t see you, then you aren’t there. Perform the examination while the child stands on the parent’s lap, facing the parent.
- Hand the child an age-appropriate book and engage the child in reading.
- If 2-year-olds are holding something in each hand (such as tongue depressors), it is more difficult for them to fight or resist.
- If unable to console the child, give the child a short break.
- Useful Toys and Aids
- “Blow out” the otoscope light. “Beep” the stethoscope on your nose. Make tongue-depressor puppets. Use the child’s own toys for play. Jingle your keys to test for hearing.
- Shine the otoscope through the tip of your finger (or the child’s finger) to show it doesn’t hurt, “lighting it up,” and then examine the child’s ears with it. Use age-appropriate toys and books. Use a fun toy attached to the stethoscope to make it less scary. Note: Make sure to clean toys and your stethoscope in between patients. BP Pediatrics Pg. 1007 For Children Age 1 to <13 years For Children Age
/=13 years Normal BP <90th percentile <120/<80 mm Hg Elevated BP ≥90th percentile to 120/<80 to 129/<
an attempt to get adolescents to talk is usually not a good idea. Once you have established rapport, return to more open-ended questions. Adolescent behavior is related to th eir developmental stage and not necessarily to chronological age or physical maturation. Their appearance may fool you into assuming that they are functioning on a more future oriented and realistic level. Make confidentiality unlimited. Always state explicitly that you will need to act on any information that makes you concerned about the patient's safety. For example “I will not tell your parents what we talk about unless you give me permission, or I am concerned about your safety. For example if you were to talk to me about hurting yourself or someone else and I thought you really were at risk to follow through, I would need to discuss this with your parents in order to help you.” Encourage adolescents to discuss sensitive issues with their parents and offer to be present or help. HEEADSSS Assessment : H ome environment, e ducation and employment, e ating, a ctivities, d rugs and alcohol, s exuality, s uicide depression and s elf harm, and s afety. Physical exams approach the sequence in context of the physical examination of the adolescent are similar to those in the adult. Keep in mind however issues unique to adolescence such as puberty, growth, development, family and peer relationships, sexuality, health decision making and high risk behaviors. Modesty is an important period patients should remain dressed until the examination begins. ADOLESCENCE PHYSICAL EXAM. FIRST ADDRESS THE FOLLOWING: +Confidential unless at risk of danger +Encourage them to bring concerns to parents
+Health considerations +Anticipatory guidance: Risky behaviors Safety Sensitive subjects THEN>>>>> IAPP •VS
