Well-Child Care case file

Well-Child Care case file

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 5

A 6-month-old male infant is brought to your office by his mother for a routine well-child visit. His mother is concerned that he is not yet saying "mama;' because her best friend's baby said "mama" by age 6 months. Your patient was born via an uncomplicated pregnancy to a 23-year-old GlPl mother. He was delivered by a spontaneous vaginal delivery at full term and there were no complications in the neonatal period. You have been following him since his birth. He has had appropriate growth and development up to this age and is up-to-date on his routine immunizations. He had one upper respiratory infection at age 5 months that was treated symptomatically. There is no family history of any developmental, hearing, or speech disorders. He has been fed since birth with an iron-fortified infant formula. Cereals and other baby foods were added starting at age 4 months. He lives with both parents, neither of whom smokes cigarettes.

On examination, he is a vigorous infant who is at the 50th percentile for length and weight and 75th percentile for head circumference. His physical examination is normal. On developmental examination, he is seen to sit for a short period of time without support, reach out with one hand for your examining light, pick up a Cheerio with a raking grasp and put it in his mouth, and he is noted to babble frequently.

⯈ What immunizations would be recommended at this visit?

⯈ By what age should an infant say "mama" and "dada"?

⯈ The child's mother asks when she can place him in front-facing car seat. What is your recommendation?

ANSWER TO CASE 5:

Well-Child Care

Summary: A 6-month-old healthy infant is brought in for a routine well-child examination.

• Recommended immunizations for a 6-month well-child visit {in a child who is up-to-date on routine immunizations): Diphtheria, tetanus, and acellular pertussis (DTaP) no. 3, hepatitis B no. 3, Haemophilus influenzae type b (Hib) no. 3, pneumococcal conjugate vaccine (PCV 13) no. 3, and rotavirus no. 3; inactivated polio vaccine (IPV) no. 3 can be given between 6 and 18 months. If the encounter is during "flu season;' annual influenza vaccination is recommended beginning at 6 months.
• Age by which a child should say "mama'' and "dada'': Most children will start to say "dada" or "mama" nonspecifically between 6 and 9 months. It usually becomes specific between 8 and 15 months.
• Recommendations for continuing in a rear-facing car seat: A child should stay in a rear-facing car seat until the age of 2 or until the child reaches the maximum height and weight limit for the car seat.

ANALYSIS

Objectives

1. Learn the basic components of a well-child examination.
2. Know the routine immunization schedule for children.
3. Know common developmental milestones for young children.

Considerations

The pediatric well-child examination serves many valuable purposes. It provides an opportunity for parents, especially first-time parents, to ask questions about, and for the physician to address specific concerns regarding, their child. It allows the physician to assess the child's growth and development in a systematic fashion and to perform an appropriate physical examination. It also allows for a review of both acute and chronic medical conditions. When performed at recommended time intervals, it gives the opportunity to provide age-appropriate immunizations, screening tests, and anticipatory guidance. Finally, it supports the development of a good doctor-patient-family relationship, which can promote health and serve as an effective tool in the management of illness.

Approach To:

Well-Child Examination

DEFINITIONS

AMBLYOPIA: Monocular childhood vision reduction caused by abnormal vision development. Strabismus is the most common cause of amblyopia.

STRABISMUS: Ocular misalignment.

CLINICAL APPROACH

Pediatric History

For the purposes of routine well-child visits, a comprehensive history should be obtained at the initial visit with more focused, interval histories obtained at subsequent encounters. The initial history should include an opportunity for the parent to raise any questions or concerns that the parent may have. New parents, especially first-time parents and young parents, often have many questions or anxieties about their child. The ability to discuss them with the physician will help to engender a positive physician-patient-family relationship and improve the parent's satisfaction with their child's care.

A complete past medical history should be obtained. This should start with a detailed prenatal and pregnancy history, including the duration of the pregnancy, any complications of pregnancy, any medications taken, the type of delivery performed, the child's birth weight, and any neonatal problems. Any significant chronic or acute illnesses should be recorded. The use of any medications, both prescription and over-the-counter, should be reviewed.

A detailed family history, including information (when available) on both maternal and paternal relatives should be obtained. A thorough social history is critical in pediatric care. Information, including the parents' education levels, relationships, religious beliefs, use of substances (tobacco, alcohol, drugs), and socioeconomic factors, can provide significant insight into the health and development of the child.

Efforts should be made to obtain old medical records, if any are available. Growth charts, immunization records, results of screening tests, and other valuable information that can assist with the child's assessment can often be found and reduce the unnecessary duplication of previously performed interventions.

Growth

At each well-child visit, the child's height and weight should be recorded and plotted on a standard growth chart. Head circumference is measured and plotted in children of 3 years and younger. Children older than 3 years should have their blood pressure recorded using an appropriate-size pediatric cuff. Significant variances from accepted, age-adjusted, population norms, or growth that deviates from predicted growth curves, may warrant further evaluation. The CDC and the American Academy of Pediatrics (AAP) recommend measuring body mass index (BMI) to screen for overweight and obesity in children of 2 years and older. The measurement ofBMI in children is calculated the same way as it is for adults, but it is compared to typical values for other children of the same age. Weight classifications based on BMI in children are as follows:

Failure to thrive is defined by some as weight below the third or fifth percentile for age, and by others as decelerations of growth that have crossed two major growth percentiles in a short period of time. Either significant loss or gain of weight may prompt an in-depth discussion of nutrition and caloric intake.

Development

An assessment of the child's development in the areas of gross motor, fine motor/ adaptive, language, and social/personal skills is an important aspect of each well child visit. Numerous screening tools, such as the Denver II developmental screening test, the Parents' Evaluations of Developmental Status (PEDS), and others, are available to assist with these assessments. These assessments typically involve both responses from the parents regarding the child's behavior at home and observations of the child in the office setting. Persistent delays in development, either globally or in individual skill areas, should prompt a more in-depth developmental assessment, as early intervention may effectively aid in the management of some developmental abnormalities. Children who are raised in a bilingual environment may have some language and development delay. Proficiency in both languages is often reached by age 5. The threshold for referral to a specialist should be the same for bilingual children as monolingual children. Table 5-1 summarizes many of the important motor, language, and social developmental milestones of early childhood.

Screening Tests

There are a variety of screening tests used to prevent disease and promote proper developmental and physical growth. These include tests for congenital diseases, lead screening, evaluating children for anemia, and hearing and vision screens.

Each state requires screening of all newborns for specified congenital diseases; however, the specific diseases for which screening is done vary from state to state. All states require testing for phenylketonuria (PKU) and congenital hypothyroidism, as early treatment can prevent the development of profound mental retardation. Diseases for which testing commonly occurs include hemoglobinopathies (including sickle cell disease), galactosemia, and other inborn errors of metabolism. This screening is done by collecting blood from newborns prior to discharge from the hospital. In some states, newborn screening is repeated at the first routine well visit, usually at about 2 weeks of age.

Modified, with permission, from Hay WW, Hayword AR, Levin Ml, Sondheimer JM. Current Pediatric Diagnosis and Treatment.

17th ed. New York, NY: McGraw-Hill; 2005.

Nationwide, the prevalence of childhood lead poisoning has declined, primarily because of the use of unleaded gasoline and lead-free paints. However, in some communities, the risk of lead exposure is higher. T he Advisory Committee on Childhood Lead Poisoning Prevention recommends that all children not previously enrolled in Medicaid be screened for elevated blood levels between 12 and 24 months or at 36 and 72 months. All children at risk of lead exposure should be screened at 1 year. All children born outside of the United States should have a blood level measured on arrival to the United States. In other communities, screening should be targeted to high-risk children (Table 5-2).

Iron deficiency is the most common cause of anemia in children. Iron-containing formula and cereals have helped to reduce the occurrence of iron deficiency. Children who drink more than 24 oz of cow's milk, have iron-restricted diets, were low birth weight or preterm, or whose mother was iron deficient are at higher risk. In 2010, the AAP recommended universal screening for anemia in all children at 1 year. Additional laboratory screening for iron deficiency is recommended at later ages in those children at high risk for iron deficiency anemia. T he American Academy of Family Physicians (AAFP) and the United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening asymptomatic children for anemia. An anemic child can empirically be given a trial of an iron supplement and dietary modification. Failure to respond to iron therapy should warrant further evaluation of other causes of anemia.

Reproduced, with permission, from Stead LG, Stead SM, Kaufman MS. First Aid for the Pediatrics Clerkship. New York,

NY: McGraw-Hill Education; 2004:39-40.

Most states now mandate newborn hearing screening by auditory brainstem response or evoked otoacoustic emission. All high-risk infants, regardless of requirement, should be screened. High-risk infants include those with a family history of childhood hearing loss, craniofacial abnormalities, syndromes associated with hearing loss (such as neurofibromatosis), or infections associated with hearing loss (such as bacterial meningitis). Older infants and toddlers can be assessed for hearing problems by questioning the parents or performing office testing by snapping fingers, or by using rattles or other noisemakers. Office-based audiometry should be performed in children aged 4 and older. Any hearing loss should be promptly evaluated and referred for early intervention, if necessary.

Vision screening can also start in the newborn nursery. Evaluation of the neonate for red reflexes on ophthalmoscopy should be a standard part of the newborn examination. The presence of red reflexes helps to rule out the possibility of congenital cataracts and retinoblastoma. The evaluation of an older infant should include a subjective evaluation of the child's vision by the parent. Infants should be able to focus on a face by 1 month and should move their eyes consistently and symmetrically by 6 months. An examining light should reflect symmetrically off of both corneas; asymmetric light reflex may be a sign of strabismus. The cover-uncover test also is a screening examination for strabismus. The child focuses on an object with both eyes and the examiner covers one eye. Strabismus is suggested when the uncovered eye deviates to focus on the object. Strabismus should be referred to a pediatric ophthalmologist as soon as it is detected, as early intervention results in a lower incidence of amblyopia. After the age of 3, most children can be tested for visual acuity using a Snellen chart, modified with a "tumbling E" or pictures, instead of letters.

Other screening tests may be recommended for high-risk children. Tuberculosis (TB) screening is recommended for children who were born or live in a region of high TB prevalence or who have close contact with someone known to have TB.

Data from Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122(1):198-202.

The Mantoux test (an intradermal injection of PPD tuberculin) is the screening test of choice. In accordance with the National Heart, Lung and Blood Institute (NHLBI), the American Heart Association (AHA), and AAP recommend universal screening of high cholesterol for all children at least one time between the ages of 9 and 11 and again between 17 and 21. Screening for hyperlipidemia should begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors (Table 5-3 ).

With early childhood caries being one of the most prevalent chronic conditions during childhood, it is important to discuss good oral hygiene and the establishment of a dental home during well-child visits. At the 4-month visit, sources of systemic fluoride should be assessed. One of the most effective tools to prevent teeth decay is systemic fluoride. If there are concerns with the amount of fluoride in drinking water supplies, especially well water, appropriate testing should be performed. At 6 months, infants should begin to receive appropriate topical (fluoride toothpaste) and systemic fluoride. By the 12-month visit, each appointment should include a complete dental screening during the physical examination and reassurance that the child has a regular source of dental care. The American Academy of Pediatric Dentistry recommends that all children see a dentist by 12 months.

Anticipatory Guidance

A primary feature of the well-child visit should be education of the patient and family on issues that promote health and prevent illness, injury, or death. This anticipatory guidance should be focused and age appropriate. The use of preprinted handouts can reinforce issues discussed in the office, address issues that could not be discussed because of time limitations, and allow for the parent to review the information as needed at home. Subjects that should routinely be addressed include injury prevention, nutrition, development, discipline, exercise, mental health issues, and the need for ongoing care (eg, immunization schedules, future well-child visits, dental care). During the well-child examination, it is important to evaluate how much time is spent watching television, using the computer, and playing video games. Screen time should be limited to 1 to 2 hours or less daily. The number and quality of sleep should be asked at each visit. Abnormalities in sleep should be further investigated and managed appropriately.

Accidents and injuries are the leading cause of death in children older than 1 year. Accidents involving motor vehicles, both traffic and pedestrian accidents, are the leading cause of these accidental deaths. All states now require the use of car safety seats for children, although the regulations vary from state to state. The general recommendation is that a child should be in the back seat of the vehicle whenever possible. If there is no back seat, the child should only ride in the front seat if there is no air bag or if the air bag can be disabled. A child should sit in a rear-facing car seat until the child is 2 years old or has reached the maximum height or weight limit of the rear-facing seat. When the child weighs more than 40 lb, the child may use a booster-type seat along with the lap and shoulder seatbelts. The child can stop using the booster when he or she can sit with his or her back squarely against the back of the seat with the legs bent at the knees over the front of the seat. The child usually will need to be at least 4 ft 9 in in height and 8 to 12 years of age to meet these requirements. No child should ride in the front seat unless they are 13 years or older and meet height and weight requirements.

According to the CDC, the top three causes of death in infants younger than 1 year are congenital abnormalities, short gestation, and sudden infant death syndrome (SIDS). The Back-to-Sleep campaign advises parents to place their infant on the infant's back-not abdomen or side-when the infant is put down to sleep, as this reduces the risk of dying of SIDS. In addition, the infant should be placed on a firm mattress with nothing else in the crib-this includes pillows, positioning devices, and toys. Heavy coverings and soft mattresses have been associated with an increased risk of SIDS.

As children get older, anticipatory guidance on other safety issues become important. As children learn to crawl and walk, stairwells should be blocked to reduce the risk of injuries from falling. Cleaning supplies, medications, and other potential poisons need to be stored safely out of reach of children, preferably in locked cabinets. Similarly, firearms should be stored safely, preferably unloaded and in locked cabinets or safes. Parents should be counseled on keeping matches and lighters in a safe place out of the reach of children. Older children should be advised regarding the importance of wearing a helmet while riding a bicycle, skateboard, scooter, or other similar vehicle. The National Highway Traffic Safety Administration recommends that in addition to helmets, bicyclists should wear clothing that is right and reflective, ride with the flow of traffic and obey all traffic laws. All families should be advised to have smoke detectors throughout the home, especially in rooms where people sleep, and to keep the hot water heater set at or below 120°F to reduce the risk of scald injuries. The AAFP recommends that all caregivers be trained in cardiopulmonary resuscitation. When a pool or hot tub is accessible to children, a nearby telephone with emergency contacts should be at poolside. All children under the age of 4 should have supervision within arm's length at all times.

Nutrition is another important area of anticipatory guidance. Infants younger than 1 year should be breast-fed or receive an iron-containing formula. Cereals, other baby foods, and water can be introduced between 4 and 6 months. Whole cow's milk is introduced at 12 months and continued until at least the age of 2, before considering changing to reduced fat milk.

Figure 1. Recommended Immunization schedule for persons aged 0 through 18 years - United States, 2015.

(FOR THOSE WHO FALL BEHIND OR START LATE. SEE THE CATCH-UP SCHEDULE [FIGURE 21).

These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opport

To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are shaded.

This schedule Includes recommendations In effect as of January 1, 2015. Any dose not administered at the recommended age should be administered at a

feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers shou

on Immunization Practices (ACIP) statement for detailed recommendations, available onllne at http://www.cdc.gov/vacclnes/hcp/aclp-recs/lndex.html. a1

vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) on line (http://www.vaers.hhs.gov) or by telephone (B00-822-7967

diseases should be reported to the state or local health department Addltlonal Information, Including precautions and contraindications for vaccination, I

(http-J/www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [B00-232-4636]).

This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics

Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).

Figure 5-1. Recommended immunization schedule for persons aged 0 through 18-United States

Immunizations

Ensuring that each child has received the child's age-appropriate immunizations is a key component of each well-child visit. The child's immunization status also should be reviewed at acute care visits. Minor illnesses, even those causing lowgrade fevers, are not contraindications to vaccinating children, allowing an acute care visit to be an excellent opportunity to provide this service. True contraindications to providing a vaccination include a history of an anaphylactic reaction to a specific vaccine or vaccine component or a severe illness, with or without a fever. The recommended childhood vaccination schedule (Figure 5-1) and catch-up schedules for children who are either completely unimmunized or who have missed doses of the recommended vaccines are published by the CDC.

COMPREHENSION QUESTIONS

5.1 A 7-month-old male infant is brought into the office for a possible ear infection. In assessing the infant's posture, you note that he is not able to sit very well without support. You also observe other fine motor skills and speech. Which of the following is the most accurate statement?

A. By 3 months, a child should be able to sit up without support.

B. By 6 months, a child should be able to transfer objects from one hand to another.

C. By 9 months, a child should be able to walk.

D. By 1 2 months, a child should be able to put two words together.

5.2 A 5-year-old child presents to your clinic for a school physical. The child weighs 42 lb and is up-to-date on his immunizations. Which of the following anticipatory guidances is most appropriate for a child at this age?

A. He should ride in a rear-facing car seat in the back seat of the vehicle.

B. He should ride in a forward-facing car seat in the back seat of the vehicle.

C. He should ride in a forward-facing car seat in the front seat of the vehicle.

D. He should ride in a booster seat in the back seat of the vehicle.

5.3 A 4-month-old infant is brought into the family physician's office for routine checkup and immunizations. Which of the following vaccines is routinely recommended at this time?

A. Diphtheria, tetanus, and acellular pertussis (DTaP)

B. Oral polio vaccine (OPV)

C. Measles, mumps, rubella (MMR)

D. Varicella

5.4 A 5-year-old child is brought into the pediatrician's office for immunization and physical examination. The mother is concerned that her child is a little "under the weather': Which of the following is a contraindication to vaccinating the child?

A. Acute otitis media with a temperature of 100°F requiring antibiotic therapy

B. Previous vaccination reaction that consisted of fever and fussiness that lasted for 2 days

C. History of an allergic reaction to penicillin

D. Previous vaccination reaction that consisted of wheezing and hypotension

ANSWERS

5.1 B. It is critical to understand the normal milestones for gross motor, fine motor, speech, and social categories. Delay in one or more areas can indicate problems which if addressed can alleviate long-term issues. Most 6-month-old infants would be expected to sit without support. They would also be expected to transfer objects from one hand to the other, roll from a prone to supine position, babble, and recognize strangers.

5.2 D. A child who is older than 2 years may sit in a forward-facing car seat in the back seat of the car. A child who weighs more than 40 lb is usually big enough to use a booster seat, also in the back seat of the car.

5.3 A. DTaP is routinely recommended at 2, 4, 6, 12 to 18 months, and 4 to 6 years. Oral polio vaccination is no longer routinely recommended in children; the inactivated, injectable polio vaccine is recommended in its place and is recommended at 2, 4, 6 to 18 months, and 4 to 6 years. MMR and varicella vaccination are recommended at 12 to 15 months and 4 to 6 years.

5.4 D. A previous anaphylactic reaction is a true contraindication to vaccination. Minor illnesses or vaccination reactions, even with fever, are not contraindications. Penicillin is not a component of vaccines and history of allergy to this medication is not a contraindication.

CLINICAL PEARLS

⯈ True contraindications to providing vaccinations are rare; acute care visits are an excellent opportunity to provide childhood vaccinations .

⯈ SIDS is the leading cause of death in infants younger than 1 year. Parents should place their children on their"Back-to-Sleep':

REFERENCES

Bright Futures/ American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care, 2014. Available at: https://www.aap.org/en-us/professional-resources/practice-support/ Periodicity/Periodicity%20Schedule_FINAL.pdf. Accessed May 24, 2015. 

Centers for Disease Control and Prevention. Vaccines and Immunizations. Available at: http:/ /www. cdc.gov/vaccines/. Accessed May 24, 2015. 

Douglass JM, Douglass AB, Silk HJ. A practical guide to infant oral health. Am Fam Physician. 2004 Dec 1;70(11):2113-2120. 

Durbin DR for the AAP Committee on Injury, Violence and Poison Prevention. American Academy of Pediatrics Policy Statement: Child passenger safety. Pediatrics. 2011 April 1;127( 4):788-793. 

Warniment C, Tsang K, Galazka SS. Lead poisoning in children. Am Fam Physician. 2010 Mar 15;81(6):751-757.

HomeFamily Medicine Case FileWell-Child Care case file