Pedi Preventive Med 2023 (1).pptx

Pediatric Health Screening and Prevention Marci Contreras, Ed.D., PA-C Fall 2023 Objectives 1. 2. 3. 4. 5. 6. 7. 8. Identify goals for preventive medicine in the pediatric population. Describe the timetable for immunizations for infants, children, and adolescents. Indicate precautions and/ or con...

Pediatric Health Screening and Prevention Marci Contreras, Ed.D., PA-C Fall 2023 Objectives 1. 2. 3. 4. 5. 6. 7. 8. Identify goals for preventive medicine in the pediatric population. Describe the timetable for immunizations for infants, children, and adolescents. Indicate precautions and/ or contraindications for childhood immunizations. Summarize how a clinician should approach parents who refuse vaccination for their children. List the most common causes of infant mortality. Define and understand the screening of newborns. List the most common causes of mortality in children ages 5-14 years. List the recommended period for screening and referrals in children: -Surveillance screen -Autism screen -Standardized developmental screen -Dental referral Objectives 9. Discuss screening requirements for lead in children. 10. Describe the sequelae of high lead levels in children. 11. Discuss the screening requirements for anemia in children. 12. Discuss the causes and clinical symptoms of iron deficiency anemia in children. 13. Indicate the screening guidelines for lipid disorders in children. 14. Discuss impairments of special senses (hearing & vision) in children. 15. Identify the hallmarks for suspecting a child with autism. 16. Discuss the importance of confidentiality when caring for adolescents. 17. Identify the risk factors for suicide and depression in the pediatric population. 18. State behavioral symptoms of adolescents which may be warning signs for potential suicide and what to do with patients displaying these symptoms. 19. Describe the components of the “HEEADSSS” interview format and include why each area is important. Principles of Child Development 1. Child development proceeds along a predictable pathway. 2. The range of normal development is wide. 3. Various physical, social, and environmental factors, as well as diseases, can affect child development. 4. The child development level affects how you conduct the Hx & PE. Health Promotion Themes • • • • • • • • • Family support Child development Mental health Healthy weight/ nutrition Physical activity Oral health Healthy sexual development & sexuality Safety & injury prevention Community relationships and resources Health Promotion Themes Family Support • Health and well-being is dependent on parents and other caregivers—their families. • Focus on both the family’s growth and development along with the growth and development of the child. • Basis of partnership Child Development • Health promotion to ensure physical, cognitive and social emotional health. • Protect the child from infectious diseases and injuries (intentional and unintentional). • Take into account the development reality of the child now, as well as their development expectations for the next months and the development potential for growth over time. Health Promotion Themes Mental Health • Parents, family, community and professionals help foster the development of a child’s mental health. • Aimed at prevention, risk assessment and diagnosis as well as to offer an array of resources and interventions. • Age 14—mental disorders are chronic diseases of the child. ½ of disorders start here. Healthy Weight • Is important to childhood and future adult health. • Has interrelationships with lifestyle, behavior, the environment and family life. • Focus on assessing, managing and preventing overweight and obesity. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Health Promotion Themes Healthy Nutrition • Every child’s and adolescent’s growth, health, and development depends on good nutrition. • Influenced by numerous environmental and cultural forces. Physical Activity • It is an essential component of a healthy lifestyle. • Increases self esteem, capacity for learning, handling stress, and psychological well being. • It should be emphasized early in life. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Health Promotion Themes Oral Health • Covers a range of health promotion and disease prevention concerns. • Health care professionals teach oral hygiene, healthy diet and feeding practices, optimal exposure to fluoride and timely referral to a dentist. • Dental caries: most chronic disease in children • 5 times more common than asthma • Can lead to problems with eating, speech • 1 year old: dentist should be established Healthy Sexual Development and Sexuality • Integrate into health supervision from early childhood through adolescence – address sexual maturation, family/cultural values, informed sexual decision making, safety, personal goals, etc. • Health care professionals should provide confidential, culturally sensitive and nonjudgmental counseling and care. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Health Promotion Themes Safety and Injury Prevention • Assess the parents’ and the child’s current safety strategies. • Help educate and motivate parents in keeping their children safe. • Encourage and praise positive behaviors. • Intentional injury vs. unintentional injury • Considered preventable and mainly predictable. • Intentional- result from behaviors that are designed to hurt one-self or others. -Homicide is the 2nd leading cause of death among 1-21 y/o. -Suicide is the 3rd leading cause of death. • Unintentional injury continues to be the leading cause of death and morbidity among children older than 1 year, adolescents and young adults (e.g. MVA). • Provide guidance about potential risks and recommend participation in community interventions that promote safety – like First Aid and CPR classes, have a first aid kit, know Poison control number, know when to call PCP and when to go to ER. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Health Promotion Themes Community Relationships and Resources • • Broad range of community-based services Build community relationships and resources – family support, housing, employment, social services, educational services, mental health services, substance misuse treatment, language assistance, recreation opportunities, services for child and youth with special health care needs, etc. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Well Child Examination General Considerations Ages and Stages of Development Infancy (prenatal – 11 mo.) Early childhood Middle childhood Adolescenc e ( 1 – 4 yrs.) (5 – 10 yrs.) (11 – 21 yrs.) What is a Well Child Examination (WCE)? Age-specific health supervision visit Aimed at disease detection and prevention along with health promotion and anticipatory guidance Family-centered emphasis (parental concerns) NOT only in the WCE, but… • Prevention should be incorporated into every health care visit, no matter the chief complaint. • These “opportunistic” discussions should focus on: 1. 2. 3. Expressed parental concerns (fever and rash) Issues to note regarding the physical exam (child is overweight) The most threats to the child’s health at that age (3 years…most common injuries discussion) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition . Approach to Well Child Examination History Physical exam Laboratory or Screening Tests (if appropriate) Immunization Anticipatory guidance Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Pediatric History Geared at discovering current problems and potential threats to the child’s health. Integrate concerns of family with agenda for visit because it is significant indicator of developmental delay. -speech delay is most common delay Special attention to: Birth and perinatal history Immunizations Developmental and school history Family history (tailored to childhood-onset diseases) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition Pediatric Physical Exam Growth measurements (i.e. weight, length, BMI, head circumference) -Measure head circumference until age 2 y/o -BMI—not a predictor of adult obesity Vital signs: *See next slide. Ophthalmic exam to screen for: Retinoblastoma or congenital cataracts Amblyopia or strabismus Defects in visual acuity (subjective until around age 3 yo) Cardiovascular exam Genitourinary exam Detect abnormalities like undescended testes or inguinal hernia Discuss issues such as modesty, prevention of sexual molestation and information about normal development Scoliosis exam (rule out asymmetry of scapula or iliac crests) Pediatric Vital Signs Laboratory & Screening Tests Laboratory Tests Screening Tests • • Autism • • Developmental Depression • • Hearing Vision • • • • Newborn Anemia Lead TB Lipid Pediatric Laboratory Tests Newborn Anemia Lead TB Lipid • See Canvas for NBS brochure • Screens for 29 disorders • RF: Pre-term, low birth weight, multiple pregnancy, mother with deficiency, use of non-fortified formula or cow’s milk before 12 mo • Universal screen at 12 mo • RF: Live in home built in 1950 or in 1978 that is being renovated, sibling being treated • Universal screen at 12 mo and 24 mo for patients with Medicaid or in high prevalence areas • RF: Recent immigration, exposure to known person- TB/incarcerated/IV drug user/HIV+ • RF: +FH, child with DM and HTN, BMI > 95th percentile, chronic kidney disease, chronic inflammatory disease • Universal screen between ages 9-11 yo and 18-21 yo Pediatric Screening Tests Autism Developmental • Universal screen at 18 mo and 24 mo • Article posted on Canvas • Surveillance is an ongoing process in which the clinician’s conscientious, skilled observation permits detection of obvious abnormalities or concerns • Screening is a formal process applied to a patient in whom surveillance has revealed a concern • 9 mo, 18 mo, 30 mo. Depression • Universal screen in adolescence • GLAD-PC, PHQ-9 (see Canvas for Questionnaire) • http://www.gladpc.org/ Hearing • Universal screen at newborn, 4-6 yo, 8 yo and 10 yo Vision • Universal screen at age 3-6 yo, 8 yo, 10 yo, 15yo and 18 yo PHQ-9 Interpretation Score Depression Severity 5 – 9 Mild 10 – 14 Moderate 15 – 19 Moderately Severe 20 – 27 Severe Pediatric Immunizations • Should be given at the earliest recommended age. • For most vaccines, simultaneous administration does not impair antibody responses or increase rates of adverse reactions. • Unfounded reasons for deferring vaccines: 1. 2. 3. 4. 5. 6. Mild illnesses Low-grade fever Penicillin allergy History of premature birth Family history of allergies Current antibiotic therapy How should a clinician approach parents who refuse vaccinations for their children? • • • • • • • Listen carefully and respectfully. Attempt to understand the parent’s concerns and correct any misperceptions/misinformation. Refer parents to one of several reputable and evidence-based websites: • http://www.immunize.org/talking-about-vaccines/responding-to-parents.a sp Be flexible – may need to modify schedule. Explore the possibility that cost is a reason. Revisit the discussion at each subsequent visit. Good documentation of the discussion of the benefits of immunization and risks associated with remaining parents sign waiver. unimmunized; Well Child Examination Age-specific considerations Infancy (Prenatal – 11 months) Prenatal and Newborn visits First week visit 1 month visit 2 month visit 4 month visit 6 month visit 9 month visit Prenatal Visit • Establish a relationship. • Provides an opportunity to introduce parents to the practice, gather basic information, provide guidance, identify high-risk situations and promote parenting skills. • Some topics include: 1. 2. 3. 4. 5. Newborn screening test Breastfeeding Immunization Family resources Safety (i.e. car seat, pets, smoking, smoke detectors, water heater settings, etc.) Newborn Visit • Occurs while still in the hospital • Development: periods of wakefulness, responsive to parents voice and touch, looks at parents when awake, calmed when picked up, moves in response to visual or auditory acuity • Tests: Obtain newborn screen, hearing screen, give 1st Hepatitis B vaccine before discharge • Some topics include: 1. 2. 3. 4. 5. Family readiness Infant behaviors Feeding Safety Routine baby care First Week Visit • Occurs within 3 – 5 days of birth and within 48 – 72 hours after discharge • Development: follows face to midline, briefly fixes on faces/objects, communicates needs through behaviors, lifts head briefly in prone position • Known health risks include: jaundice, feeding difficulties, excessive weight loss, sepsis, detection of congenital malformations • Some topics include: 1. 2. 3. 4. 5. Parental well-being Newborn transition Nutritional adequacy Safety Newborn care 1 Month Visit • Routine health surveillance, response to parental concerns, encouragement; support and practical guidance about infant’s growth and nutrition, development, sleep pattern • Development: able to follow parents with eyes, recognizes parent’s voices, smiles, lift head when on tummy; undifferentiated cry • Tests: 2nd Hepatitis B vaccine • Some topics include: 1. 2. 3. 4. 5. Parental well-being Family adjustment Infant adjustment Feeding routines Safety 2 Month Visit • Routine health surveillance, reinforce good practices • Development: able to console and comfort self, differentiated cries, coos, begins to push up in prone, consistent head control in supported sitting • Tests: 1st doses of Rotavirus, DTaP, Hemophilus influenza type b, Pneumococcal, Inactivate Poliovirus • Some topics include: 1. 2. 3. 4. 5. Parental well-being Infant behavior Infant-family synchrony Nutrition adequacy safety 4 Month Visit • Development: smiles spontaneously, babbles, indicates pleasure and displeasure, pushes chest to elbows, good head control, begins to roll and reach for objects • Tests: 2nd doses of Rotavirus, DTaP, Hemophilus influenza type b, Pneumococcal, Inactivate Poliovirus • Some topics include: 1. 2. 3. 4. 5. Family functioning Infant development Nutrition adequacy and growth Oral health Safety 6 Month Visit • Development: socially interactive, recognizes faces, enjoys voice turn taking, rolls over, sits, stands and bounces, crawl • Tests: 3rd doses of Rotavirus*, DTaP, Hemophilus influenza type b*, Pneumococcal, Inactivate Poliovirus and Hepatitis B; annual influenza vaccine (if applicable) • Some topics include: 1. 2. 3. 4. 5. Family functioning Infant development Nutrition and feeding Oral health Safety * = depends on vaccine used 9 Month Visit • Development: apprehension to strangers, seeks out parents, repetitive consonants and vowel sounds, explores environment • Tests: Structured development screen, catch up immunizations • Some topics include: 1. Family adaptations 2. Infancy independence 3. Feeding routine 4. Safety Early Childhood (1 – 4 years) 12 month visit 15 month visit 18 month visit 2 year visit 2 ½ year visit 3 year visit 4 year visit 12 Month Visit • Development: plays interactive games, waves “bye-bye”, speaks 1-2 words, follows simple directions, stands alone, bangs objects together • Tests: Anemia, oral health; lead; 4th dose of Pneumococcal, 1st dose of MMR, Varicella and Hepatitis A • Some topics include: 1. 2. 3. 4. 5. Family support Establishing routines Feeding and appetite changes Establishing a dental home Safety 15 Month Visit • Development: listens to story, imitates activities, says 2-3 words, scribbles, walks well, can step backwards, drinks from cup • Tests: 4th dose of DTaP, 2nd dose of Hepatitis A • Some topics include: 1. 2. 3. 4. 5. Communication and social development Sleep routines and issues Temper tantrums and discipline Healthy teeth Safety 18 Month Visit • Development: laughs in response to others, stacks 2 or 3 blocks, uses spoon/cup, walks up steps, runs, speaks 6 words, points to 1 body part • Tests: Autism and structured development screens oral health; catch up immunizations • Some topics include: 1. 2. 3. 4. 5. Family support Child development and behavior Language promotion/hearing Toilet training Safety ; 2 Year Visit • Development: imitates adults, refers to self as “I” or “me”, 50 word vocabulary, follows 2-step command, uses 2 word phrases, turns pages, throws ball overhead, jumps • Tests: Autism screen, lead, oral health; catch up immunizations • Some topics include: 1. 2. 3. 4. 5. Assessment of language development Temperament and behavior Toilet training Television viewing Safety 2 ½ Year Visit • Development: plays with other children, has fears, uses 3-4 word phrases, understandable to others 50% of time, points to 6 body parts, brushes teeth with help • Tests: structured development survey, oral health; catch up immunizations • Some topics include: 1. 2. 3. 4. 5. Family routines Language promotion and communications Promotion social development Preschool considerations Safety 3 Year Visit • Development: has self-care, converses in 2-3 sentences, understandable 75% of the time, identifies self as boy/girl, day toilet trained, copies circle, knows name • Tests: oral health, vision; catch up immunizations • Some topics include: 1. 2. 3. 4. 5. Family support Encouraging literacy activities Playing with peers Promoting physical activity Safety 4 Year Visit • Development: describes features of self, engages in fantasy play, names 4 colors, balances on 1 foot for seconds, dresses self, brushes teeth, draws person with 3 body parts • Tests: vision, hearing; 5th dose of DTaP, 4th dose of Inactivated Poliovirus, 2nd dose of MMR and Varicella • Some topics include: 1. 2. 3. 4. 5. School readiness Developing healthy personal habits Television/media Child and family involvement in community Safety Middle Childhood (5 – 10 years) 5 and 6 year visits 7 and 8 year visits 9 and 10 year visits 5 and 6 Year Visits • Development: able to tie knot, mature pencil grasp, prints some letters and numbers, counts to 10, names 4+ colors, can draw person with at least 6 body parts • Tests: oral health, vision, hearing; 5th dose of DTaP, 4th dose of Inactivated Poliovirus, 2nd dose of MMR and Varicella • Some topics include: 1. 2. 3. 4. 5. School readiness Mental health Nutrition and physical activity Oral health Safety 7 and 8 Year Visits • Opportunity for health care professional to talk directly with child and build a trusting relationship • Begins to assume personal responsibility for health • Tests: vision, hearing; catch up immunizations • Some topics include: 1. 2. 3. 4. 5. School Development and Mental health Nutrition and physical activity Oral health Safety 9 and 10 Year Visits • Puberty is beginning in some children. May want to meet with child alone. • Development: Sense of self-confidence and hopefulness, increasingly responsible and independent decision making • Tests: vision, hearing, lipid; catch up immunizations • Some topics include: 1. 2. 3. 4. 5. School readiness Mental health Nutrition and physical activity Oral health Safety Can you see a minor without parental consent? While most states do require parental consent for most medical procedures, there are numerous exceptions allowing for Minor Consent. Here are the typical treatment areas where many states allow Minor Consent to suffice: • STIs • Drug and alcohol use • Mental health care • Blood donation • Pregnancy-related care https://docs.google.com/document/d/19Dxg-VMqTGwFnoLRMGmB_XL bXA5bDHjVX3GMNzsW2YU/edit Adolescence (11 – 21 years) Early adolescence (11 – 14 years) Middle adolescence (15 – 17 years) Late adolescence (18 – 21 years) Adolescence • *Important Confidentiality HEEADSSS Assessment • Home environment • Education/Employment • Eating • Activities • Drugs & alcohol • Sexuality • Suicide/Depression/Self-harm • Safety from injury & violence HEEADSSS Assessment Home: Who lives at home? How are things at home? How do you get along with everyone? Education: Tell me about school? What grade are you in? What is your favorite class? Eating: Any recent changes in weight or appetite? Likes/dislikes about body? Worry about having food to eat? Activities: Are you in any after school sports or clubs? Youth groups? What do you do for fun? Do you have a best friend? Concerns about online activity? Drugs & alcohol: Illicit drugs? ETOH? Tobacco? Sexuality: Men, women, or both? Anal, Oral, Vaginal? Contraception? H/o STI? Suicide/self-harm: Have you ever been so sad or mad that you thought about hurting yourself or killing your self? Safety: Has anyone ever touched you sexually in a way you did not want them to? Have you ever been physically abused? Ever been picked on or bullied? Violence in home or school? Access to firearms? 11 – 14 Year Visits • Development: Sense of self-confidence and hopefulness, increasingly responsible and independent decision making; resiliency when confronted with life stressors. • Tests: vision, depression screen; booster Tdap, 1st dose of HPV vaccine and Meningococcal vaccine • Some topics include: 1. 2. 3. 4. 5. Physical growth and development Social and academic competence Emotional well-being Risk reduction Violence and injury prevention 15 – 17 Year Visits • Development: Sense of self-confidence and hopefulness, increasingly responsible and independent decision making; resiliency when confronted with life stressors, positive engagement with community • Tests: vision, STI/HIV and depression screen; booster Meningococcal • Some topics include: 1. 2. 3. 4. 5. Physical growth and development Social and academic competence Emotional well-being Risk reduction Violence and injury prevention 18 – 21 Year Visits • Development: Sense of self-confidence and hopefulness, increasingly responsible and independent decision making; resiliency when confronted with life stressors, positive engagement with community • Tests: lipid, STI/HIV and depression screen • Some topics include: 1. 2. 3. 4. 5. Physical growth and development Social and academic competence Emotional well-being Risk reduction Violence and injury prevention Additional Resources American Academy of Pediatrics. (2023). Bright futures guidelines and pocket guide. https://www.aap.org/en/practice-management/bright-futures/bright-futures-materials-and-tools/bright-f utures-guidelines-and-pocket-guide/ CDC developmental milestones. https://www.cdc.gov/ncbddd/actearly/milestones/index.html CDC Screening and diagnosis of Autism Spectrum Disorder (ASD). https://www.cdc.gov/ncbddd/autism/screening.html Vaccine Preventable Diseases https://www.healthychildren.org/English/health-issues/vaccine-preventable-diseases/Pages/default.as px References 1. Abzug, M. J., Deterding, R. R., Hay, W. W., & Levin, M. J. (2014). Current Diagnosis and Treatment Pediatrics 22nd Edition. New York: McGraw-Hill Education. 2. Duncan, P. M., Hagan, J. F., & Shaw, J. S. (2008). Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, 3rd Edition. Elk Grove Village: American Academy of Pediatrics. 3. Engorn, B., & Flerlage, J. (2015). The Harriet Lane Handbook: A Manual for Pediatric House Officers 22nd Edition. Philadelphia: Elsevier Saunders. 4. Ferguson, L. E., & Moyer, V. A. (2008). Health Promotion and Disease Prevention for Children and Adolescents 2nd Edition. In S. Jonas, E. Kaplan-Liss, & S. H. Woolf, Health Promotiona and Disease Prevention in Clinical Practice (pp. 435-459). Philadelphia: Lippincott Williams & Wilkins. 5. Wolfe, R. M. (2008). Immunizations. In S. Jonas, E. Kaplan-Liss, & S. H. Woolf, Health Promotion and Disease Prevention in Clinical Practice 2nd Edition (pp. 359434). Philadelphia: Lippincott Williams & Wilkins.