Beneficial Things About Well-Child Care
Form relationship with parents & child
Vaccinations
Pick up odd things in a child
Approach to a Well Child Visit
Laid-back Attitude Speak directly to child Complement the child in some way Smile Be non-threatening
What Should be Assessed in a Well-Child Visit?
Growth measurements Interval History PE abnormalities Developmental assessment Anticipatory Guidance Immunizations Answer questions
What types of measurements should we measure?
Height
Weight
Head circumfrence
Interval History Questions
How you feeling? Baby/child doing? How things going since last visit? Appropriate follow-up questions Devote entire time to situation
Areas to be Assessed for a Developmental Assessment
Gross motor Fine motor Language Personal-social Vision Hearing
Developmental Delays
Motor delays- 1st year
Language delays- toddler-preschool years
Learning disabilities- school years
Reasons for a Motor Delay
Neuromuscular
Genetic/Metabolic
Infectious
Reasons for Language Delay
Hearing loss
Mental retardation
Importance of Early Detection of Developmental Programs
Live independently
Graduate from HS
Contribute to society
Save society $30,000-$100,000 per child
Types of Standardized Instruments for Developmental Assessment
Denver II
Ages & Stages Questionnaire (ASQ)
Brigance Screening
Parents’ Evaluation of Developmental Status (PEDS)
Denver II Developmental Assessment Scale
Children 0-6 years
Four areas included: gross motor, fine motor, personal-social, and language
Denver II Advanced
Child passes item that falls completely to the right of the age line
Denver II Normal
Child passes, fails, or refuses item on which the age line falls between the 25th and 75th percentile
Denver II Caution
Child fails or refuses item on which the age line falls between the 75th and 90th percentile
Denver II Delayed
Child fails or refuses item that falls completely to the left of the age line
Denver II Pass
No delays and a maximum of one caution
Denver II Failure
Two or more delays noted
Denver II Re-evaluate in 3 months
1 Delay and/or 2 or more cautions
Denver II Untestable
Significant number of refusal or no opportunity test items
Denver II Criticisms
Takes time
Norms established not representative of whole population
Some items difficult to test
Requires a number of items to administer test thoroughly
High over-referral rate
Ages & Stages Questionaire (ASQ)
Info from parents Developmental problems 10-15 minutes to complete 4 months-5 years Separate form for each visit Available in English, Spanish, Korean, & French Standardized scoring Photocopied
Brigance Screening
Observation & elicitation of skills
Newborn- 8 years
Based on age
10-15 minutes
Parents’ Evaluation of Developmental Status (PEDS)
Info from parents Newborn- 8 years 10 questions English, Spanish, & Vietnamese 2 minutes Standardized scoring
What is one advantage of the ASQ?
Gets parents involved in child’s care
More aware of child’s abilities/limitations
Saves time
High Impact Anticipatory Guidance
No smoking
Reading to the child
Newborn Anticipatory Guidance
Review feeding method Sleep position & environment Care of skin, cord, circumcision Breast engorgement, vaginal discharge Jaundice Injury Prevention When/why to call Dr. Individuality of infant
Newborn Injury Prevention
Microwave safety (bottles) Car seat safety Crib safety Siblings Pets Smoke detectors Hot water heater temp setting (120) UV protection Smoke free home
Two-week Anticipatory Guidance
Answer questions about breast or formula feeding
Sleep patterns
Social Interaction with family
Injury prevention
Two-week Injury Prevention
Car seat safety Smoke detectors Hot water temp "Back to sleep" Violence prevention Education about colic Educate on shaken baby syndrome UV protection Smoke free home
Why shouldn’t we give a little child honey?
Clostridium botulinum
Two-month Anticipatory Guidance
Nutrition (Vit. D, iron, fluoride, defer solids and honey) Sleeping issues Pay with, talk to, cuddle infant Read to child Educate about sibling time Signs of maternal depression Injury Prevention
Two-month Injury Prevention
Smoke free home
Gun safety
Four-month Anticipatory Guidance
6 URI’s/year
Elimination
Nutrition (solids, avoid honey)
Injury Prevention
Four-month Injury Prevention
Smoke free home
Safe toys
Heating food in microwaves
UV protection
Six-month Anticipatory Guidance
Nutrition (cup sips, solids) Discuss sleep patterns "Stranger danger" Reading to infant Injury Prevention
Six-month Injury Prevention
No smoking Childproof home Poison control telephone number NO infant walkers Never leave infant alone in bathtub
Nine-month Anticipatory Guidance
Nutrition (mealtimes, soft foods, cups, no milk)
Sleep patterns (regular bedtime routine)
Interaction with child
Injury prevention
Nine-month Injury Prevention
No smoking Childproof home Avoid foods to be aspirated Poison control number No infant walkers Car seat safety Heating food in microwave Never leave infant in bathtub
12-month Anticipatory Guidance
Nutrition
Behavioral Development
Injury Prevention
12-month Nutrition
Appetite may be decreased
Wean to cup
Baby food to table foods
Limiting cow’s milk
12-month Behavioral Development
Seek increased autonomy
Interact with child
12-month Injury Prevention
No smoking Window & stair safety Childproof home Never leave child alone in bathtub Appropriate car seat Hot stoves, heaters, irons UV protection
15-month Anticipatory Guidance
Nutrition
Don’t expect potty training
Behavioral
Injury Prevention
15-month Nutrition
Regular meals
Sits still to eat
15-month Behavioral
Drive for autonomy More "yes" than "no" messages State "no" clearly Lots of distraction Participate in games Temper tantrum management Limit TV
15-month Injury Prevention
No smoking Appropriate car seat Door, window, stairwell safety Hot stoves, pots, pans, heaters, irons Water safety UV protection
18-month Anticipatory Guidance
Nutrition
Toilet training techniques
Behavioral
Injury Prevention
18-month Nutrition
Balanced diet
Encourage cup
Discourage bottle
18-month Behavioral
Parallel play, not interactive
Self-conforting behaviors
Time-out
Allow decision making
18-month Injury Prevention
Durable toys No smoking Appropriate car seat Door, window, stairwell safety Hot stoves, pots, pans, heaters, irons Water safety UV protection
2-year Anticipatory Guidance
Nutrition
Note signs of toilet training readiness
Behavioral
Injury Prevention
2-year Nutrition
Discontinue bottle-feeding
Balanced diet
2-year Behavioral
Choices between acceptable alternatives
Read to child
Limit TV
Positive outcomes for desired behaviors
2-year Injury Prevention
Durable toys No smoking Appropriate car seat Door, window, stairwell safety Hot stoves, pots, pans, heaters, irons Water safety UV protection Gun safety
3-year Anticipatory Guidance
Nutrition Support toilet training May discontinue naps Interact appropriately with child Injury Prevention
3-year Nutrition
Encourage self-feeding (utensils)
Dental referral
3-year Injury Prevention
Gun safety
Stranger danger
Water safety
4-year Anticipatory Guidance
Regular dental care Nocturnal enuresis Opportunities to play with peers Chores Clear limits & consequences Praise desired behavior Injury Prevention
4-year Injury Prevention
Bicycle helmets
Stranger danger
Animal danger
Water safety
5-year Anticipatory Guidance
Regular physical activity
Increasing autonomy
Praise liberally
Injury prevention
5-year Injury Prevention
Bicycle helmets Pedestrian, bicycle safety Dealing with strangers Poisons, tools, guns Water safety
How to close the well-child visit?
Reschedule next appt. Never appear hurried Never check watch Don't cut off parents sentences Ask "Is there anything else I can do for you today?"
Types of Pediatric Visits
Well-child Acute care Sports physical Chronic disease Counseling
Five Critical Areas of Normal Development
Physical growth Gross motor control Fine motor control Language Personal-social
First Year Normal Physical Development
Triples birth weight by one year of age
First Year Normal Gross Motor Control
Lift head while prone Rolls over Sits independently Crawl Walk
First Year Normal Fine Motor Control
Ulnar grasp Thumb joins the party Raking grasp, transfers objects Pincer grasp, holds bottle, throws object Fine pincer grasp
First Year Normal Language Development
Smiles socially Coos Laughs, orients to voice Babbles Says "mama/dada" indiscriminately, waves bye-bye 2 words other than mama/dada, jargoning
First year Personal-Social Development
Recognizes parent
Recognizes strangers
Starts exploring, plays gesture games
Imitates actions, comes when called
Second Year Gross Motor Control
Creeps upstairs, walks backwards independently
Runs, throws objects from standing without falling
Walks up & down steps without help
Second Year Fine Motor Control
Scribbles in imitation, builds tower of 2 blocks
Scribbles spontaneously, 3 block tower, turns 2-3 pages at a time
Imitates stroke with pencil, 7 block tower, turns 1 page at a time, removes shoes, pants
Second Year Language Development
4-6 words, one-step command without gesture
Mature jargoning, 7-10 word vocabulary, knows 5 body parts
Uses pronouns inappropriately, follows 2 step commands, 50 word vocabulary, uses 2 word sentences
Second Year Personal-Social Development
Uses spoon & cup
Copies parents in tasks, plays in company of other children
Parallel play
Three Year Gross Motor Control
Alternate feet when going up steps
Pedals tricycle
Three Year Fine Motor Control
Copies a circle Undresses completely Dresses partially Dries hands if reminded Unbuttons
Three Year Language Development
250 word minimum
3-word sentences
Uses plurals
Knows all pronouns
Three Year Personal-Social Development
Group play Shares toys Takes turns Plays well with others Knows full name Age Gender
Four Year Gross Motor Control
Hops
Skips
Alternates feet going down steps
Four Year Fine Motor Control
Copies a square
Buttons clothing
Dresses self completely
Catches ball
Four Year Language Development
Knows colors
Says song or poem from memory
Asks questions
Four Year Personal-Social Development
Tells “tall tales”
Plays cooperatively with a group of children
Five Year Gross Motor Control
Skips alternating feet
Jumps over low obstacles
Five Year Fine Motor Control
Copies triangle
Ties shoes
Spreads with knife
Five Year Language Development
Prints first name
Asks what a word means
Five Year Personal-Social
Plays competitive games
Abides by rules
Likes helping in household tasks
Years 5-7
Move from dealing with one variable to dealing with multiple variables
Magical thinking diminishes
Reality of cause-effect relationships better understood
Years 7-11
Devotion of energy to school & peers
Progressive interaction with opposite sex
Expectations for behavior and academics intensifies