Pediatrics Module 3: History & Physical Checks

Pediatrics and Adolescent Medicine

• Module 3 covers History & Physical (H&P) and well-child checks.
• This subject matter is taught by Angela Deubel, PA-C, at the University of New Mexico.

Introduction to Development & Growth: Pediatric Health Maintenance

• Development and growth are tracked from birth.
• Screening is done to identify problems.
• Resources include: The American Academy of Pediatrics Bright Futures, the Center for Disease Control, NM Department of Health, and CDC.

Development

• Development is a broad term encompassing four domains:
  • Physical/motor skills
  • Cognitive skills
  • Language skills
  • Behavioral, social-emotional, and mental health domains.
• Well-child checks aim to identify developmental delays or risks.

4 Principles of Child Development

• Development is predictable.
• Pathways are measurable (milestones).
• There is a developmental trajectory.
• Developmental norms vary widely (age, sex, individual rate).
• H&P examinations vary based on the developmental level and understanding of norms. Factors affecting development include physical, social, environmental, and disease.

To Recognize Abnormal Growth

• To understand abnormal growth, one must understand normal growth.
• Determinants of growth include maternal nutrition, intrauterine environment, genetics, environment/diet, and chronic illness.
• Patterns of growth are predictable, pulsatile, and seasonal.
• Parameters of growth include weight, length/height, weight-for-length/BMI, head circumference, and Tanner Stages.

How do Social Determinants of Health (SDoH) affect growth and development?

• Adverse childhood experiences (ACEs) like maltreatment, poverty, family instability, unsafe neighborhoods, lead exposure, and racism influence growth and development negatively.
• Negative effects include inadequate coping skills, difficulty regulating emotions, reduced social functioning, cognitive delays, poor academic achievement, chronic diseases, and tobacco/alcohol/drug use.

Overcoming Adversity: Early Childhood Programs

• High-quality, developmental/educational programs are crucial.
• Programs like Head Start can improve:
  • Health outcomes
  • Learning and social skills
  • School readiness
  • School meals
  • Home visitations
  • Supportive social services
  • Parent classes

Well-child Checks (WCC)

• WCCs prevent illness (immunizations, safety, nutrition).
• WCCs track growth and development (milestones, social behaviors, learning).
• WCC addresses parental concerns (sleeping, eating, development, social skills).
• WCCs use a team approach to support infants, children, and adolescents.

Standardized Developmental Screening Tools

• Standardized developmental screening tools are used as a minimum at 9, 18, and 24/30-month well-child visits.
  • Screening occurs anytime concerns are raised.
• Examples of gross motor milestones in infancy:
  • 1 month: chin up when prone
  • 2 months: visual tracking of object
  • 4 months: reaching for objects
  • 6 months: sitting unassisted
  • 8 months: pincer grasp
  • 9 months: crawling
  • 11 months: can stand and cruise
• Development screening tools like ASQ-3.

Pediatric History: Infants and Toddlers (0-3yrs)

• Information collected covers birth history, medical history, family history, social history, developmental milestones, feeding, sleeping, stooling/urination, and vaccinations.

Examples of Infant and Toddler Norms

• Feeding: 2-month-old infants: 4-5 oz formula every 3-4 hours; 4-6 months: up to 8 oz every 3-4 hours.
• Sleeping: 0-6 months: 15-16 hrs/day; 6 months and beyond: 10-11 hrs/day.
• Stooling/Urination: Infants may defecate once, many times, or even skip a day. Infants have 4-6 wet diapers per day or more.

History: School-Aged Children (4-11yrs)

• This history includes: birth history (if applicable), medical history, family history, social history, developmental milestones, feeding, sleeping, vaccinations, and school performance.

Pediatric Vital Signs

• A table of normal vital signs by age is provided (newborn to 13+ years), including heart rate, respiratory rate, systolic blood pressure, and diastolic blood pressure.

Examples of Pediatric Growth Charts

• WHO for 0-2 years
• CDC for 2-20 years
• CDC for children with Down Syndrome
• Life Expectancy for cerebral palsy

Normal Variants in Growth

• Common growth variants, including constitutional delay of growth and adolescence, familial short stature, congenital GH deficiency, Turner syndrome, and primary nutritional deficiency.

Growth Chart Practice

• Plotting examples using WHO charts for ages <2 and CDC charts for ages >=2.
• Calculating percentiles for weight, length/height, weight-for-length/BMI and determining if the results are normal.

Well-Child Checks: Components

• Context (age & development of child, environment)
• Priorities of the Visit (address family’s needs first)
• Health Supervision: History, surveillance of development, ROS, observe interaction with others, Screening, Vaccinations
• Anticipatory guidance: injury prevention, violence prevention, sleep positioning, nutritional needs, and general development.

Timing of WCC: Infants, Toddlers & Children

• The recommended frequency for well-child visits (newborn/nursery; 1 week; 1, 2, 4, 6, 9 months; 12, 15, 18 months; 2, 2.5 yrs; and annually from 3 to 10 years.)

Infants

• Discussion about the unique and challenging aspects of examining infants and well-child visits in infants.

Childhood Vaccines: Practice

• Checking the 2025 immunization schedule for the specific ages of 1 day old, 6 months old, 15 months old, 5 years old, and 10 years old.

Toddlers & School-aged Children

• Discussion about the unique and challenging aspects of examining toddlers/school-aged children. What is a well-child visit like?

A Note on Lead Screening

• All children enrolled in NM Medicaid are to be screened for lead at 12 and 24 months.
• AAP recommends universal lead screening for all children.
• Acceptable levels are <5 mcg/dL
• If 5+ mcg/dL, further screening, retesting and followup care needed.

Group Work: 6-month-old WCC

• A case study of a 6-month-old girl presenting for a well-child visit.
• Questions to be answered about growth, immunizations, developmental milestones, introduction of solids, anticipatory guidance, and universal screening. Note that the patient is breastfeeding exclusively.