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Title: HEALTH SUPERVISION III VISIT GUIDELINES Author: george hescock Last modified by: peds Created Date: 8/16/2006 6:28:36 PM Document presentation format – PowerPoint PPT presentation

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  • Interval history/ Interview with behavioral
  • Child How are you? How old are you? Do you go
    to school? Where?
  • Parent Have there been any illnesses,
    hospitalizations or ED visits since our last
    visit? How is your child doing in pre-school or
    child care? Do you have any particular concerns
    youd like to discuss?

4 Year Old Visit
  • Nutrition
  • Child What do you like to eat?
  • Parent Do you have any concerns about your
    childs eating habits?
  • Describe a typical dinner in your home?
  • Anticipatory Guidance
  • Kids age 4-8 need 800mg of Calcium per day one 8
    oz glass of milk contains 300mg
  • Recommend limiting juice to no more than 6 oz of
    100 fruit juice.
  • Food jags (favoring 1 or 2 foods) and picky
    eating are normal behaviors.
  • Explain the growth chart
  • Suggestions for picky eaters
  • Offer small portions first, then second helpings
  • Try to create a pleasant atmosphere at meal time
  • Include child in conversation at the dinner table
  • Offer a variety of foods and repeat them

  • Elimination
  • Parent Does the child use the toilet for
    urination and having bowel movements?
  • Have you noticed any discomfort when the child
    has a bowel movement?
  • By age 4, 95 of children are bowel trained
  • 90 are dry during the day
  • 75 are dry at night
  • Anticipatory Guidance
  • No specific interventions are warranted for night
    time wetting because its so common at this age.
  • Stress importance of balanced diet in preventing

4 Year Old Visit
  • Sleep Patterns
  • Child Where do you sleep?
  • Parent How does your child get to sleep at
    night? Does your child nap? Does your child
    experience nightmares, night terrors, or
  • Nightmares are common and involve vivid, scary or
    exciting events which are easily recalled by the
    child upon awakening.
  • Night terrors are common particularly in boys
    ages 5-7 but can see as early as 4. They occur
    in 1 3 of children and are usually short
    lived. Characterized by sudden onset, usually
    between midnight and 200am during stage 3 or 4
    of slow wave sleep. The child screams, appears
    frightened, tachycardic and may hyperventilate.
    Child my thrash violently, there is little or no
    verbalization and cannot be consoled. Sleep
    follows in a few minutes and there is total
    amnesia of the event upon waking.

4 Year Old Visit
  • Sleep Patterns
  • Anticipatory guidance
  • Encourage children to sleep in their own beds if
    that is compatible with the familys culture
  • Create a calm bedtime ritual like reading or
    story telling
  • Reassure parents that nightmares and night
    terrors are common

4 Year Old Visit
  • Development and Behavior
  • Child What sort of things are you good at
    doing? Can you get yourself dressed?
  • Parent What skills do you expect of a 4 year
    old that your child cannot perform?
  • Ages and Stages Questionnaire
  • Milestones
  • Gross motor Pedals tricycle, hops on one foot,
    balances on one foot, walks up and down stairs
    with alternating gate
  • Fine motor Draws a circle and cross, draws a
    person with 3 to 6 body parts, cuts with scissors
  • Cognitive skills complex pretend play, may have
    imaginary friend, recognizes some of the alphabet
  • Language skills Uses full sentences of at least
    6 words, 100 intelligible
  • Social skills engages in interactive play, able
    to share, can play a board or card game.
  • Self-help skills Able to put on shirt, pants,
    socks, able to button and zip able to brush
    teeth toilet trained

4 Year Old Visit
  • Physical Exam
  • Height
  • Weight
  • Blood Pressure
  • General physical exam to include
  • Visual acuity- objective
  • Hearing screen- objective
  • Check for obvious dental caries
  • Check gait, spine and extremities
  • Be alert for signs of abuse
  • Screening Hemoglobin if at risk for anemia
    (i.e., special health needs, low iron diet or
    environmental factors
  • Immunizations See current recommended schedule
    (DTaP, IPV, MMRV)

4 Year Old Visit Injury Prevention
  • Toys should be age appropriate
  • Falls are common
  • Keep dangerous materials out of reach matches,
    tools and poisons
  • Helmets for tricycle safety
  • Car seats and seat belts
  • Start booster seat at 40lbs and 40 inches tall
  • Adult supervision near water, consider swimming
  • Good touch/bad touch
  • Careful around strange dogs
  • Gun safety AAP recommends that they be removed
    from the home
  • Teach child how to dial 911
  • UV protection

4 Year Old Visit
  • Close the visit
  • Are there any issues that we missed?
  • Set time and reason for next appointment

  • Interval History/ Interview with Behavioral
  • O.K. to talk to child alone for a few minutes.
    As the child grows older the time period
    gradually increases. This is patient and family
  • Child Have you been sick since I saw you last?
    How many brothers and sisters do you have?
  • Parent How is your family doing? Have there
    been any changes in the family?

5 Year Old Visit
  • Nutrition
  • Child What are your favorite snacks?
  • Parent Do you have any concerns about your
    childs weight?
  • Anticipatory Guidance
  • Same as the 4 year old visit
  • Discuss healthy snacking

5 Year Old Visit
  • Elimination
  • Child do you have any problems with bowel
    movements (poop) or urinating (pee)?
  • Parent Does your child wet the bed at night?
  • At age 5 approximately 20 of children wet the
    bed at least monthly.
  • Approximately 5 of boys and less than 1 of
    girls wet the bed nightly
  • Anticipatory Guidance
  • No specific interventions are warranted for night
    time wetting at this age.

5 Year Old Visit
  • Sleep Patterns
  • Same as 4 year old visit

5 Year Old Visit
  • Development and Behavior
  • Child Can you write your name?
  • Parent Can your child tie his shoes? Is your
    child comfortable in speaking to others?
  • ASQ (Ages and Stages Questionnaire)
  • Milestones
  • Gross motor balances on one foot, hops, skips
  • Fine motor able to tie a knot, has mature
    pencil grasp, draws a person with at least 6 body
    parts, able to copy squares and triangles.
  • Language Names at least 4 colors, counts to 10,
    tells a simple story using full sentences,
    appropriate tenses, pronouns.
  • Social skills follows simple directions, able
    to listen and attend, dresses and undresses with
    minimal assistance.

5 Year Old Visit
  • Physical Exam
  • Same as the 4 year old visit
  • Screening
  • Urinalysis
  • Other screening as indicated by risk lead,
    hemoglobin, PPD

5 Year Old VisitAnticipatory Guidance Injury
Prevention/Health Promotion
  • Fire safety (alarms, fire escapes, home plan for
  • Dealing with strangers
  • Discourage skate boarding or in-line skating
    unless helmets, wrist, elbow and knee pads are
  • Violence prevention
  • Pedestrian and bicycle safety
  • Regular exercise/family activities
  • Brush teeth at least 2 times per day. See
    dentist 2 times per year.
  • TV viewing should be limited and monitored
  • Encourage interaction with other kids,
    grandparents and adults
  • Spend time playing with child every day

6-7 Year Old Visit
  • Interval History/Interview with Behavioral
  • Child What grade are you in? Have you been
    sick since our last visit? Any broken bones or
  • Parent Have there been any family crisis or
    stressors? Is your child on any medications?

6 7 Year Old Visit
  • Nutrition
  • Child Do you eat fruits and vegetables?
  • Parent What does your child eat for protein?
    How much milk does your child drink?
  • Anticipatory Guidance
  • Continue to promote well-balanced diet.
  • Avoid junk foods
  • Consider need for vitamins, iron supplements
  • Encourage regular exercise
  • Elimination
  • Child Do you have a bowel movement every day?
    Is it hard or soft? Does it hurt?
  • Parent Does your child have problems with day
    time wetting, night time wetting or soiling?
  • Anticipatory Guidance
  • By age 6 only 10 of children will wet the bed
  • If problems are identified, enuresis,
    constipation and encopresis.

6 7 Year Old Visit
  • Development and Behavior
  • Child Can you ride a bike? Show me your left
  • Parent How would you evaluate your childs
    abilities in sports? How are your childs
    abilities to draw and write?
  • Milestones
  • Gross motor skip
  • Fine motor Draw a picture of a person with 8 to
    10 features
  • Language/Cognitive Recount a personal story
    about a recent event, count to 20

6 7 Year Old Visit
  • Physical Exam
  • Same as 5 year old
  • Screening
  • Same as 5 year old
  • Injury Prevention/Health promotion
  • Same as 5 year old

School Readiness
  • Years from 3 to 6 are historically called
    preschool because of their importance for
    preparing the child for the tasks of school
  • Determine any parental concerns about school
    readiness by asking trigger questions
  • How does your child feel about going to school?
  • How are you feeling about John/Jane going to
  • When you were Johns/Janes age, did you enjoy
  • How did John/Jane do in preschool?
  • Is there anything you would like checked before
    he/she goes to school?
  • Is there anything the school or teacher should

School ReadinessParental concerns regarding
developmental milestones
  • Communication/Language
  • Knowledge of letters, words and symbols
  • Ability to recognize letters and numbers
  • Articulate speech
  • Behavioral/Emotional Skills
  • Ability to take another persons point of view and
    follow rules
  • Separation anxiety
  • Social shyness
  • Temper tantrums and tendency to be aggressive
    when fearful are indicators of emotional
  • Gross motor/Fine motor
  • Ability to print letters and numbers
  • Good gross motor coordination can provide
    important status with peers and is a source of
    self-esteem through athletics. This is least
    predictive of school achievement when compared
    with other areas of development.
  • Physical size and stature

Developmental milestones necessary for Elementary
School Success
  • Cognitive
  • Long term memory, storage and recall
  • This is the ability to acquire skills that are
  • Deficit Delayed mastery of the alphabet, slow
    handwriting and the inability to progress past
    basic mathematics
  • Selective Attention
  • Ability to attend to important stimuli and ignore
  • Deficit Difficulty following multi-step
    instructions, completing assignments and behaving
  • Sequencing
  • Ability to remember things in order
  • Deficit Difficulty organizing assignments,
    planning, spelling and telling time
  • Levine MD Developmental-Behavioral Pediatrics.
    Nelsons 2004

Developmental Milestones necessary for Elementary
School Success
  • Perception
  • Visual Analysis
  • Ability to break a complex figure into components
    and understand spatial relationships
  • Deficit Persistent letter confusion (between
    b,d and g), difficulty with basic reading and
    writing and limited sight vocabulary
  • Proprioception and fine motor control
  • Ability to obtain information about body position
    by feel and unconsciously program complex
  • Deficit Poor handwriting often with overly
    tight pencil grasp, difficulty with timed tasks
  • Levine MD Developmental-Behavioral Pediatrics.
    Nelsons 2004

Developmental Milestones necessary for Elementary
School Success
  • Language
  • Receptive
  • Ability to comprehend constructive function words
    like if, when, only, except. Ability to
    understand nuances of speech and extended blocks
    of language (e.g. paragraphs)
  • Deficit Difficulty following directions,
    wandering during lessons and stories, problems
    with reading comprehension, problems with peer
  • Expressive
  • Ability to recall required words effortlessly
    (word finding), to control meanings by varying
    position and word endings, to construct
    meaningful paragraphs and stories
  • Deficit Difficulty expressing feelings and
    using words for self-defense, with resulting
    frustration and physical acting out struggling
    during circle time and language based subjects
  • Levine MD Developmental-Behavioral
    Pediatrics. Nelsons 2004

  • Bright Futures, Health Supervision III Guidelines
    2008 AAP Publication
  • Caring for your Baby and Young Child AAP
  • Nelsons Textbook of Pediatrics 2004
  • Pediatrics A Primary Care Approach,
  • Carol Berkowitz, MD, FAAP, 2008

(No Transcript)
General Approach to the Well Child Visit
  • Interval History/Behavioral Observation
  • Nutrition
  • Elimination
  • Sleep Patterns
  • Development/Behavior/School Performance
  • Physical Exam
  • Anticipatory Guidance
  • Disease Prevention, Health Promotion, Injury

8 9 Year Old Visit
  • Interval History/Interview with Behavioral
  • Child How are things going?
  • Parent Have there been any changes in your
    childs health?
  • Middle childhood is marked by considerable
    development in academic skills, physical
    abilities, social interactions and emotional
    regulation. School success and home life are
    both important for self-esteem.
  • Nutrition
  • Child How is your appetite? What do you eat
    for breakfast?
  • Parent How is your childs appetite?
  • Encourage child to eat breakfast daily
  • Reinforce need for balanced diet avoiding junk
  • With a balanced diet and exercise there should be
    no need for dieting

8 9 Year Old Visit
  • Elimination
  • Child How often do you have bowel movements?
  • Parent Do you have any concerns about your
    childs toilet habits?
  • Enuresis Defined as normal voiding that occurs
    at an inappropriate time or involuntarily in a
    socially unacceptable setting.
  • Defined as occurring at least 2 per week for at
    least 3 consecutive months
  • Diagnosis is reserved for girls older than 5 and
    boys older than 6
  • Diurnal enuresis occurs during the day
  • Nocturnal enuresis occurs at night
  • Primary enuresis refers to kids who have never
    achieved sustained dryness
  • Secondary enuresis refers to kids whose urinary
    incontinence occurs after 3 to 6 months of
  • 75 to 80 of kids with enuresis have primary
  • Incidence of secondary enuresis increases with
    age and makes up 50 by age 12
  • Causes of primary enuresis include faulty toilet
    training, maturational delay, small bladder
    capacity, sleep disorders, nocturnal polyuria
  • Causes of secondary enuresis include UTIs,
    diabetes mellitus and insipidus, genitourinary
    anomalies, seizure disorder, medication use

8 9 Year Old Visit
  • Sleep Patterns
  • Child What time do you go to bed at night? How
    many hours do you sleep on a school night?
  • Children age 8 frequently sleep 9 to 12 hours per
  • School
  • Child What subjects do you like? What do you
    think about your grades?
  • Parent How are your childs reading and writing
    skills? What did you learn at the parent-teacher
  • If school failure is suspected discuss need for
    comprehensive approach involving parents, school
    and pediatrician.

8 9 Year Old Visit
  • Development and Behavior
  • Child What do you like to do for fun? How many
    hours each day do you watch T.V?
  • Parent What are your expectations for your
    child in terms of sports and extracurricular
    activities? How does your child get along with
    friends and peers at school?
  • Parents should encourage peer play outside the
    home, i.e. clubs, camps or athletic teams.
  • Parents should consider giving an allowance to
    encourage independence and responsibility.
  • Recommend fair, understandable rules about
    chores, T.V., outside activities, homework and
  • Encourage follow through with stated consequences
    when rules are broken.
  • Consider discussing puberty.

8 9 Year Old Visit
  • Physical Exam
  • Height
  • Weight
  • Blood Pressure
  • Look for signs of puberty
  • Screening
  • Hemoglobin, PPD if high risk
  • Injury Prevention/ Health promotion/ Disease
  • Discuss participation in team sports where
    emphasis is fun and not winning
  • For those children that dont like team sports,
    encourage individual sports like swimming,
    tennis, dance or gymnastics
  • Trampoline use should be discouraged
  • Children can learn CPR at this age
  • Gun Safety
  • Smoke detectors in the home

10 11 Year Old Visit
  • Interval History/ Interview with Behavioral
  • Speak to child alone during some portion of the
  • Explain confidentiality to the child and parents
  • At this age peer groups become an increasingly
    important influence on style, attitudes and
    values. They may begin risk-taking behaviors
    such as cigarette smoking or drinking alcohol.
  • Nutrition
  • Child What is meant by a well balanced diet?
  • Parent Is there a history of elevated
    cholesterol in your family?
  • Encourage child to eat breakfast before school
  • Encourage regular exercise
  • Advise parent and child about adequate hydration
    during warm climate sports or outdoor activities

10 11 Year Old Visit
  • Elimination
  • Child Do you experience pain or burning with
  • Sleep Patterns
  • Child How do you feel when you wake up in the
  • Parent How much sleep does your child get at
  • Children this age should still get at least 9
    hours of sleep per night
  • Development/ Behavior
  • Child Where do you spend your time after
  • Parent What are the most enjoyable activities
    you do together? What activities are most likely
    to cause friction or problems?
  • Age 10 is a prime year for sports competition.
    Year round participation in multiple sports my
    reduce over-use injuries of same muscle groups.
  • Strength training is appropriate with proper
  • Parents should discuss tobacco, alcohol and
    illicit drug use.
  • Encourage parents to prepare girls for menarche.

10 11 Year Old Visit
  • Physical Exam
  • Height
  • Weight
  • Blood Pressure
  • Make sure to include assessment for scoliosis,
    Tanner staging and exam of genitalia
  • Screening
  • Hemoglobin for menstruating females
  • Urine dipstick should be done between 11 and 21
  • Cholesterol and PPD for high risk kids
  • Injury Prevention
  • Seat belts
  • No power tools unless supervised
  • Water activities should be supervised
  • Children this age should not operate personal
  • Sunburn protection

School Failure
  • Failure in school can have lifelong consequences.
    The causes of school failure are often multiple
    including chronic illness, behavioral,
    emotional and social issues
  • Background
  • 10 15 of school age children repeat or fail a
  • More likely among males, minorities, low
    socio-economic status and single parent
  • Children with disabilities are nearly 3 times as
    likely to repeat a grade as those with no
  • Disability
  • Learning
  • Speech or language impairment
  • Mental retardation
  • Emotionally disturbed
  • Children who are small for gestational age are
    nearly twice as likely to experience school

School Failure
  • Background
  • Grade failure is linked strongly to subsequent
    dropping out of high school
  • 10 of drop-outs had no failures
  • 22 of drop-outs failed one grade
  • 39 of drop-outs failed 2 grades
  • Grade failure causes children to be older than
    their same-grade peers
  • Old for grade high school students are more
    likely to report smoking regularly, chewing
    tobacco, alcohol use, driving in a car with
    someone who has been drinking, using alcohol
    prior to a sexual experience and using cocaine or
    other illicit drugs.
  • They have more suicidal ideations, risky sexual
    behavior and violent behaviors
  • Grade retention alters peer group formation
  • Grade retention has a negative impact on
    self-esteem, social adjustment, behavior,
    self-confidence, attitudes towards school and is
    stressful for children

School FailureConditions and Associated Factors
  • Endogenous Factors
  • Chronic disease
  • Anemia
  • Asthma
  • Sleep Apnea
  • Cystic Fibrosis
  • SLE
  • Crohns Disease
  • Acute conditions causing school absence
  • Sensory impairment
  • Vision
  • Hearing
  • Perinatal conditions
  • Prematurity
  • FAS
  • In utero drug exposure
  • Maternal conditions affecting pregnancy
  • Neurologic disorders
  • Brain injury
  • Endogenous Factors
  • Learning disability
  • Language and Speech Disorder
  • Phonologic language
  • Expressive language
  • Receptive language
  • Stuttering
  • Learning disorder
  • Reading
  • Writing
  • Mathematics
  • Mental Retardation
  • Communication disorders
  • ADHD
  • Autistic spectrum disorders
  • Genetic disorders Fragile x
  • Endocrine disorders Hypothyroidism
  • Psychiatric disorders
  • Oppositional defiant disorder

School FailureConditions and Associated Factors
  • Exogenous Factors
  • Family
  • Divorce/Separation/conflict
  • Poverty
  • Frequent moves
  • Substance abuse
  • Depression
  • Attitudes towards education
  • Low level of family support
  • Inadequate accommodations for studies at home
  • Neglect/Abuse
  • Environment
  • Neighborhood/housing
  • TV/computers
  • Peers
  • Peer pressure for low performance
  • Substance abuse
  • Exogenous Factors
  • Competing priorities excessive extramural
  • Social
  • Work
  • Sports
  • School
  • Mismatch between student and teacher
  • Unrealistic expectations
  • Inadequate school environment
  • Violence/safety
  • Classroom size
  • Transitions
  • Third grade
  • Elementary school to middle school
  • Increases in testing standards without increasing
    educational support
  • Excessive testing

School FailureMedical Assessment and Subsequent
  • History
  • Developmental history
  • Motor milestones
  • Language milestones
  • Regression
  • Social skills
  • Temperament
  • Current Medical Conditions
  • Acute
  • Chronic
  • Medications
  • Past medical history
  • Head trauma
  • CNS conditions
  • Sleep history
  • Social history
  • Peer group
  • Family stress poverty, conflict, single parent
  • Family orientation toward education
  • History
  • School history
  • Details of current difficulties
  • School setting
  • Educational support
  • School absences
  • Achievement
  • Onset of problems
  • Results of educational testing
  • Preschool performance
  • Communication with the school
  • Attention profile
  • Attention
  • Hyperactivity
  • Impulsivity
  • Family history
  • Educational achievement and difficulties
  • Mental retardation
  • ADHD

School FailureMedical Assessment and Subsequent
  • School Failure Interventions
  • As indicated by assessment (e.g., treatment of
  • Advocate for more complete assessment
  • Attend school meetings
  • Advocate for IEP that consists of more than
    simply having a child repeat the grade that was
  • Advocate for alternatives to grade retention
  • Mixed-age classes
  • Individualized instruction
  • Tutoring
  • Home assistance program
  • Smaller class size
  • Alternative education settings
  • Guidance counseling
  • Help families get more involved in their childs
  • Assist families with peer group issues
  • Improve environment for learning at home
  • Limit amount of television watching
  • Provide a quiet place to do homework
  • Help develop childs strengths
  • Assess siblings for school problems and take the
    opportunity to promote school readiness prior to
    the failure of a younger sibling

School FailureMedical Assessment and Subsequent
  • Prevention
  • Promote school readiness during health
    supervision visits
  • Assess childrens strengths and weaknesses
  • Assess educational progress at all health
    supervision visits
  • Implement some interventions listed previously
    before failure occurs
  • Assess peers, activities, and health-impairing