WELL CHILD CARE

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WELL CHILD CARE

• The Newborn Exam and General Pediatric Screening.
• By Dr Chi Jokonya

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General Rules

• Get a good FHx for congenital problems
• Perinatal hx ie substance abuse
• Examine each part of the baby
• Develop a routine or system

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Developmental Dysplasia of the Hip (DDH, formerly
CHD)

• 1 in 100 unstable hip, only 1 in 1000 true
  dislocation.
• Types a) Typical normal child b) Teratological
  syndrome or abnormal bone
• FHx (20), firstborn, female (FM 91), breech
  (40)
• Associations congenital muscular torticollis
  metatarsus adductus

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DDH contd.

• Audible click means nothing.
• Dx highest yield at 1 month newborn screeing
  maybe ineffective and perhaps harmful.
• Dynamic uss screen breech babies at 4wks
• X-rays AP and frog
• Other CT, MRI, arthrography

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Treatment DDH

• Double/triple diaper for 2-3wks probably
  ineffective in true DDH
• Pavlik harness, Frejka splint, van Rosen splint
  95 successful in dysplastic hips, 80 in DDH
• Surgery at 6-12mths cast and traction
• 3 recurrence

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Fingers and Toes

• Extra digit 2 in 1000 births, 30 FHx, usually
  5th toe or finger tie off EMLA or lidocaine
  anesthesia
• Syndactyly x-ray to be certain bones present.
  Think of syndrome (toes Smith-Lemli-Opitz)
• Polydactyly may need x-ray to preclude presence
  of bone in digit

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Funny Looking Kids

• FAS
• Downs/Edwards/Pataus trisomy syndromes
• Cornelia de Lange

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Umbilical Problems

• Single umbilical artery 0.55 deliveries, 27
  associated malformations.
• Umbilical hernia 35 African American babies, 4
  white babies, increased in LBW. Association
  trisomy 18, 21 and hypothyroidism. Usually close
  spontaneously if not surgery at 3 to 5yrs

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Umbilical Problems contd

• Gastrochisis
• Omphalocoele
• Omphalitis
• Umbilical granuloma rx with AgNO3

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Birth Injuries

• Cephalohematoma
• Brachial nerve injury -90 Erbs palsy
  C5,C6,C7-1 Klumpkes palsy C8,T1
• Facial nerve palsy 0.5, forceps/syndrome
• Clavicular fracture may occur in utero

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Nose Disorders

• Hemangioma
• Choanal atresia
• Cleft lip/palate/nose
• Tilted, flattened or deviated-oligohydramnios
  renal agenesis, Potters syndrome-think syndrome

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Eyes

• NB Check red reflex!! - retinoblastoma
• Cataracts numerous causes. 50 missed at birth
• Glaucoma 50 primary infantile glaucoma,
  remainder familial so get FHx

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Ears

• Low set many syndromes
• Abnormal pinna-large flabby urogenital
  malformations-flat pressed against head Potters
  syndrome-pits Beckwith Weidemann (BWS)-tags
  (BWS)

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Screening in Pediatrics
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When Should PE Be Done

• Birth 1mo, 6mo, 1yr
• 1, 2, 5, 10 and 14yrs
• Both of above for screening purposes and neither
  conforms with recommendations of various primary
  care specialty groups.

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The Physical Exam

• A composite of screens, most effective when
  purpose is health maintenance.
• Yield of new abnormalities LOW
• Hx defines most abnormal findings
• NB need to be using BMI to identify obesity,
  chart and review growth curves.

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Genetic and Metabolic Screens

• Newborn PKU, tyrosinemia, galactosemia,
  hypothyroidsim, SCD.
• Potential future screens-CAH in boys, some
  states already doing-biotinidase deficiency (1
  in 70 000) 9 states decided yes cheap and easy
  to treat-cholesterol in late childhood and
  adolescence? Insufficient evidence

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Tuberculin Testing

• PPD preferred (most standardized)
• Low risk screen at 12-15mths, before school and
  at 14-16yrs
• High risk screen annually
• 15mm always ve, 10-14mm ve in high risk gps,
  5-9mm doubtful unless immunosuppressed.

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Anemia

• Screen at 6 and 18mths
• Hct more reliable than Hb
• If positive MCV will distinguish IDA from
  thalassemia trait (smaller rbcs in TT)

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Lead Poisoning

• Screen all children at 1yr?
• All abnormal levels interview, educate, give
  questionnaire
• Levels 10-14mcg/dl repeat in 1yr 15-20mcg/dl
  repeat in 3mths 20-30mcg/dl consider EDTA
  gt30mcg/dl requires intervention
• www.ahrg.gov/clinic/uspstf/uspslead.htm

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Scoliosis

• Late childhood/early adolescent mild types rarely
  progress and almost never cause significant
  disability.
• Evidence show screening not cost effective and
  harm exceeds benefits.
• Routine screening NOT recommended
• www.ahrg.gov/clinic/uspstf/uspsaisc.htm

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Urinalysis

• Screening NOT recommended-proteinuria FP
  common fever, exercise-orthostatic proteinuria
  transient and harmless-bacteria non treatment
  of asymptomatic bacteruria does NOT increase freq
  of pyelo or cause renal insufficiency. Rx may
  INCREASE freq of pyelo
• Screening NOT recommended but high index of
  suspicion in febrile illness

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Auditory Screening

• 1 in 2000 severely hearing impaired
• Healthy Newborns, screening safe insufficient
  evidence to recommend routine screening
• Older children gross assessment at all CV.
• Test in kindergarten grades 1,3,5,7
• Pure tone audimetry at 4yrs refer if fails to
  hear 2 frequencies at 25db (NB r/o OM)

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Visual Screening

• During each health maintenance visit, lt5yrs look
  for strabismus, ambylopia and as soon as possible
  visual acuity (USPSTF 2004)
• Use fixation pattern in lt3yrs. Cover one eye,
  encourage fixation. Child will not like having
  good eye covered.
• School checks generally suffice in older children

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Developmental Screening

• Must be in contesxt of HP, vision and hearing
  screens.
• Know normal developmental stages.
• Major focus first year of life then preschool
  years.
• Newer instruments such as ASQ (The Ages and
  Stages Questionnaires) are easier to use and more
  accurate than the DDST (Denver Developmental
  Screening Test)Journal of FP May 2006 Vol55
  No.5 415-421

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Sickle Cell Conditions

• Screen at birth HB electrophoresis
• Imperative to start penicillin prophylaxis once
  diagnosis is made CT until 10yrs
• 2-16yrs transcranial doppler screening inc BF
  gt/1 major blood vessel inc reisk of stroke, 2
  ve screens institute chronic transfusion therapy
  to keep HbS lt30

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Gyn Screening

• Annual pap once sexually active
• Routine chlamydia screen all sexually active
  adolescent females.
• Testicular cancer USPSTF recommends against
  routine screening, however, encourage regular
  self examination and examine at every visit.

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Short List Birth to 10yrs

• Ht, wt, BMI
• BP
• Vision (3-4yrs)
• Hemoglobinopathy at birth
• PKU, T4 and or TSH at birth

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Short List 11 to 24yrs

• Ht, wt and BMI
• BP
• Pap test
• Chlamydia screen (females gt20yrs)
• Rubella serology or vaccination
• Assess for substance abuse

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Case Scenarios

• Cases
• Questions
• DiscussionChildren are not little adultsKnow
  age specific milestonesMonitor growth charts/BMI
  !