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Screening and preventive care: an important part of well-baby exams that also may provide an answer to a question about a child with a complaint. For example, the mother complains of a 4-year-old child who sleeps J 1 hours every night (this is normal). The answer to the question, "What should you do next?" may be to get an objective hearing exam, which is a routine screening procedure in a 4-year-old child. Height, weight, blood pressure, developmental and behavioral assessment, history and physical exam, and anticipatory guidance (counseling and discussion about age-appropriate concerns) should be. done at every visit. Remember the following:

1. Metabolic/congenital disorders: all states mandate screening for hypothyroidism and phenylketonuria at birth (within the first month). Most mandate screening for galactosemia and sickle cell disease. If any of the screens are positive, the first step is a confirmatory test to make sure that the screen gave you a true positive.

2. Anticipatory guidance: remember to tell parents the following: « Keep the water heater < i 10-120°E

m Put baby to sleep on the .side or back to help prevent sudden infant death syndrome

(most common cause of death in children aged 1-12 months), si Do not use infant walkers (which cause injuries). m Watch out for small objects (risk of aspiration). » Do not give cow's milk before 1 year of age. u Introduce solid foods gradually, starting at 6 months, a Supervise children in a bathtub or swimming pool.

3. Height, weight and head circumference: head circumference should be measured rou tinely in the first 1 years, height and. weight routinely until adulthood. All are markers of genera! well-being. The pattern of growth along plotted growth curves (which you need to know how to read) tells you more than any raw number. If a patient has always been low or high compared with peers, this pattern is generally benign. Parents commonly bring in a child with delayed physical growth or delayed puberty, and you must know when to reassure and follow up and when to do furl her testing and questioning. If a patient goes from a normal curve to an abnormal curve, this is a much more worrisome pattern.

¡a Failure to thrive (< _Sth percentile for age): most commonly due to psychosocial or functional problems. Watch for child abuse. Organic causes usually have specific clues to trigger your suspicion. ® Obesity: usually due to overeating; < 5% of cases are due to organic causes (Gushing's or Prader-Willi syndrome), »Increased head, circumference may mean hydrocephalus or tumor, whereas decreased head circumference may mean microcephaly (e.g., from congenitalTORCI i infection).

4. Hearing and vision : should be measured objectively once by or at; 4 years old. Measure every few years until adulthood, more of ten if history dictates.

® After a bout of meningitis, all children should be screened objectively for hearing loss (the most common neurologic complication of meningitis). Hearing screening is also important after congenital TORCH infections, measles and mumps, and chronic: middle ear effusions and otitis media. ® Check the red re Ilex at birth, and routinely thereafter to detect congenita! cataracts (usually due to congenital rubella, other TORCH infections, or galactosemia) or retinoblastoma (know what they look like on exam). »It is normal for children to have occasional ocular misalignment (strabismus) until 3 months; after that, it should be evaluated further to prevent, possible blindness in the affected eye.

5. Anemia: routine screening (hemoglobin and hematocrit) is somewhat controversial; traditionally screening was done once in the first year (8 -1 2 months), once between 4-6 years, and once during adolescence. If any risk factors for iron deficiency are present during infancy (prematuri ty, low birth weight, ingestion of cow s milk before 1 2 months, low dietary intake, low socioeconomic status), definitely screen the hemoglobin and hematocrit if given the option. Give all infants prophylactic iron supplements; start full term infants at 4—6 months, preterm infants at 2. months.

li. Lead: initial screen at 12 months if risk is low, at 6 months if risk is high (residence in old building, paint chip eater, home near battery-recycling plant). If level is < 10, re screen at 24 months if risk is low or at 12 months if risk is high. After 2, years old, screen annually only in high risk patients. If level > 10, closer follow up and intervention are needed. The best first course of action is to stop the exposure.

7. Fluoride: start, supplementation in first few years of life if water is inadequately fluoridated (rare) or if the patient is fed exclusively from a premixed, ready-to-eat formula (nonfluoridated water is used in such products). Most children need no supplementation.

8. Vitamin D: some authorities still recommend that all breast-fed infants should receive vitamin D; most recommend it only for high-risk patients (inadequate maternal vitamin D intake, little sunlight exposure, and/or dark skin, exclusively breast-fed beyond 6 months of age). Start supplements by 6 months. Formula-fed infants do not require vitamin D supplements, which the formula already contains.

9. Tuberculosis: screen for tuberculosis immediately if it is suggested by history or annually at any age if risk factors are present (HIV, incarceration). If the only risk factor is living in a high-risk area or immigrant parents, screen once at 4-6 years old and once at 11-16 years old. If no risk factors are present, do not screen.

10. Urinalysis: universal screening is not recommended. Do, however, screen for renal disease when a boy < 6 years old develops a urinary tract infection or a girl < 6 years old has repeated urinary tract infections. Get a voiding cystourethrogram and a renal ultrasound.

11. Immunizations: when to give normal immunizations is constantly being updated, so the administration schedule for common vaccines is usually given. Special patient populations (pneumococcal vaccine for patients with sickle cell disease or splenectomy) and vaccine contraindications (no measles, mumps, and rubella or influenza vaccine for egg-allergic patients, no live vaccines to pregnant women or immunocompromised patients) are high yield.

12. Other: give sexually active adolescents an annual Pap smear and screen for sexually transmitted diseases. The first dental referral should be made around 2-3 years old.

Tanner stages: Stage 1 is preadolescent, stage 5 is adult. Increasing stages are assigned for testicular and penile growth in males and breast growth in females; pubic hair development is used for both, sexes. Average age of puberty (when the patient first shows changes from stage 1 status) is 11.5 years in males (the first event usually is testicular enlargement) and 10.5 years in females (the first event usually is breast development).

Delayed puberty: no testicular enlargement in males by age 14, no breast development or pubic hair in females by age 13. The usual cause is constitutional delay. Parents often have a similar history. In this normal variant, the growth curve lags behind others of same age but is consistent. Delayed puberty is rarely due to primary testicular failure (Klinefelter s syndrome, cryptorchidism, history of chemotherapy, gonadal dysgenesis) or ovarian failure (Turner's syndrome, gonadal dysgenesis). Other rare causes include hypotbalamic/pituitary defects, such as Kallmann's syndrome or tumor.

Precocious puberty: usually idiopathic but may be. due to McCune-Albright, syndrome (in females), ovarian tumors (granulosa, theca cell, or gonadoblastoma)/ testicular tumors (Leydig cell), central nervous system disease or trauma, adrenal neoplasm, or congenital adrenal hyperplasia (males only; usually 21-OH deficiency). Most patients with an uncorrectable, idiopathic precocious puberty are given long-acting gonadotropin-releasing hormone agonists to suppress progression of puberty and thus prevent premature epiphyseal closure.

Cavernous hemangioma: first noticed a few days after birth. Lesions increase in size after birth and gradually resolve within first 2, years. The best treatment is to do nothing but observe and. follow up.

Caput succedaucum: diffuse swelling or edema of the scalp that crosses the midline and is benign. Cephalhematomas are subperiosteal hemorrhages that are sharply limited by sutures and do not cross the midline. Cephalhematomas are usually benign and self-resolving but rarely may indicate an underlying skull fracture; get an x-ray to rule it out.

Large anterior iontanelle: may indicate hypothyroidism, hydrocephalus, rickets, or intrauterine growth retardation. It usually is closed by 1 8 months; delayed closure may be due to tire same factors.

Important points:

1. Check the umbilical cord at birth for two arteries, one vein, and the absence of the ura chus. 11 there is only one artery, consider the possibility of congenital renal malformations.

2. Female infants may "have a milky white (and possibly blood tinged) vagina! discharge in the first week of life. Tins discharge is physiologic and due to maternal hormone withdrawal.

Child abuse: watch for failure to thrive; multiple fractures, bruises, or injuries in different stages of healing; shaken baby syndrome (.subdural hematomas and retinal hemorrhages with no external trauma signs); behavioral, emotional, and interaction problems; sexually transmitted diseases; and multiple personality disorder (sexual abuse). Consider abuse whenever die injury does not fit the story. Reporting any suspicion is mandatory; you do not need proof and cannot be sued.

Note: Children have different normal laboratory and physiology values (normal values usually are given): lower blood pressure, higher heart and respiratory rates, and different hemoglobin and hematocrit values (higher at birth, lower throughout childhood). Renal, pulmonary, hepatic, and central nervous system still not fully mature and functional at birth.

APGAR score: commonly done at I and 5 minutes. Do not wait until the 1 -minute mark to evaluate the newborn; you may have to suction or intubate the infant 3 seconds after delivery. The APGAR score includes five categories with a maximal score of 2 points per category and a total maximum of 10 points:

1. Heart rate: 0 = absent, 1 ~ < 100, 2 = > 100

Respiratory effort: 0 = none, I ~ slow, weak cry, 2 ~ good, strong cry 3- Muscle tone: 0 — limp, 1 some flexion of extremities, 7. active motion

4. Reflex irritability (response to stimulation of sole of foot or catheter put in nose): 0 none. 1 ~ grimace, 2. — grimace and strong cry, cough, or sneeze

5. Color: 0 ™ pale, blue, 1 = body pink and extremities blue, 2. ■ completely pink Continue to score every 5 minutes until the infant teaches a score of 7 or more (while resuscitating). Important points:

1- Reyes syndrome may cause encephalopathy and/or liver failure in children taking aspirin. The syndrome usually develops after influenza or varicella infection. Avoid aspirin in children; use acetaminophen instead.

2. Moro and palmar grasp reflex should disappear by 6 months.

Side effects: bizarre, unique, and fatal side effects are tested as well as common side effects of common drugs.

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