Well Child Care

Proper methods of obtaining length in pediatric pts <2 years: ≥2 years: Read to nearest: Identify:

- <2 years old measure recumbent length - ≥2 years old and is able to stand, measure standing height -Read to nearest: 0.5 cm or ¼ inch -Identify: percentile based on length

General rules for weight gain/loss in babies

- Lose 5-10% birth weight first few days of life **Return to birth weight ~7-10 days of life • 2xs birth weight at ~4 months of age • 3xs birth weight at 1 year • 4xs birth weight at 2 years

Healthy newborn average weight

-5 lb, 8 oz to 8 lbs, 13 oz

When are routine visits recommended in adolescence?

-Annually from 11 yr- 21 yrs -Can be combined with sports physicals

In a HBsAg-positive mother be able to give the appropriate vaccination and treatment to the infant. x

-HepB vaccine -0.5 mL Hepatitis B Immune Globulin (HBIG) within 12 hours of birth at separate sites

What vaccinations are recombinant products, subunit, conjugate, or polysaccharide?

-Hepatitis B -Hib (Haemophilus influenzae type b) disease -HPV -Whooping cough -Pneumococcal disease -Meningococcal disease -Shingles (Shingrix)

Lead level that may cause problems

-Lead level as low as 5-10 mg/dL may cause learning problems. -Oct 2021, CDC lowered the population-based blood lead reference value from 5 to 3.5 mg/dL

What vaccinations are live attenuated?

-MMR -Varicella -Rotavirus -Yellow fever -Smallpox -Shingles (old- Zoster) -Influenza (Intranasal) -Oral Typhoid

Development (0-5 years) is subdivided into categories with milestones for each age. What are these categories?

-MSK (Gross Motor and Fine Motor Development) -Language/communication Development -Social/emotional Skills - Cognitive development

What conditions indicate newborn at high risk of anemia?

-Maternal anemia -comorbid obesity and DM delivered large for gestation

When are pediatric visits routinely recommended in infancy?

-Newborn exam (Inpatient) -3-5 days after birth (The first week of life visit) -1 mo, 2 mo, 4 mo, 6 mo, 9 mo

What vaccinations are inactivated/killed?

-Polio -Hepatitis A -Rabies -Influenza (inactivated or recombinant)

Risk factors for developmental and behavioral problems in childhood

-Prenatal exposures: Infections, alcohol, smoking -Birth complications: Prematurity or low birth weight -Perinatal infections: Herpes simplex virus, Zika virus) -Medical conditions: Lead poisoning, congenital heart disease -Genetic conditions: Down syndrome, fragile X syndrome -Adverse childhood or family experiences: Poverty, housing or food insecurity; exposure to racism; abuse or neglect -Parental/ caregiver unemployment or mental health problems: Depression, anxiety, substance use -Parents /caregivers with limited education/literacy -Teenage parents

Factors protective against developmental problems in childhood

-Strong connections within a loving, supportive family -Active caregiver-child engagement (eg, teaching, soothing, back-and-forth conversation, sharing books, etc) -Opportunities to interact with other children -Opportunities to grow in independence in an environment with appropriate structure

Define underweight, overweight and obesity according to pediatric BMI percentiles

-Underweight (<15%) -Overweight (85-95%) -Obese (≥95%) - Severe (class II) obesity >120 percent

Guidelines for vision screening in pediatrics

-Visual evoked response testing (infants) - Acuity by Snellen chart (age specific) - Annually from 3-10 years, then @ 12, 15, 18 yrs of age (unless concern)

What growth patterns are concerning?

-Weight, length, head circumference all < 5 percentile - Markedly discrepant percentiles **Example: Wt and Lt 10%, HC 75% - Declining percentiles; Must establish pattern over time

What growth charts are used to for determining pediatric health in 0-36 months of age? what about 2-20 years?

0-36 months -Wt for age -Length for age -HC for age -Wt:Length 2- 20 years -Wt for age -Height for age (stand) -(no HC) -Body mass index

How do you talk to an anti-vaxxer parent

1. Be respectful 2. Don't bombard them with facts 3. Ask questions 4. Find out where they're coming from 5. Encourage additional research with reliable resources and time to consider. Don't try to pressure them into the vaccination that day.

Normal growth for infants during the first year of life

10 inches during the first year of life

When are routine visits recommended in early childhood?

12 mo, 15 mo, 18 mo, 24 mo, 30 mo, 3 yr, and 4 yr

Normal growth for children age 4 until puberty?

2 inches per year (5 cm per year)

Normal length of newborn

20 inches

When do children reach half their adult height?

24 to 30 months

When are routine visits recommended in middle childhood?

5 yr, 6 yr, 7 yr, 8 yr, 9 yr, 10 yr

When is height measured?

>24-36 months when cooperative child can do so

Pneumococcal polysaccharide vaccine recommendations

Adults >65 years of age and Persons >2 years with: •Chronic illness •Anatomic or functional asplenia •Immunocompromised (disease, chemotherapy, steroids) •HIV infection with low CD4+ count •Environments or settings with increased risk •CSF leaks •Cochlear implants

General topics covered in HPI at well child visits? 1-4 months and on: 6-12 months add: 15-24 months add: 30-36 months add: 4 yrs add: 5 yrs add: 6-11 yrs add:

All ages (1-4 months and on): - Historian and who does the patient live with - Nutrition/Breastfeeding/Formula/Feeding problems - Elimination - Sleep - Safety /environment - Screenings /immunizations - Social 6-12 months add: - dental - additional nutrition? solid food intake? 15-24 months add: - nutrition (food groups, junk food) -behavior 30-36 months: - add elimination issues (toilet training?) - sleeping in a different room than parents? 4 year old add: -dental/flossing? 5 year old add: - school location?, learning disabilities?, social?, screen time? 6-11: - bedwetting/elimination problems?

Guidelines for auditory screening in older children

Annual testing 4-10 years, then @ 12, 15, 18 yrs of age (unless concern)

Growth charts assess for: Often best indicator of: What should always be plotted in infant up to 2 yrs old:

Assesses for: abnormal changes in growth patterns **A well-plotted growth chart is often best indicator of many medical conditions -Wt:Ht ratio and HC should always be plotted in infants and children up to 2 years of age

How is BMI calculated?

BMI= [(Kg) ÷ (m)2] OR Lbs / (in)2

What vaccine is mRNA?

COVID

What is caused by inadequate caloric intake in pediatric patients?

Causes predictable "failure" in growth: 1st-weight 2nd-height, 3rd- Head circ. ***Loss of HC is ominous—brain growth

Length vs height in pediatric patients are the same

Child's length > height because lordosis is common in young children **Length and height are not the same: use correct growth chart.

Ohio guidelines for lead screening in pediatric patients

Children should be tested at age 1 and 2 years, or up to age 6 if no previous test has been done, based on the following criteria: -If your child is on Medicaid, your child must be tested. -If your child resides in a high-risk ZIP code (see the link below for the list), he/she must be tested. n(FYI we are a high-risk zip code)

What are "milestone" screenings?

Developmental assessments performed at every well visit -Observe and "test" child during exam

Physical exam for well-child check

General: Assess nutrition status and developmental status. Current appearance and demeanor in office. Skin: General skin assessment, looking for abnormal lesions, rashes, or markings HEENT Cardiac: Examine as discussed, assess for auscultation abnormalities (murmurs, rate, or rhythm issues) recognize normal for rate and rhythm based on age. Palpate pulses to assess for equal strength. (Sports physical: Auscultate during a patient squat or valsalva). Pulmonary: Assess chest wall for any deformities or abnormalities, auscultate lungs as taught. GI: Observe, auscultate, palpate, assess as taught, you will likely have to distract kids as they more easily flex against palpation. GU: Every year, every kid, it is recommended to do a GU exam. Tanner stages, rashes, anatomic abnormalities, etc. Chaperoned** MSK Neuro: Mental status, motor function and balance, sensory examination, reflexes, CN examination (as able). Psych: General mood, affect, attention, judgement, speech, and behavior.

Recommendations for influenza vaccination in children

Given yearly •IIV (inactivated influenza vaccine) -Trivalent or quadrivalent flu vaccines -Can be given yearly starting as early as 6 months •LAIV (live, attenuated) -Only available as nasal spray - Not given to children under the age of 2 years

Pediatric HEENT exam

Head: Palpate skull- Anterior and posterior fontanelles, examining for any skull or facial deformities or hair abnormalities Eyes: Pupil assessment, conjunctiva, tracking, deviations (cover/uncover), red light reflex, general anatomy. Ears: Examine ears as taught including hearing, pull downward for infants, upward for toddlers and up, use smaller tip for otoscope. (if young wait till end) Nose: Assess as taught, look for any deformities or abnormalities Throat: Assess as taught, checking teeth/dental hygiene, looking for any deformities or abnormalities of mouth, oral mucosa, and oropharynx. (If young, wait till end of exam)

Screening guidelines for pediatric anemia High risk: Normal/healthy: Sooner if: Adolescents:

Infants: -Newborns tested if high risk - 9-12 months of age: healthy term infant with additional screening between ages of 1 and 5 years for patients at risk. -Sooner if: premature, low birth weight infant - If anemic: hemoglobin electrophoresis Adolescents: -Once for males - Annual for menstruating females

When should head circumference measurements be taken?

Measure every "well" visit from birth - 2 y/o and identify percentile based on growth chart **Measure annually thereafter or if concerned

Normal newborn head circumference

Newborn average 35 cm (13.7 in)

Good DAILY weight gain for a healthy Newborn 0-3 months: Infant 3-6 months: 6-12 months:

Newborns: 30g (1oz) per day Infants: 20g per day (0.67oz) 6-12 months: 10g per day between

How should vaccination be approached when the patient has a mile/acute illness

No evidence that acute illness reduces vaccine efficacy or increases vaccine adverse reactions •Vaccines may be delayed until the illness has improved •Mild illness, such as otitis media or an upper respiratory infection, is NOT a contraindication to vaccination

Pediatric MSK exams Non sports physical: Sports Physical:

Non-sports physical: Check for bony deformities, ROM in all major joints, Barlow, Ortolani, gait assessment, spinal assessment for curvatures. Sports physical: Add ROM and strength of all muscles/joints, duck walk, single leg hop. Additional cardiac assessment (Squatting or Valsalva).

Normal vision ages 3: 4-5: 6-7:

Normal findings: -3 y/o 20/40 -4-5 y/o 20/30 -6-7 y/o 20/20

risks for lead poisoning

Old home (before 1978), peeling lead-based paint, industrial exposure, eating on pottery with lead glaze, lead water pipes, hobbies or jobs involving lead. Association with poverty

Proper method of obtaining height in a pediatric patient?

Place heels, buttocks, shoulders against wall

What vaccine is a monoclonal antibody?

RSV

MCC of diarrhea in infants and children

Rotavirus •The most severe disease occurs among children 3-24 months of age

Guidelines for urinalysis in pediatrics

Screening urine dipstick test: -Annual for sexually active adolescents -Obtain microscopy if +RBCs or + WBCs

15 month milestones Social: Language: Cognitive: Physical/Movement:

Social: -copies other children while playing -shows you object they like -claps when excited -hugs doll -shows you affection Language: -tries to says two words besides mama or dada Cognitive: -tries to use things right way cup/phone stacks two small objects Physical/Movement: -take few steps on own -uses fingers to feed themselves food

6 month milestones Social: Language: Cognitive: Physical/Movement:

Social: -knows familiar people -likes to look at self in mirror -laughs Language: -takes turns making sounds with you -blows raspberries -makes squealing noises Cognitive: -things in mouth to explore -reaches/grabs -closes lips to show they don't want more food Physical/Movement: -roll from tummy to back -push onto straight arms -leans on hands to support when sitting

12 month milestones Social: Language: Cognitive: Physical/Movement:

Social: -plays games with you Language: -waves bye bye -calls mama or dada -understands no Cognitive: -put something in container -looks for things you hide Physical/Movement: -pulls to stand -drinks from cup w/o lid -cruising -picks things up with thumb and pointer finger

9 month milestones Social: Language: Cognitive: Physical/Movement:

Social: -shy/clingy -facial expressions -looks when name is called -reacts when you leave -smiles/laughs when you play game Language: -makes sounds -lifts arms to be picked up Cognitive: -looks for objects when out of sight -bangs things together Physical/Movement: -sitting position by self without support -moves things from one hand to another -rakes food towards them

2 month milestones Social: Language: Cognitive: Physical/Movement:

Social: -calm when spoken/picked up -look at you -happy when they see you -smile when you talk Language: -makes sounds other then crying -reats to loud sounds Cognitive: -watches you as you move -looks at toy for several seconds Physical/Movement: -holds head up when on tummy -moves both arms and legs -opens hands breifly

18 month milestones Social: Language: Cognitive: Physical/Movement:

Social: -moves away from you but looks to make sure your close -points to show you something -puts hand out to wash -helps dress themselves (arm through sleeve) Language: -three or more words -follows one step directions Cognitive: -copies chores -plays with toys (simple) Physical/Movement: -walks w/o holding anything -drinks from cup without lid -feeds self with fingers -tries to use spoon -climbs on and off couch

4 months milestones Social: Language: Cognitive: Physical/Movement:

Social: -smiles on own -cuckles -looks, moves or movement to get attention Language: -cooing -makes sounds back -turns head towards sound Cognitive: -opens mouth when hungry -looks at hands in interest Physical/Movement: -holds steady w/o support -holds toy in clenched hand -swings toy -hand to mouth -pushes to elbows

Normal growth for toddlers 12-24 months: 24-36 months: 36-48 months:

Toddlers grow: • 4 inches between 12 and 24 months • 3 inches between 24 and 36 months • 3 inches between 36 and 48 months

What vaccinations are toxoids?

Toxoids (from bacteria) -Diptheria -Tetanus

when are comprehensive developmental screenings done

at 9 months, 18 months, and 30 months

How is lead screening done?

blood lead level (BLL). -Can be measured on a capillary or venous blood sample -The blood lead reference value 3.5mg/dL is used to guide decisions about medical or environmental follow up for individual children

Proper method of obtaining weight measurement in a newborn/infant?

• Weigh baby NAKED • Use an infant scale and measure in oz or grams. **Ideal to use same scale each visit. •Read weight to nearest 10 gm or ½ oz when infant is most still •Identify percentile based on weight •Be sure to use corrected chart if baby is a pre-term infant.

Rotavirus vaccine schedule

•Administered at 2, 4, (and potentially 6) months of age •Minimum age of first doses is 6 weeks •First dose should be administered between 6 and 12 weeks of age (until age 13 weeks) •Do not initiate series after 12 weeks of age •Rotarix (RV1)- 2 dose series (2 and 4 months) •RotaTeq (RV5)- 3 dose series (2, 4 and 6 months)

recall the principals of vaccination general rules

•All vaccines can be administered at the same visit as all other vaccines (efficiency, early protection, lower cost of visits) •Increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine. •Decreasing the interval between doses of a multidose vaccine may interfere with antibody response and protection. •Therefore, vaccine doses should NOT be administered at intervals less than the minimum intervals or earlier than the minimum age

Guidelines for cholesterol screening in pediatric patients

•Birth- 2 years: Generally, not indicated •2-8 years: Selective screening if there are risk factors for premature CVD. •9-11 years: ALL due to lipid stability during this time before puberty •12-16 years: Universal screening is not recommended because of normal changes in lipid levels during puberty. •17-21 years: ALL

Routine Hib Primary Vaccination Schedule

•Children who have fallen behind schedule with Hib vaccine may not need all the remaining doses of a 3 or 4 dose series •The number of doses needed to complete the series should be determined using the catch-up schedule, published annually with the childhood schedule

Difference between a contraindication to a vaccine and precaution?

•Contraindication: •A condition in a recipient that greatly increases the chance of a serious adverse reaction •Example: Use of live vaccines in immunocompromised individuals •Precaution: •A condition in a recipient that might increase the chance or severity of an adverse reaction, or •Might compromise the ability of the vaccine to produce immunity •Example: Inactivated vaccines are safe to use in immunosuppressed persons but the response to the vaccine may be decreased

Difference between DTaP and Tdap

•DTaP (pediatric) •Approved for children 6 weeks through 6 years (to age 7 years) •Contains same amount of diphtheria and tetanus toxoid as pediatric DT •Tdap (adolescent and adult) •Approved for persons 10-18 years (Boostrix) and 11-64 years (Adacel) •Contains lesser amount of diphtheria toxoid and acellular pertussis antigen than DTaP

Recall the signs and symptoms of congenital rubella and how to prevent it from occurring.

•Deafness •Cataracts •Heart defects •Microcephaly •Intellectual disability •Bone alterations •Liver and spleen damage •Ways to prevent: Mother should be vaccinated against rubella

How do influenza vaccine recommendations change based on presence of egg allergy

•Egg allergy, hives only: Any influenza vaccine appropriate for age and health status annually • •Egg allergy more severe than hives (angioedema or respiratory distress): Give vaccine in medical setting under supervision of health care provider that can manage severe allergic reactions

Approach to developmental surveillance

•Elicit and attend to caregiver concerns •Maintain a developmental history to review at subsequent visits •Observe caregiver-child interactions •Identify risk and protective factors •Record findings and plans; collaborate

MMR vaccine schedule

•First Dose: -Between 12-15 months of age •Second dose: -Between ages 4 to 6 years

Dental screening recommendations for pediatrics

•Frist oral exam by dentist is recommended no later than 12 months of age. •Children at higher risk for dental caries would benefit at greater frequency of visits, consider q3 months instead of q6 months

Normal head circumference growth in newborn/infant?

•HC increases ~1 cm/month for 1st year of life •Most rapid growth is first 6 months •Most head growth is complete by 4 years of age.

HPV vaccination recommendations for children

•HPV vaccination routinely recommended for all adolescents age 11-12 years (can start at age 9) and through age 18 if not previously adequately vaccinated •Age 9-14 an initial vaccination •2 dose series at 0, 6-12 months from first shot •Age 15 years or older at initial •3 dose series at 0, 1-2 months from first shot, 6 months from 2nd shot •Hx of sexual abuse or assault: Start at age 9

Guidelines for infant auditory screening

•Hearing evaluation done before hospital discharge after birth: Earphones playing sounds, transmission of impulse to brain is documented •If abnormal » refer for BAER testing (Brainstem auditory evoked response)

Hepatitis A recommendations in children

•Hepatitis A vaccine is recommended for children and adolescents in selected states and regions and for certain high-risk groups •Special consideration for international travelers •The 2 doses in the series should be administered at least 6 months apart. •Minimum age: 12 months for routine vaccination

Meningococcal vaccine recommendations for pediatric patients

•Meningococcal serogroup B •Bexsero and Trumenba •16-23 years old, most get before college •Functional or anatomic asplenia, complement component deficiencies, immunocompromised patients need booster doses regularly. •Meningococcal conjugate vaccine (serogroups A, C, W, Y vaccine) •Menactra and Menveo •1st dose 11-12 years, 2nd dose 16 years Sooner for high-risk patients

What are invalid reasons NOT to give a vaccination

•Mild illness •Antimicrobial therapy •Disease exposure or convalescence •Breastfeeding •Preterm birth •Allergy to products not present in vaccine or allergy that is not anaphylactic •Family history of adverse events •Tuberculin skin testing •Multiple vaccines

Varicella vaccine schedule

•Routine vaccination at 12-15 months of age •Routine second dose at 4-6 years of age

Know the protocol to follow if you have an infant born to a mother whose HBsAg status is unknown.

•Should receive the first dose of the HepB series within 12 hours of birth. •Maternal blood should be drawn as soon as possible to determine the mother's HBsAg status; if the HBsAg test is positive, the infant should receive HBIG as soon as possible (no later than age 1 week).

Primary pneumococcal vaccination (PCV-13 and PPV) recommendations

•The heptavalent pneumococcal conjugate vaccine (PCV-13) is recommended for all children age 2 to 23 months. •Doses at 2, 4, 6, months of age, booster dose at 12-15 months of age •Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups

When should LAIV not be used

•Those with a history of severe allergic reaction to any component of the vaccine (excluding eggs) •A severe allergic reaction to a previous dose of any influenza vaccine •Children and adolescents receiving concomitant aspirin or salicylate containing meds •Children age 2-4 with a hx of asthma or wheezing •Immunocompromised patients •Pregnancy

What should be assessed at every routine pediatric visit?

•Weight •Length •Head Circumference •BMI

How to properly measure head circumference in pediatric patients

•Wrap the tape around the widest possible circumference of head •Broadest part of the forehead above eyebrow •Above the ears •Most prominent part of the back of the head

When are metabolic screening tests done in pediatric patients?

•all 50 states; tests vary by state •Done after 1st day of life