DOS Course 20171 Oxtober 20101Confidential
Pediatric Issues and Updates
Cheryl Cairns, DNP CPNP Community Pediatrics
Pediatric Institute
© Cleveland Clinic 2017
• Participants will be able to discuss pediatric screening
guidelines for primary care
• Participants will be able to discuss anticipatory guidance
for parents of children in the primary care setting
• Participants will be able to identify crucial aspects of the
first primary care visit for an adopted child
Objectives
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• AAP Bright Futures
– Set of principles, strategies and tools used to improve health and
well-being of children
• Periodicity Schedule
– Published annually
– https://www.aap.org/en-us/Documents/periodicity_schedule.pdf
AAP Screening Guidelines
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• Recommended for all expectant families
– Establishing a positive family-provider relationship
– Anticipatory guidance
– Anticipation of any high risk concerns
– Gathering information
– Concerns
– History
– Social
– Medical
– Family
https://www.healthychildren.org/English/ages-stages/prenatal/Pages/Preparing-for-Delivery.aspx
Prenatal Visit
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• Full visit
– First pregnancy
– For adolescent and other young parents
– Pregnancy complications or newborn problems are anticipated
– When parents are unusually anxious for any reason
• Brief office visit
– Parents who are still deciding on a pediatrician
– 5-10 minutes
– Introduction to office
• Phone contact visit
– Get basic information / send out information
• Group visit
– Encourages mutual support
Prenatal Visit Types
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• 0.5 to 5 in every 1000 neonates and infants - congenital
sensorineural deafness or severe-to-profound hearing
impairment
• Permanent hearing loss identified by newborn hearing
screening program were:
– ~1/1000 (Brazil, bilateral; and Sweden)
– 1–3/1000 (China, bilateral) and ~5/1000 (China, unilateral)
– 1.6/1000 (Germany, bilateral) and 0.7/1000 (Germany, unilateral)
– 1.61/1000 of at-risk infants (India, bilateral)
– 1/1000 (Serbia, bilateral) and 0.3/1000 (Serbia, unilateral)
– 1.05/1000 (United States, Colorado, bilateral) and 0.45/1000
(United States, Colorado, unilateral)
Hearing Loss
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• 1.Definition targeted hearing loss
– Congenital permanent bilateral, unilateral sensory, or permanent
conductive hearing loss
– Neural hearing loss - infants admitted to the NICU
– NICU infants admitted for more than 5 days
–Auditory brainstem response (ABR) included as part of their screening
so that neural hearing loss will not be missed
– Those who do not pass ABR evaluated by an otolaryngologist
– Genetics consultation should be offered
Hearing Loss
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• Newborn evaluation after birth
– Breastfeeding should be encouraged and instruction and support
should be offered
• Infant should have an evaluation within 3 to 5 days of
birth and within
– 48 to 72 hours after discharge from the hospital
– Evaluation for feeding and jaundice.
– Breastfeeding infants should receive formal breastfeeding
evaluation, and their
– Mothers should receive encouragement and instruction
Newborn Exam
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• Screening
– Patient Health Questionnaire-2 (PHQ-2) | Instructions
– Patient Health Questionnaire-9 (PHQ-9)Instructions
– Edinburgh Postnatal Depression Scale
• May have lasting impact on a child’s health and well-
being if left untreated
– When parents are depressed it can negatively
– Impact a child’s development
– Impede their ability to learn
– Effects that can last into adulthood
Maternal Depression
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• Level A recommendation
– Back to sleep for every sleep
– Use a firm sleep surface
– Room-sharing without bed-sharing is recommended
– Keep soft objects and loose bedding out of the crib
– Pregnant women should receive regular prenatal care
– Avoid smoke exposure during pregnancy and after birth
– Avoid alcohol and illicit drug use during pregnancy and after birth
– Breastfeeding is recommended
– Consider offering a pacifier at nap time and bedtime
– Avoid overheating
– Do not use home cardiorespiratory monitors as a strategy for
reducing the risk of SIDS
Safe Sleep
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• Expand the national campaign
• Major focus on the safe sleep environment
• Reduce the risks of all sleep related infant deaths
– SIDS
– Suffocation
– Accidental deaths
– Pediatricians, family physicians and other primary care providers
should actively participate in this campaign
• Level B recommendations
– Infants should be immunized in accordance with
recommendations of the AAP and CDC
Safe Sleep
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• Vitamin D
– encourage parents of infants who are either breastfed or
consuming <1 L/day of infant formula to give their infants an oral
vitamin D supplement.
• Iron supplementation in breast fed infants
– Begin at 4 months
– Until iron containing foods in diet, and meat is better than iron
fortified cereals
Nutritional Supplementation
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• Safety first
• Accept help from others
• Need routine
• Adjust their schedules
• Rest
• Enjoy
Anticipatory Guidance First Year
http://images.mentalfloss.com/sites/default/files/styles/article_640x430/public/baby_0.jpg
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• Physical
– Raises head and chest when on stomach
– Stretches and kicks on back
– Opens and shuts hands
– Brings hand to mouth
– Grasps and shakes toys
• Social
– Begins to develop social smile
– Enjoys playing with people
– More communicative
– More expressive with face and body
– Imitates some movements and expressions
0-3 months
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• Physical
– Rolls both ways
– Sits with and without support of hands
– Supports whole weight on legs
– Reaches with one hand
– Transfers object from hand to hand
– Uses raking grasp
• Social
– Enjoys social play
– Interested in mirror images
– Responds to expressions of emotions
• Cognitive
– Finds partially hidden object
– Explores with hands
4-7 months
http://static.guim.co.uk/sys-
images/Guardian/About/General/2010/8/16/1281977987910/B
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• Physical
– Gets to sitting position without help
– Crawls forward on belly
– Assumes hands-and-knees positions
– Gets from sitting to crawling position
– Pulls self up to stand
– Walks holding on to furniture
• Social
– Shy or anxious with strangers
– Cries when parents leave
– Enjoys imitating people in play
– Prefers certain people and toys
– Tests parental response
8-12 months
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• Clinical impression rather than formal screening-
children's developmental status are much less accurate
• Survey at every well child exam
• Screen at 9, 18 or 30 months or when concern expressed
– PEDS
– ASQ
• Perform Autism-specific screening at 18 and 24 months
– MCHAT
Developmental Surveillance and Screening
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Developmental Screening Workflow
http://pediatrics.aappublications.org/content/118/1/405.full
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• Motor skills advancing
• Visual and hearing abilities.
• Early communication skills emerging
• Autism traits - may be recognizable in the first year of life
– Lack of eye contact,
– Orienting to name being called
– Pointing
9 Month Developmental Screen
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• Delays in communication and language development are
often evident by 18 months of age
• Mild motor delays more apparent at 18 months of age
• Medical interventions for motor disorders have been
shown to be effective in children at 18 months of age
• Effective early intervention for delayed language
development is also available
• Symptoms of autism are often present at this age
18 Month Developmental Screen
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• Most motor, language, and cognitive delays may be
identified with screening instruments
• Evaluation of and intervention for those children with
delayed development
Thirty Month Developmental Screen
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• Parent-completed
• 19 age-specific categories
• Communication
• Gross motor
• Fine motor
• Problem-solving
• Personal adaptive skills
• 10-15 minutes
• Pass/fail score
• English, Spanish, French and Korean versions available
Ages and Stages (ASQ)
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• PEDS
• Parent-interview form
• 10 questions
• 2-10 minutes
• Developmental and behavioral problems needing further
evaluation
• English, Spanish, Vietnamese, Arabic, Swahili,
Indonesian, Chinese, Taiwanese, French, Somali,
Portuguese, Malaysian, Thai and Laotian
Parents' Evaluation of Developmental Status
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• M-CHAT
• Parent-completed
• Risk of autism
• 23 items
• 5-10 minutes
• Pass /fail
Modified Checklist for Autism in Toddlers
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• Apply beginning with first tooth eruption
• Does not cause fluorosis
• Position
– For an infant or very small child, use the knee to knee position and
have the caretaker lower the child’s head onto the provider’s lap
– A young child or infant may be placed on an exam table; the
provider may work from above and behind the head
Fluoride Varnish
https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Recommends-Fluoride-to-Prevent-Dental-Caries.aspx#sthash.ULuVVz1y.dpuf
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• Open the child’s mouth using finger
• Remove excess saliva and plaque from the teeth
– Gauze sponge
– Teeth should be as dry as possible
• Use your fingers and the sponges to isolate the teeth and
keep them dry
– Work on one quadrant of teeth at a time
– Apply a thin layer of varnish to all surfaces of the teeth
– Fluoride varnish will set upon contact with saliva.
Fluoride Varnish Application
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• Physical
– Walks alone
– Pulls toys behind when walking
– Begins to run
– Stands on tiptoe
– Kicks a ball
• Social
– Imitates behavior of others
– Aware of herself as separate from others
– Enthusiastic about company of other children
• Cognitive
– Finds objects even when hidden 2 or 3 levels deep
– Sorts by shape and color
Toddler (1-3 years)
http://1.bp.blogspot.com/y+w
alking.jpg
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• Safety First
• Meal times should be with family
– Limit grazing
– Provide healthy choices
– Toddlers are picky
• No screen time for children younger than 24 months,
except for video chats with family
• Encourage independence
• Toilet training (parents will survive )
Toddler Anticipatory Guidance
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• Physical
– Climbs well
– Walks up and down stairs, alternating feet
– Kicks ball
– Runs easily
– Pedals tricycle
– Bends over without falling
• Social
– Imitates adults and playmates
– Show affection for familiar playmates
– Can take turns in games
– Understands "mine" and "his / hers”
Preschool
http://www.koreaittimes.com/images/children%20playing%20in%20mud.jpg
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• Cognitive
– Makes mechanical toys work
– Matches an object in hand to picture in book
– Plays make believe
– Sorts objects by shape and color
– Completes 3 - 4 piece puzzles
– Understands concept of "two
• Tips for parents
– Yell less, love more
– Label behavior
– Give child your full attention in frequent, small doses
– Redirect with creativity
– *Screen time one-hour limit for children ages 2 to 5
Preschool
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• Nutrition
– Vegetables: 3-5 servings per day
– Fruits: 2-4 servings per day
– Bread, cereal, or pasta: 6-11 servings per day
– Protein foods: 2-3 servings of 2-3 ounces
– Dairy products: 2-3 servings per day
• Fitness
– 1 hour per day
• BMI
– <5th percentile Underweight
– 5th–84th percentile Healthy weight
– 85th–94th percentile Overweight
– ≥95th percentile Obesity
School Age Healthy Living
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• Depression
– Only 50% of adolescents with depression are diagnosed
before they reach adulthood
– In primary care as many as 2 in 3 depressed youth are not
identified
– Even when diagnosed by PC physicians only half
of these patients are treated appropriately
• http://www.glad-pc.org/
Adolescent Depression
http://i.ytimg.com/vi/-YbSs6A6gNw/hqdefault.jpg
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• Ages 12-18
• PHQ 2
• PHQ 9
Depression Screening
http://www.psy-world.com/images/phq-9.jpg
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Depression Workflow
http://pediatrics.aappublications.org/content/pediatrics/120/5/e1299.full.pdf
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• Dyslipidemia
– Fasting lipid profile before puberty and in late adolescence
– Consider screening in younger children with a family h/o
hypercholesterolemia
– Once b/w 9-11 yrs
– Once b/w 17-21 yrs
• Hearing
– Include higher frequencies
–6000 and 8000 Hertz in screening audiogram
– Counsel regarding risk of hearing loss due to environmental
exposure
Adolescence
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• Tobacco, Alcohol and Drug Use
– Provide interventions, education and counseling to prevent
initiation of tobacco use in adolescents
• SBIRT (Screening, brief intervention, referral, treatment)
– assesses the severity of substance use and identifies the
appropriate level of treatment.
– Brief intervention focuses on increasing insight and awareness
regarding substance use and motivation toward behavioral
change.
– Referral to treatment provides those identified as needing more
extensive treatment with access to specialty care
• http://www.sbirttraining.com/node/2374
• http://files.hria.org/files/SA3541.pdf
Adolescence
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• HIV
– USPSTF - Screen all 15-65 year olds, and younger/older at risk
– CDC/AAP – Screen once b/w 16-18
• Chlamydia
– Screen all sexually active females <= 24 yrs
• Gonorrhea
– Screen all sexually active females <= 24 yrs
– Screen young men who have sex w/ men
• Syphilis
– Screen individuals at increased risk of infection
Adolescence STI
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• Who are the Children
– Orphanage care
– Foster Care
– Prenatal adversity
– Substance exposures, malnutrition, stress
– Malnutrition, abuse, neglect, abandonment
– Complex special medical needs
– May or may not have received needed care
Adoption
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• Most families travel to adopt
– International travel safety & health needs
–Vaccines & travel health needs
–CDC traveler’s health website: http://wwwnc.cdc.gov/travel
– Siblings: to take them or not?
–Needs of siblings left at home
– Infectious diseases brought home by new child
Adoption Process for Families
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Question 1
• Which of the following vaccines is recommended for all
close personal contacts of a newly adopted child?
• HAV
• HBV
• Varicella
• Pertussis
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• Hepatitis A
– 1-6% of new adoptees with acute Hepatitis A
– CDC recommends HAV for all unvaccinated persons who will
have close personal contact with a child arriving from a country
with endemic Hepatitis A
– First dose at least two weeks before arrival
• Hepatitis B
– 5-6% new adoptees HBsAg +
–Known special need, or surprise
– Household contacts should have HBV series
Preparing for Infectious Risks
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• Help families to assess their own abilities to meet hardest
possible needs
• Help families to locate community resources to meet
predictable needs
• Preparation for & support during travel
– First aid & urgent health problems while abroad
• May be best left to adoption medical specialists
– http://www2.aap.org/Sections/adoption/directory/map-adoption.cfm
– http://eclevelandclinic.org/adoption
Pre-Adoption Medical Review
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• Feeding and sleep
• Attachment and bonding
• Behavior
• Family adjustments
• Anticipatory guidance
The First Office Visit
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• Review of known medical history
– Include any new information
• Document growth - Ht, Wt and OFC
– Early assessment of age
• Careful, detailed physical examination
– Identify scars, physical anomalies, signs of illness, malnutrition,
past abuse
• Hearing and vision
Initial Medical Evaluation
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• Detailed assessment of current development
– Standardized tools often not useful yet
–Child never exposed to most test items
– Detailed history & observations of child’s skills in all
developmental domains
– Allows assessment of catch-up rate over next several months
Initial Medical Evaluation
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• CBC
• Lead level
• Stool O&P (3)
• RPR or VDRL
• HGsAg
• HCV
• HIV I&II
• PPD (or IGRA>5yr)
– Re-check these after 6 mos to r/o recent infection
Initial Medical Evaluation Labs
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• Also consider:
– HAV IgG and IgM
– If any GI sx, jaundice
–Older children, & those from endemic countries
– Chagas Disease, Strongyloides, Schistosomiasis, Malaria
– TFT’s if unusually small/delayed, or not improving rapidly over first
months home
– Ca, PO4, Alkaline Phosphatase if from northern climate or severe
malnutrition
Initial Medical Evaluation Labs
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• Different from immigrant children who come to US with
their original families, where:
– Parents can verify vaccines
– Medical facilities meet WHO standards
• If records meet timing standards, then can check titers
(for children > 12 mo.) or start series over
– Parental preference
– Easiest for child
• Check titers for:
– Tetanus, Diptheria
– Measles, Mumps, Rubella, Varicella
– Hepatitis A & B
– Polio neutralizing antibodies
Immunizations
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• Prioritize medical needs
– Balancing emergency, urgent, and non-urgent needs with child
and family’s emotional and bonding needs
• Prioritize developmental needs
– Urgent or can wait 1-2 months
– Most children make huge progress in first several months
Completing the First Visit
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• See them early and often
– E/M visits, to follow-up identified medical needs, nutrition,
developmental delays, immunization catch-up, and child and
family adjustments to adoption
–Attachment
–Feeding
–Sleeping
–School transition
• Routine Well Child Care schedule as issues resolve
The First Year Home
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• http://pediatrics.aappublications.org/content/124/4/1227.full
• http://www.who.int/blindness/publications/Newborn_and_Infant_Heari
ng_Screening_Report.pdf
• http://pediatrics.aappublications.org/content/120/4/898.full
• http://pediatrics.aappublications.org/content/118/1/405.full
• https://www.aap.org/en-us/advocacy-and-policy/state-
advocacy/Documents/MaternalDepressionScreeningGuidance.pdf
• http://pediatrics.aappublications.org/content/pediatrics/early/2011/10/
12/peds.2011-2284.full.pdf
References
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