Well Child Care 1-4 years old

Med Peds RoundsSeptember 8, 2010

Debra Lotstein, MD, MPH

What is Ideal Well Child Care?• A transformational shift from acute to

preventive care• Incorporates a lifespan perspective in health

care• An opportunity for engagement with other

health producing sectors of society– Education– Social services

Outcomes of WCC at Age 5: Physical Health and Development

• No undetected hearing or vision problems• No undetected birth defects/congenital

anomalies• No chronic health problems with a

management plan• Immunizations complete for age• No undetected lead poisoning• Good nutritional habits and no obesity

Outcomes of WCC at age 5:Development

• No unrecognized or untreated delays – Emotional, social, cognitive, communication

• Ready for school– Child recognizes relationship between letters and

sounds– Child has positive social behaviors with peers and

adults

Outcomes of WCC at age 5:Family Capacity

• Parents are knowledgeable about child’s physical health and needs

• No unrecognized maternal depression, violence, substance abuse

• No undetected early warning signs of child abuse and neglect

• Parents feel valued and supported in role • Parents understand and are able to fully use

well child care services

A Systematic Approach to Well Child Care

• Diet• Elimination• Sleep• Development• Home• School• Safety• Vaccines• Anticipatory Guidance

Guidelines for WCC 1-4 yo• The first priority is to attend to the parents’

concerns• Be sure to cover each area but avoid having a

“spiel” for everything• Use clinical practice tools to help you

1. Preventive Services Prompting Sheet2. Standardized screening tools3. Vaccine registry/charts4. Reach out and Read5. Community Resource Guide

1. Preventive Services Prompting Sheet: Based on CHDP periodicity,

AAP guidelines

• 12 months• 15 months• 18 months• 2 years• 3 years• 4 years

2. Standardized Screening Tools

• Surveillance:– general process of identifying children at risk for

developmental problems

• Screening: – use of standard tools for identifying those at risk

• Evaluation: – complex process to identify specific disorders

Routine Use of Structured Developmental Screening Tools

• Used if concerns arise AND periodically at well visits (9 (or 12),18,30 month visit per AAP)

• Easy to use tools with good sensitivity (75%) and specificity (at least 75%) for problems needing referrals– PEDS– Ages and Stages Questionnaires– MCHAT for autism (at 18 and 24 mos)

• Promotes conversations and parent engagement in their child’s development

2. Standardized Screening Tools

• Development–PEDS/ASQ

• Family Stressors–Domestic Violence–Maternal Depression

• Lifestyle Log for Overweight/Obese– After 2 years old

3. Vaccine Registry and Charts

• Catch up missed vaccines• Live vaccines• Boosters

4. Reach out and Read

• National program started in Boston• Using books as a way to – Promote child’s readiness for reading– Promote social/emotional development– Use as a tool in the exam room to assess

development, parenting skills, can use to model how to share books

– Assure there are books in the home

5. Community Resource Guide

• Special Needs• Child care and early education• Mental Health• Other

Approach to the Physical Exam 1-4 yo

• Approach the child indirectly • Keep child with parent as much as possible• Use parent as example • Use distraction

A Systematic Approach to Well Child Care: Routines/ Concerns to Discuss

• Diet• Elimination• Sleep• Development• Home• School• Safety• Vaccines• Anticipatory Guidance

Diet: Feeding• Child should be in control of eating– Avoid forcing/struggles about food

• Give up on a well rounded “adult- like” diet until 3 years old

• Diet 1 through 3 years old: – Approx 16 oz whole milk a day (end meal with milk)– 3-4 oz protein– Iron rich foods– Fruits– Variety of cooked vegetables/leafy greens

• Need to offer multiple times

Diet: Obesity Prevention• Plot height and weight on growth curve• Plot BMI on curve from 2 years old on• Assess diet and activity– See lifestyle log for those overwt (85-95) or obese (>95%)

• 5-4-3-2-1– 5 servings fruits and vegetables per day– 4 glasses of water– 3 servings dairy products– 2 or hours or less screen time per day– 1 hour or more of exercise per day

Elimination: Toilet Training

• Developmentally need to:– Feel urine or BM coming, hold onto it, walk to

toilet, sit down, produce, and let them be flushed away

• Avoid struggles over toileting• Likely to be more ready at end of second year

(just before turning 2)

Sleep

• Bedtime routines/rituals are key– Rocking chair, bedtime story, transitional object

• Goal is to teach self-soothing• More night time awakenings can be expected

with learning to walk• 2 naps a day decrease to 1 nap round 15

months

Development

• “Touchpoints” theory (Brazelton)• With each developmental growth spurt comes

with predictable struggles and also regressions

• Helping parents understand and anticipate these normal progressions helps prevent family conflict and promote positive development of the child

Development

• Motor milestone of walking (12-14 mos) is accompanied by emotional development of urge for independence

• In the second year new independence at 1 yo comes ambivalence and fears– “Do I want to walk away, or don’t I?”– This “inner turmoil” underlies outer “negativism”

and temper tantrums, peak 2nd and 3rd years of life

Discipline

• Its about teaching, not punishing• Setting limits so that eventually the child can

learn self-control and respect for others• Save discipline efforts for the important things

(e.g. safety of self or others)– Pick your battles

Discipline

• First control the environment– Avoid the avoidable

• “Acting out” is often worst at predictable times: end of day (when tired), when parent is distracted, or if child over-excited (public place)

• Use quiet “time out” or hug to break the cycle of buildup– when quiet, can explain “I’ll have to stop you until you

learn to stop yourself”

Development: LanguageAge Range Receptive Language Expressive Language

12-15 months Shakes head noFollows one-step commands

5-10 wordsSays Mama, dadaImitates soundsPoints to 2-4 body partsUses jargon mixed with real words

15-18 months Shakes or nods to questionRecognizes pictures when named

3-20 words

18-24 months Points to body partsUnderstands personal pronouns

100-200 words

24-36 months Follows 2 step directionsResponds to yes/no questions

Up to 900 word vocabulary3-4 word phrases50-75% speech is understood

36-48 months Identifies 4 colorsUnderstands negatives

4 or more word sentences75% speech is understoodRelates experiences

Language Delay• A wide range of normal speech and language development

between 1-3 yo

• Consider referral if:– No first words by 15 months– No consistent words by 18 months– No word combinations by 24 months– Speech is difficult for parents to understand at 24 months– Speech is difficult for strangers to understand at 36 months

• Some will be familial late talkers: increase in males, family history

• Where to refer:– < 3yo Regional Center (speech rx, other stimulation)– >3yo: School

• Home– Who lives at home with you? Any changes?

• School– Who is with child during the day? Day care?

Thinking of daycare or preschool? • Safety– Car Seats• 0-1 :rear –facing until 1 year AND 20 lbs• 1-4: Car seat until 4 yo AND 40 lbs• 4-6 : Booster seat until 6 yo AND 60 lbs (or 8 and 80)

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12 Month Visit

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15 Month Visit

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18 Month Visit

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2 Year Visit

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2 ½ Year Visit

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3 Year Visit

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4 Year Visit