The Well Child Visit

1
The Well Child Visit

• Mary Tedesco-Schneck MSN, CPNP

2
Focus

• Child adolescent friendly, safe office
  environment
• Health screening anticipatory guidance
• Immunizations
• For select pediatric age groups
• Focus areas
• Identify normal variations on physical exam

3
Child-Adolescent Friendly Safe Office
Environment

• Considerations in practices and policy

4
Friendly

• Staff trained in normal growth and development of
  children and adolescents
• Raising readers http//www.raisingreaders.net/
• Toys/books/games for waiting area
• Props to facilitate exam

5
Pediatric Equipment Supplies

• Band aids, stickers etc.
• Child size chairs/tables
• Changing tables
• Areas for breastfeeding
• 100 juice
• Pediolyte (drink pops)
• Formula
• Diapers/wipes

6
Safety

• Time allocation for acute well child visits
• Reference books
• General Specialty pediatric reference books
• Triage book for ancillary staff
• Web resources (e.g. Up to Date)

7
Pediatric Equipment Supplies

• Exam room considerations
• Observation room
• Outlet covers
• Guards for sharp corners
• Emergency equipment
• Policies/procedures

8
Frush, K.S. Bordley, W.C. (2013).Preparing an
office practice for pediatric emergency. Up to
Date.

• Office visits by children requiring emergency
  care are common.
• Office-based self-assessment
• Likely types of emergencies based on population
• Office resources
• EMS capability and response time to the practice
• Closest facility for higher level of pediatric
  care

9

• Development of an emergency response plan.
• Recognition triage of pediatric emergency
• Children already in the office
• Telephone triage
• Internal notification
• EMS activation
• Office resuscitation (emergency equipment and
  medications)
• Patient transfer
• Training (mock resuscitation)

10
Well Child

• Resources
• NAPNAP
• http//www.napnap.org/index.aspx
• AAP
• http//www.aap.org/en-us/Pages/Default.aspx
• Kids Health
• http//kidshealth.org/
• Bright Futures
• http//brightfutures.org/

11
Minors Rights

• http//maineaap.org/wp-content/uploads/2013/02/Min
  ors-Rights-to-Confidential-Health-Care-in-Maine-Po
  cket-Card.pdf

12
Immunizations

• http//www.cdc.gov/vaccines/schedules/easy-to-read
  /child.html

13
Immunizations

• General Recommendations on Immunization
• Recommendations of the Advisory Committee on
  Immunization Practices (ACIP)
• http//www.cdc.gov/mmwr/pdf/rr/rr6002.pdf

14
Contraindications

• A contraindication is a condition in a recipient
  that increases the risk for a serious adverse
  reaction (Centers for Disease Control, 2011, p.
  10).
• The only contraindication applicable to all
  vaccines is a history of a severe allergic
  reaction (i.e., anaphylaxis) after a previous
  dose of vaccine or to a vaccine component (unless
  the recipient has been desensitized see Special
  Situations section) (Centers for Disease
  Control, 2011, p. 11).

15
Precautions

• A precaution is a condition in a recipient that
  might increase the risk for a serious adverse
  reaction or that might compromise the ability of
  the vaccine to produce immunity (e.g.
  administering influenza vaccine to someone with a
  history of Guillain-Barré syndrome within 6 weeks
  of a previous influenza vaccination) (Centers
  for Disease Control, 2011, p. 11).
• The presence of a moderate or severe acute
  illness with or without a fever is a precaution
  to administration of all vaccines (Centers for
  Disease Control, 2011, p. 11).

16
Pain Management
17
Baulch I (2010) Assessment and management of pain
in the paediatric patient. Nursing Standard,
25(10,)35-40.

• Newborns localize pain poorly
• pain fibers are not myelinated at birth
• uncontrolled pain can effect this processing for
  a lifetime

18
Prostaglandins

• Prostaglandins initially found in seminal fluid
  of the prostrate.
• Not hormones but unsaturated carboxylic acids.
• Hypothalamus influences their release.

19
Pain Medication

• Acetaminophen (10-15 mg/kg/dose) inhibits
  prostaglandin synthesis from the CNS
• Ibuprofen (10 mg/kg/dose) blocks activity of
  cycooxygenase an enzymes necessary for
  prostaglandin synthesis which mediates the
  inflammatory response.
• Codeine phosphate for moderate pain (10 of the
  population lacks enzyme cytochrome p450 that
  converts codeine to morphine therefore no the
  analgesic effect).

20
Reducing vaccine injection pain

• Administering brands of vaccines that are less
  painful
• Positioning children upright (and holding
  infants)
• Stroking the skin close to the injection site
  before and during injection
• Administering the least painful vaccine first
• Performing intramuscular injections rapidly,
  without aspiration (Taddio, A., lIersich, A.,
  Ipp, M., Kikuta, A., Shah, V., 2009, p. S69).

21

• Sucrose and glucose of various doses and
  concentrations moderately reduces crying
  incidence, crying duration and pain scores during
  or following immunization, beyond the neonatal
  period up to 12 months of age (Harrison, D.,
  Stevens, B., Yamada, J., Adams-Webber, T.,
  Beyene, J., Ohlsson, A., 2010, p. 412).

22
Family Newborn Health
23
Family Health

• Screening
• Postpartum depression
• Social barriers (e.g. substance abuse, poverty)
• Feeding (Breast or Bottle)
• Parents Sleep
• Support
• Family Friends
• Adjustment to new baby
• Partners
• Siblings
• Pets
• Daycare plans/Back to Work

24
Resources

• http//brightfutures.aap.org/tool_and_resource_kit
  .html
• http//www.childcarechoices.me/ccchoices/Home.aspx
  

25
Well Child Forms

• http//www.maine.gov/dhhs/oms/provider/well_child_
  visits.html
• Maine The Bright Futures guidelines have been
  applied as the states standard of care for
  physicians. The guidelines also were used to
  revise state nursing standards. MaineCare, the
  States public health insurance program, has
  developed new clinical forms based on Bright
  Futures to be used for all recommended well-child
  visits. Providers who complete the forms are
  reimbursed at an enhanced rate.

26
Dental Health

• http//www2.aap.org/oralhealth/docs/RiskAssessment
  Tool.pdf

27
Kids Health

• http//kidshealth.org/parent/pregnancy_center/chil
  dbirth/newborn_variations.html
• Tells it like it is .

28
Discipline

• http//www.youtube.com/watch?vtbm1XFNY7sM

29
Newborn Care

• http//kidshealth.org/parent/pregnancy_center/newb
  orn_care/guide_parents.html
• Videos
• http//brightfutures.aap.org/video_families.html

30
Newborn

• 0 to 28 Days

31
Newborn Skin
32
Milia

• Papules lt 2 mm primarily on face scalp
• Contain keratinized stratum corneum
• Present at birth or may appear later in infancy

33
Salmon patch (nevus simplex)AKA stork bite,
angel kisses

• Present at birth
• Pink to red macule commonly on nap of the neck,
  eyelids, glabella (smooth area between
  eyebrows)
• Most fade by 1-2 years of age

34
Mongolian spot (Dermal Melanosis)

• Slate blue, gray or black
• Lower back sacrum
• More frequently darker skinned individuals

35
Jaundice

• Results from transient elevation of serum
  bilirubin (5 7 mg/dl)
• Apparent in the 3rd to 4th day of life

36
Erythema Toxicum

• 50 - 72 of all newborns
• Etiology is unknown
• Onset 24-48 hours of life can appear as late as
  10 days of age
• Lesions wax and wane and are filled with
  eosinophils
• 1-3 mm yellowish papules or pustules

37
Epsteins pearls

• 1-2 mm yellow to gray-white papules on the medial
  palate
• Microkeratocytes

38
Hemangioma

• Most common pediatric vascular tumors 5 of
  infants in the United States
• Increase incidence
• Prematurity
• Twins
• Family history

39
Hemangioma

• Proliferation out of proportion to growth of
  the infant up to 9 months of age
• Involution
• 30 by 3 years
• 50 at 5 years
• 70 at 7 years
• 90 by 10-12 years

40
Treatment if

• Permanent disfigurement
• Ulceration
• Bleeding
• Visual compromise
• Airway obstruction

41
Treatment for hemangioma

• Collaborative
• Dermatologist for on-going treatment
• Cardiologist initial evaluation prn
• PCP on-going monitoring

42
Involution of Hemangioma
43
Dysmorphic Features
44
Polydactyl Syndactyl
45
SimianCrease
46
Retinoblastoma
47
Check Nose for Patency

• Choanal Atresia
• http//www.youtube.com/watch?vigiLag2zfHM

48
Spinal Dysraphism

• Incomplete closure of the vertebrae
• Lumbosacral lipoma
• Lumbosacral hemangioma or PWS
• Lumbosacral tail
• Lumbosacral dermal sinus
• Lumbosacral aplastic cutis congenita

49
Hip Dislocation
50
Ortalani Barlow Maneuvers

• https//www.youtube.com/watch?vqgAHQI74BfU
• https//www.youtube.com/watch?vV7_8yaggwxoorefh
  ttps3A2F2Fwww.youtube.com2Fwatch3Fv3DV7_8yag
  gwxohas_verified1

51
Cardiac Defects
ASD VSD PDA Coarctation
Mid-systolic murmur ULSB with wide split of second heart sound Holosystolic murmur LLSB Continuous murmur under left clavicle, referred to the back Systolic ejection murmur in left intraclavicular region with transmission Diminished femoral pulses
52
Car Seats

• http//www.maine.gov/dps/bhs/restraints/child-seat
  s/styles.html

53
Infancy
54
Otitis Media

• Infection of the middle ear
• Most common organisms
• S. pneumoniae, H. influenzae, M. catarrhalis
• Diagnosis based on middle ear effusion and
  inflammation

55
Potential Complications

• Cholesteatoma (Hx. Chronic OM foul smelling
  d/c vertigo hearing loss)
• Inflammation
• Perforation of the TM
• Mastoiditis (suppurative infection of mastoid
  cells)
• Hearing loss

56
Dacryostenosis http//www.youtube.com/watch?v4000
uJDRags
57
Strabismus vs. Pseudo-Strabismus

• By 3 to 4 months there should be no deviation of
  the eyes
• Assessment
• Cover/uncover
• Hirschbergs test

58

• Diastasis recti

• Umbilical hernia

59
NIH diagnostic criteria for NF1

• Two or more of the following features
• Pre-pubertal
• gt 6 CAM gt 5 mm in greatest diameter
• Post-pubertal
• gt 6 CAM gt 15 mm in greatest diameter
• Two or more neurofibromas or one plexiform
  neurofibroma
• Freckling in the axillary or inguinal regions
• Optic glioma
• Two or more Lisch nodules (iris hamartomas)
• A distinctive osseous lesion such as sphenoid
  dysplasia or tibial pseudarthrosis
• First degree relative (parent, sib, or offspring)
  with NF1 as defined by the above criteria

60
Innocent Murmurs
Stills (Head Start Murmur) Pulmonary Flow Murmur of Childhood Pulmonary Flow Murmur of Infancy Venous Hum
Most common between 2-6 years Most common between 8-14 years ?standing or sitting ? supine Infancy Any age
Midpoint, left mid-sternal border to apex Pulmonary outflow area Short, mid-systolic Constant swishing disappears head turning, or supine position varies respirations
Short, vibratory, musical Soft, blowing with split S2, no thrill Soft with middle to high pitch Soft, high pitch does not radiate
61
Skeletal Findings

• Tibial torsion
• Genu Valgum
• Genu Valgus
• Pes Planus
• Metatarus Adductus
• Scoliosis

62
Tibial Torsion vs. Tibial Version

• Version normal variation in tibial rotation
• Gradually resolves by 8 years of age

63
(No Transcript)
64
Genu Valgum (Knock Knees)

• More common in girls
• Apparent at 2 to 4 years of age disappears by 7
  to 8 years
• Orthopedic evaluation
• Angle gt 15 degrees
• Unilateral
• Associated with short stature
• Inter-malleolar distance gt 4-5 inches

65
Genu Valgus (Bow Legs)

• Common up to 2-3 years of age
• Angle between the tibia femur pronounced up to
  15 degrees before 1 year of age neutral by 18
  months
• Orthopedic evaluation
• Tibia-femoral angle gt 15 degrees
• Unilateral
• Progressive
• Associated with short stature

66
Flexible Pes Planus

• Often seen in neonates to toddlers
• Soft tissue laxity
• Familial
• Arch is seen when foot is dangling
• Resolves by 2-3 years of age but rarely persists
  in adulthood

67
Flexible Metatarsus Adductus

• Hind foot straight and forefoot adducted
• Often bilateral
• From intrauterine position
• 1/1000 births
• Stretching with diaper change/baths

68
Radiologic Evalaution

• Cobbs Angle

• Risser sign

69
Risk of Scoliosis Progression
70
Scoliosis Screening

• http//www.youtube.com/watch?vs-9A0OuEr14

71
(No Transcript)
72
References

• Baulch I. (2010) Assessment and management of
  pain in the paediatric patient. Nursing Standard,
  25 (10),35-40.
• Centers for Disease Control and Prevention.
  (2011). General recommendations on immunization
  Recommendations of the advisory committee on
  immunization practices (ACIP). MMWR, 60(2),
  1-64.
• Harrison, D., Stevens, B., Yamada, J.,
  Adams-Webber, T., Beyene, J., Ohlsson, A.
  (2010). Efficacy of sweet solutions for
  analgesia in infants between 1 and 12 months of
  age A systematic review. Archives of Disease in
  Children, 95,406413.

73

• Taddio, A., lIersich, A., Ipp, M., Kikuta, A.,
  Shah, V. (2009). Physical interventions and
  injection techniques for reducing injection pain
  during routine childhood immunizations
  Systematic review of randomized controlled trials
  and quasi-randomized controlled trials. Clinical
  Therapeutics, 31(B), S48-S76.