Child Health Early Screening PDF

Child Health Early Screening Nour Abd-Alqader, Msc Clinical Pharmacy College of Pharmacy, Jeresh University  Definition of A child The United Nations Convention on the Rights of the Child (commonly abbreviated as the CRC or UNCRC) defines a c...

Child Health Early Screening Nour Abd-Alqader, Msc Clinical Pharmacy College of Pharmacy, Jeresh University  Definition of A child The United Nations Convention on the Rights of the Child (commonly abbreviated as the CRC or UNCRC) defines a child as any human being under the age of eighteen, unless the age of majority is attained earlier under national legislation. A neonate is a child younger than 28 days. An infant is a child younger than one year of age. An adolescent is a person aged 10 to 18 years inclusive.  Why Focusing on Child Health ? 1. One of the most vulnerable segments of the population. 2. A child is dependent on adults for their optimal development and survival. 3. Critical years of life; biologic immaturity (immunity) thus increased risk of infections, and rapid growth and development. 4. The majority of child deaths are preventable/ treatable. 5. Childhood illnesses contribute substantially to the global burden of disease. 6. A good measure of societal progress.  MAJOR FOR COLLEGE CHILD DEVELOPMENT Highlight on the Problem In 2018, an estimated 6.2 million children and young adolescents under age 15 died, mostly form preventable causes. The highest risk is during the neonatal period. In 2018, 1 out of 26 children died before reaching age five. On the other hand, 1 out of 11 children died in 1990.  Causes of Death Differ by age. Common problems that occur beyond the neonatal period tend to be more easily addressed by public health strategies while neonatal problems may require more clinical based interventions. Most interventions aimed at decreasing neonatal mortality are linked to prenatal and maternal care interventions.  Leading Cause of Death Leading Cause of death in children under five years as defined by the WHO in 2018: 1. Preterm birth complications 2. Pneumonia 3. Intrapartum related events (Birth asphyxia) 4. Congenital anomalies. 5. Diarrhea 6. Neonatal sepsis and malaria.  Factors Affecting Child Health Povirety 01 05 Conflict/War/ Disaster Poor and Inadiquate Neutrition 02 06 Lacke of safe and adequate water and poor sanitation Lack of access to care and PHC 03 07 High fertility rate 04 08 Lack of Maternal Education Poor maternal health services  Morbidity Causes in Children ❖ Vitamin A deficiency: leading cause of preventable blindness worldwide ❖ Iodine deficiency: preventable cause of development delay. ❖ Iron deficiency: affects >50% of children c causing anemia and decreases performance at school. ❖ Helminthic infections: anemia, poor growth and decreased learning.  In Jordan ○ Mortality for patients younger than 5 years and infants has decreased considerably between the year 1997 and 2012, but did not meet the universal targets. ○ Neonatal mortality occupies more than 70% of children mortality under 5 years of age, one third of these are preventable. ○ Other causes of mortality among children under age 5 include diarrhea, lower and upper respiratory tract infection followed by other infectious diseases and injuries. What are the Health Services invested in Child Health? Monitoring of growth and development Care in illness Preventive and promotive care Monitoring of growth and development ❖ Growth and development are the two most important biological process of childhood. ❖ Growth: an increase in physical size of the body as a whole or any of its parts associated with Increase in cell number/size. ❖ Development: Acquiring functions and skills that Involves motor, social, emotional and intellectual abilities of the child.  Stages of Growth and development A. Intrauterine stage: This stage begins with fertilization of the ovum and ends with birth 1. Embryonic Period: it is the period of organogenesis which occurs during the 1st trimester of pregnancy , in which exposure to any adverse effect can lead to congenital anomalies of miscarriage. 2. Fetal period: during this period the mother provides her fetus with nutrients and immunoglobulins. Conditions including still birth, early labour and low birth weigh can occur this period  Stages of Growth and development B. Extrauterine stage: 1. At birth: BWt is 2.5-4.2 kg 2. Neonatal period 3. Infancy period 4. Childhood period 5. Adolescence period  Factors effecting growth and development I. Genetic Factors: Such as ethnicity. These factors are fixed, hard to modify and influence growth from conception to adulthood II. Environmental factors: Nutrition. Infections during infancy and childhood. Absence or inadequate stimulation and care of the child  Growth Monitoring The purpose is to insure that the child is growing well and that any slowing in growth is promptly detected and dealt with. ○ Growth monitoring is an indication of an indication of overall nutritional status. ○ Identify high risk children who needs attention ○ Can determine if there are growth abnormalities that point to the presence of underlying condition. ○ To prevent nutritional disorders that leads to mortality and morbidity.  Assessment of Growth 1. Longitudinal: It includes measuring the child at regular intervals. 2. Cross-sectional: it compares large numbers of children of the same age. ▪ Basic growth assessments involves weight, height and head circumference.  Assessment of Growth ▪ Most used measure is the weight for age using growth charts ▪ Average weight gain for children during the first year is about 750 g/month in the first four months, 500 g/month in the second four months and 250 g/month in the third four months. ▪ Infants double their birth weights by 4-5 months , triple by the end of the 1rst year and quadruple by the end of the second year  Assessment of Growth ▪ Most used measure is the weight for age using growth charts ▪ Average weight gain for children during the first year is about 750 g/month in the first four months, 500 g/month in the second four months and 250 g/month in the third four months. ▪ Infants double their birth weights by 4-5 months , triple by the end of the 1rst year and quadruple by the end of the second year The Weight of the Child is Plotted on Growth Charts at: 1st year Up to 5 years Every month 2nd year Every 3 months Every 2 months  Assessment of Growth ▪ Length is measured in children younger than 2 years in recumbent position. ▪ Height is measured in children older than 2 years while standing. ▪ Average length at birth is 50 cm. ▪ Length is increased 25 cm in the first year of life. ▪ At 3 years 90 cm and 100 cm at 4 years.  Growth Charts ▪ Growth charts are visible display of child’s physical growth and development. ▪ It was first designed by David Morley and was adjusted by the World Health Organization (WHO). ▪ Growth charts is the simplest inexpensive effective convenient tool for monitoring child’s health and nutritional status, so that changes can be monitored and interpreted over time. ▪ The WHO charts are international standards that show how healthy children should grow. ▪ The WHO charts use the growth of breast fed infants as the standard for growth. ▪ The WHO charts are global and applicable for all children (regardless of feeding) up to 2 years of age. ▪ In WHO growth charts, X-axis show age of the child, whereas points plotted on vertical lines corresponds to exact age in months or years ▪ The Y-axis in indicative of length/height, BMI or weight. ▪ Growth charts are available for both boys and girls. ▪ Reference lines are either percentile lines or zero scores.  Indicators used to assess growth ▪ Length/height for age ▪ Weight for age ▪ Weight for length/ height ▪ BMI for age  Growth Charts ▪ Weight for age: Weight for age reflects body weight relative to child’s age on a given day. This indicator is used to identify children whoa are underweight of severely underweight. However, it does not identify children who are severely obese or overweight. It is not sensitive in specific situations such as medicinal conditions implying increased body weight or unidentified age. ▪ Length/Height for age: It is helpful to identify children who have stunted stature due to prolonged under-nutrition or repeated illness. ▪ Weight for length/Height: This indicator is useful in situations such where age is not identified. Low weight for length/height indicate that a child is wasted or severely wasted due to malnutrition or illness. High values of this indicator may indicate child being at risk for overweight or obesity. ▪ BMI for age: It is an indicator useful for screening overweight or obiesty.  How to utilize growth chart? 1. Obtain accurate measurements. 2. Select the appropriate growth chart based on age and sex. 3. Record data. Determine age to the nearest month for infants and children up to 2 years and to the nearest forth year for children above years. Enter patient weight, length or stature.  How to Interpret a Growth Chart ▪ The line labeled 0 on each chart represents the median, which is the average. ▪ The other curved lines are z-score lines, which indicate distance from the average. ▪ Z-score lines on the growth charts are numbered positively or negatively. In general, a plotted point which is far from the median in either direction, may represent a growth problem. However, other factors must be considered such as growth trends, health conditions and parents height. ▪ The growth curve of a normally growing child will usually follow a track that is roughly parallel to the median. The track may be above or bellow the median. ▪ Any quick change in trend should be investigated. ▪ A flat line is referred to as stagnation which means that this child is not growing.  Identifying growth problems from charts ▪ Length-for-age chart: A child whose length-for-age is below the line -2 is stunted, while if below -3 is severely stunted. ▪ Weight-for-age chart: A child whose weight for age is below the line -2 is underweight, while below -3 is severely underweight. ▪ Weight-for-length chart: A child whose weight-for-length is above 3 above the line is obese, above 2 is overweight, above 1 is a possible risk of overweight. A child is below the line (-2) is wasted, while below the line (-3) is severely wasted. ▪ BMI-for-age chart: A child whose BMI for-age is 3 above the line is considered obese, above 2 is overweight and above 1 is showing a possible risk of overweight.  Development assessment ▪ Development depends on maturation and myelination of the nervous system. ▪ The sequence of development is the same for all children, but development varies from child to child. ▪ The direction of development is cephalocaudal. ▪ There are some development landmarks that can be checked.  Development assessment Development is assessed by two major aspects: 1. Motor: involves motor development (standing and setting ) and fine motor development (such as moving fingers, hands, eyes). 1. Psychological: attachment to special figures such as attachment to mother, vocalization at 9 months and development of fear at 7-8 months. Factors predisposing delay in development 01 03 Lack of training by 02 Emotional 04 the family deprivation Lack of enviromental Health problems stimuli such as malnutrition, congenital anomalies and rickets. Newborn screening program in Jordan ❖ The goal is to screen for congenital and heritable disorders in a stepwise approach as the following: 1. Blood samples obtained from infants are analyzed in Labs. 2. Any detected abnormalities in laboratory results will be notified to the case management/clinic 3. The clinic will contact the concerned families to assign follow up appointments with appropriate providers to confirm test results Newborn screening program in Jordan ❖ the National Newborn Screening Project of Jordan has expanded to include 29 conditions. These include: 1. 20 inborn errors of metabolism 2. three hemoglobinopathies (including the most recently added sickle cell disease) 3. two endocrine disorders 4. one hearing loss disease 5. three other metabolic disorders.  Hemoglobinopathies ❖ Worldwide, it is estimated that 7% of the population may carry a hemoglobinopathy with clinical significance. ❖ Newborn screening for hemoglobinopathies is done by detecting abnormal patterns using isoelectric focusing. ❖ Early identification of individuals with sickle cell disease and other hemoglobinopathies allows treatment to be initiated in a timely fashion. Hemoglobinopathies  Hemoglobinopathies ❖ In a study conducted on 6-10 yr old school children in Northern Jordan Valley, both α- and β-thalassaemias and HbS were identified: ▪ 1- HbS gene frequency was very low (carrier frequency= 0.44%). ▪ 2-Co-existing HbS/β-thalassaemias were identified. ❖ In a larger study in North Jordan, the overall prevalence of HbS and β- thalassaemia was 4.45 and 5.93 per cent, respectively and the incidence of Hb AS in the newborn sample was 3-6 per cent. The prevalence of both HbS and beta-thalassaemia was higher in the Al-Ghor area in comparison to Ajloun and Irbid. Variable clinical presentation of SCA has been reported and no correlation was demonstrated with Hb F level.  Cystic Fibrosis ❖ Cystic fibrosis is an autosomal recessive genetic disorder affecting most critically the lungs, and also the pancreas, liver, and intestine. ❖ It is characterized by abnormal transport of chloride and sodium across an epithelium, leading to thick, viscous secretions.  Cystic Fibrosis: screening ❖ by measuring immunoreactive trypsinogen (IRT) in dried blood spots, Samples with an elevated IRT value were then analyzed with molecular methods to identify the presence of disease causing mutations before being reported back to parents and health care providers  Hearing loss ❖ Undiagnosed hearing loss in a child can have serious effects on many developmental areas, including language, social interactions, emotions, cognitive ability, academic performance and vocational skills, any combination of which can have negative impacts on the quality of life. ❖ Early identification allows these patients and their families to access needed resources to help them develop.  Congenital heart defects screening Pulse oximetry has been recently added as a bedside screening test for critical congenital heart defects.  Screening in Early Childhood ❖ According to the AAP, the recommended screening tests are: Anemia TB Lead Urinalysis Cholesterole ❖ Nevertheless, in Jordan we screen only for: Anemia, Undescended testicle.  Anaemia ❖ In newborn period hemoglobin electrophoresis is used Tests to detect inherited abnormalities HB ❖ Children are screened for anemia at ages of high (g/dL) (g/L) MCV(fL) incidence of iron deficiency anaemia (at 9 month old) ❖ Routine testing resumes during adolescence. RBC distribution width (%) ❖ The type of anemia in Iron deficient patient is Reticulocyte haemoglobin content (pg) hypochromic microcytic Reticulocytes  High risk groups ❖ Infants fed non–iron fortified formula or cow's milk before 12 months of age. ❖ Breastfed infants older than 6 months without adequate iron supplementation. ❖ Children who consume more than 24 oz of cow's milk per day. ❖ Children with special health care needs.  When to screen? ❖ This recommendation is from Centers for Disease Control and Prevention : ▪ Screening should be considered for preterm and low–birth-weight infants before 6 months of age if they are not fed iron-fortified formula ▪ Infants and young children with risk factors should be assessed at : 1) 9 to 12 months of age, and 2) again 6 months later. ▪ Beginning in adolescence. ▪ all non-pregnant women should be screened every 5 to 10 years. Screening in Middle Childhood and Adolescence ❖ It is an integrated set of planned, sequential, school-affiliated strategies, activities, and services designed to promote the optimal physical, emotional, social, and educational development of students ❖ It involves and is supportive of families, and is determined by the local community, based on community needs, resources, standards, and requirements ❖ SHP should include: 1. School Environment 2. Health Protection & Promotion (Screening) 3. Special Problems 4. Health Instruction  Screening in Middle Childhood and Adolescence Should be done: ○ On school entry ○ Yearly Advantages: ○ Easy, Cheap & Productive ○ Done by a health program (health care workers) or by the teacher  Screening Recommendations for School-aged Children and Adolescents Learning process Speech Vision Hearing Dental Screening Obesity Anemia Malnutrition Strep. Infection Heart Diseases Hypertension Depression  Screening for Visual Problems The American Association of Pediatrics (AAP) recommends routine vision testing at five, six, eight, 10, and 12 years of age, with a risk assessment at other well-child visits Using an age-appropriate visual acuity test (such as the Snellen chart) Referral for formal optometry evaluation is recommended for children with visual acuity less than 20/40  Screening for Visual Problems Cases can be detected by screening: ○ Myopia (shortsightedness) ○ Hyperopia (farsightedness) ○ Squint ○ Thick cornea ○ Conjunctivitis ○ Many others ○ Visual problems should therefore be corrected early so that these will not hinder the child's learning ability  Screening for Hearing Problems Bright Futures Steering Committee recommends screening for hearing loss at five, six, eight, and 10 years of age, with a risk assessment at other well-child visits The child will be asked to put on earphones and have his hearing tested with an audiometer He will be asked to indicate on a chart when he hears a sound in each ear If he cannot hear all or some of the sounds, he will be referred to the Student Health Centre for further assessment. Some children who have difficulties with schoolwork may actually have hearing problems that affect their studies If these hearing problems are detected and treated early, their learning abilities will improve In Jordan: 0.05% of screened children found to have hearing deficit  Screening for Obesity About 17% of children and adolescents in the U.S. are obese Obesity increases the risk of developing: ○ Type 2 diabetes ○ High blood pressure and high cholesterol ○ Joint problems ○ Sleep apnea ○ Social and psychological problems. Children who continue to be overweight into adulthood are at greater risk for heart disease, stroke, and some cancers The American Academy of Pediatrics (AAP) recommends routine obesity screening of children starting at age 2, At least once a year A health care provider should assess a child's weight and height as well as age and sex to determine the child's body mass index (BMI) percentile  Screening for Obesity Overweight: when the BMI is between the 85th percentile and the 94th percentile on standardized growth charts. Obese: When the BMI is at or above the 95th percentile on standardized growth charts. Screening results are sent to parents and typically include: ○ The child's BMI-for-age percentile. ○ An explanation of the results. ○ Recommended follow-up actions, if any. ○ Tips on healthy eating, physical activity, and healthy weight management.  Dental Screening Diseases of the mouth, affects about 98% of the entire U.S. population at some point in their lives The American Dental Association recommends annual oral health screenings for every student It is performed using a tongue depressor, disposable gloves and flashlight The benefits of a dental screening program: ○ Dental defects may be discovered early so they can be corrected with the least amount of discomfort to the child ○ Irregularity of tooth position may be observed and preventive measures instituted ○ Referral for early treatment before problems become magnified will keep the cost of dental care to a minimum Dental Screening MAJOR FOR COLLEGE CHILD DEVELOPMENT Thanks! 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