HEALTH SUPERVISION VISIT GUIDELINES SCHOOL-AGED CHILD

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HEALTH SUPERVISION VISIT GUIDELINESSCHOOL-AGED
CHILD

• SUZANNE LEFEVRE MD

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GENERAL APPROACH TO THE WELL CHILD VISIT

• INTERVAL HISTORY/OBSERVATION
• NUTRITION
• ELIMINATION
• SLEEP PATTERNS
• DEVELOPMENT/BEHAVIOR/SCHOOL PERFORMANCE
• PHYSICAL EXAM
• ANTICIPATORY GUIDANCE
• DISEASE PREVENTION/HEALTH PROMOTION AND INJURY
  PREVENTION

3
4 YEAR OLD VISIT

• Interval history/ Interview with behavioral
  observations
• Child How are you? How old are you? Do you go
  to school? Where?
• Parent Have there been any illnesses,
  hospitalizations or ED visits since our last
  visit? How is your child doing in pre-school or
  child care? Do you have any particular concerns
  youd like to discuss?

4
4 Year Old Visit

• Nutrition
• Child What do you like to eat?
• Parent Do you have any concerns about your
  childs eating habits?
• Describe a typical dinner in your home?
• Anticipatory Guidance
• Kids age 4-8 need 800mg of Calcium per day one 8
  oz glass of milk contains 300mg
• Recommend limiting juice to no more than 6 oz of
  100 fruit juice.
• Food jags (favoring 1 or 2 foods) and picky
  eating are normal behaviors.
• Explain the growth chart
• Suggestions for picky eaters
• Offer small portions first, then second helpings
• Try to create a pleasant atmosphere at meal time
• Include child in conversation at the dinner table
• Offer a variety of foods and repeat them

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4 YEAR OLD VISIT

• Elimination
• Parent Does the child use the toilet for
  urination and having bowel movements?
• Have you noticed any discomfort when the child
  has a bowel movement?
• By age 4, 95 of children are bowel trained
• 90 are dry during the day
• 75 are dry at night
• Anticipatory Guidance
• No specific interventions are warranted for night
  time wetting because its so common at this age.
• Stress importance of balanced diet in preventing
  constipation

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4 Year Old Visit

• Sleep Patterns
• Child Where do you sleep?
• Parent How does your child get to sleep at
  night? Does your child nap? Does your child
  experience nightmares, night terrors, or
  sleepwalking?
• Nightmares are common and involve vivid, scary or
  exciting events which are easily recalled by the
  child upon awakening.
• Night terrors are common particularly in boys
  ages 5-7 but can see as early as 4. They occur
  in 1 3 of children and are usually short
  lived. Characterized by sudden onset, usually
  between midnight and 200am during stage 3 or 4
  of slow wave sleep. The child screams, appears
  frightened, tachycardic and may hyperventilate.
  Child my thrash violently, there is little or no
  verbalization and cannot be consoled. Sleep
  follows in a few minutes and there is total
  amnesia of the event upon waking.

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4 Year Old Visit

• Sleep Patterns
• Anticipatory guidance
• Encourage children to sleep in their own beds if
  that is compatible with the familys culture
• Create a calm bedtime ritual like reading or
  story telling
• Reassure parents that nightmares and night
  terrors are common

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4 Year Old Visit

• Development and Behavior
• Child What sort of things are you good at
  doing? Can you get yourself dressed?
• Parent What skills do you expect of a 4 year
  old that your child cannot perform?
• Ages and Stages Questionnaire
• Milestones
• Gross motor Pedals tricycle, hops on one foot,
  balances on one foot, walks up and down stairs
  with alternating gate
• Fine motor Draws a circle and cross, draws a
  person with 3 to 6 body parts, cuts with scissors
• Cognitive skills complex pretend play, may have
  imaginary friend, recognizes some of the alphabet
• Language skills Uses full sentences of at least
  6 words, 100 intelligible
• Social skills engages in interactive play, able
  to share, can play a board or card game.
• Self-help skills Able to put on shirt, pants,
  socks, able to button and zip able to brush
  teeth toilet trained

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4 Year Old Visit

• Physical Exam
• Height
• Weight
• Blood Pressure
• General physical exam to include
• Visual acuity- objective
• Hearing screen- objective
• Check for obvious dental caries
• Check gait, spine and extremities
• Be alert for signs of abuse
• Screening Hemoglobin if at risk for anemia
  (i.e., special health needs, low iron diet or
  environmental factors
• Immunizations See current recommended schedule
  (DTaP, IPV, MMRV)

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4 Year Old Visit Injury Prevention

• Toys should be age appropriate
• Falls are common
• Keep dangerous materials out of reach matches,
  tools and poisons
• Helmets for tricycle safety
• Car seats and seat belts
• Start booster seat at 40lbs and 40 inches tall

• Adult supervision near water, consider swimming
  lessons
• Good touch/bad touch
• Careful around strange dogs
• Gun safety AAP recommends that they be removed
  from the home
• Teach child how to dial 911
• UV protection

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4 Year Old Visit

• Close the visit
• Are there any issues that we missed?
• Set time and reason for next appointment

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5 YEAR OLD VISIT

• Interval History/ Interview with Behavioral
  Observations
• O.K. to talk to child alone for a few minutes.
  As the child grows older the time period
  gradually increases. This is patient and family
  dependent
• Child Have you been sick since I saw you last?
  How many brothers and sisters do you have?
• Parent How is your family doing? Have there
  been any changes in the family?

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5 Year Old Visit

• Nutrition
• Child What are your favorite snacks?
• Parent Do you have any concerns about your
  childs weight?
• Anticipatory Guidance
• Same as the 4 year old visit
• Discuss healthy snacking

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5 Year Old Visit

• Elimination
• Child do you have any problems with bowel
  movements (poop) or urinating (pee)?
• Parent Does your child wet the bed at night?
• At age 5 approximately 20 of children wet the
  bed at least monthly.
• Approximately 5 of boys and less than 1 of
  girls wet the bed nightly
• Anticipatory Guidance
• No specific interventions are warranted for night
  time wetting at this age.

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5 Year Old Visit

• Sleep Patterns
• Same as 4 year old visit

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5 Year Old Visit

• Development and Behavior
• Child Can you write your name?
• Parent Can your child tie his shoes? Is your
  child comfortable in speaking to others?
• ASQ (Ages and Stages Questionnaire)
• Milestones
• Gross motor balances on one foot, hops, skips
• Fine motor able to tie a knot, has mature
  pencil grasp, draws a person with at least 6 body
  parts, able to copy squares and triangles.
• Language Names at least 4 colors, counts to 10,
  tells a simple story using full sentences,
  appropriate tenses, pronouns.
• Social skills follows simple directions, able
  to listen and attend, dresses and undresses with
  minimal assistance.

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5 Year Old Visit

• Physical Exam
• Same as the 4 year old visit
• Screening
• Urinalysis
• Other screening as indicated by risk lead,
  hemoglobin, PPD

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5 Year Old VisitAnticipatory Guidance Injury
Prevention/Health Promotion

• Fire safety (alarms, fire escapes, home plan for
  emergencies)
• Dealing with strangers
• Discourage skate boarding or in-line skating
  unless helmets, wrist, elbow and knee pads are
  used
• Violence prevention
• Pedestrian and bicycle safety

• Regular exercise/family activities
• Brush teeth at least 2 times per day. See
  dentist 2 times per year.
• TV viewing should be limited and monitored
• Encourage interaction with other kids,
  grandparents and adults
• Spend time playing with child every day

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6-7 Year Old Visit

• Interval History/Interview with Behavioral
  Observations
• Child What grade are you in? Have you been
  sick since our last visit? Any broken bones or
  stitches?
• Parent Have there been any family crisis or
  stressors? Is your child on any medications?

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6 7 Year Old Visit

• Nutrition
• Child Do you eat fruits and vegetables?
• Parent What does your child eat for protein?
  How much milk does your child drink?
• Anticipatory Guidance
• Continue to promote well-balanced diet.
• Avoid junk foods
• Consider need for vitamins, iron supplements
• Encourage regular exercise

• Elimination
• Child Do you have a bowel movement every day?
  Is it hard or soft? Does it hurt?
• Parent Does your child have problems with day
  time wetting, night time wetting or soiling?
• Anticipatory Guidance
• By age 6 only 10 of children will wet the bed
• If problems are identified, enuresis,
  constipation and encopresis.

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6 7 Year Old Visit

• Development and Behavior
• Child Can you ride a bike? Show me your left
  hand?
• Parent How would you evaluate your childs
  abilities in sports? How are your childs
  abilities to draw and write?
• Milestones
• Gross motor skip
• Fine motor Draw a picture of a person with 8 to
  10 features
• Language/Cognitive Recount a personal story
  about a recent event, count to 20

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6 7 Year Old Visit

• Physical Exam
• Same as 5 year old
• Screening
• Same as 5 year old
• Injury Prevention/Health promotion
• Same as 5 year old

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School Readiness

• Years from 3 to 6 are historically called
  preschool because of their importance for
  preparing the child for the tasks of school
• Determine any parental concerns about school
  readiness by asking trigger questions
• How does your child feel about going to school?
• How are you feeling about John/Jane going to
  school?
• When you were Johns/Janes age, did you enjoy
  school?
• How did John/Jane do in preschool?
• Is there anything you would like checked before
  he/she goes to school?
• Is there anything the school or teacher should
  know?

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School ReadinessParental concerns regarding
developmental milestones

• Communication/Language
• Knowledge of letters, words and symbols
• Ability to recognize letters and numbers
• Articulate speech
• Behavioral/Emotional Skills
• Ability to take another persons point of view and
  follow rules
• Separation anxiety
• Social shyness
• Temper tantrums and tendency to be aggressive
  when fearful are indicators of emotional
  immaturity

• Gross motor/Fine motor
• Ability to print letters and numbers
• Good gross motor coordination can provide
  important status with peers and is a source of
  self-esteem through athletics. This is least
  predictive of school achievement when compared
  with other areas of development.
• Physical size and stature

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Developmental milestones necessary for Elementary
School Success

• Cognitive
• Long term memory, storage and recall
• This is the ability to acquire skills that are
  automatic
• Deficit Delayed mastery of the alphabet, slow
  handwriting and the inability to progress past
  basic mathematics
• Selective Attention
• Ability to attend to important stimuli and ignore
  distractions
• Deficit Difficulty following multi-step
  instructions, completing assignments and behaving
  well
• Sequencing
• Ability to remember things in order
• Deficit Difficulty organizing assignments,
  planning, spelling and telling time
• Levine MD Developmental-Behavioral Pediatrics.
  Nelsons 2004

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Developmental Milestones necessary for Elementary
School Success

• Perception
• Visual Analysis
• Ability to break a complex figure into components
  and understand spatial relationships
• Deficit Persistent letter confusion (between
  b,d and g), difficulty with basic reading and
  writing and limited sight vocabulary
• Proprioception and fine motor control
• Ability to obtain information about body position
  by feel and unconsciously program complex
  movements
• Deficit Poor handwriting often with overly
  tight pencil grasp, difficulty with timed tasks
• Levine MD Developmental-Behavioral Pediatrics.
  Nelsons 2004

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Developmental Milestones necessary for Elementary
School Success

• Language
• Receptive
• Ability to comprehend constructive function words
  like if, when, only, except. Ability to
  understand nuances of speech and extended blocks
  of language (e.g. paragraphs)
• Deficit Difficulty following directions,
  wandering during lessons and stories, problems
  with reading comprehension, problems with peer
  relationships
• Expressive
• Ability to recall required words effortlessly
  (word finding), to control meanings by varying
  position and word endings, to construct
  meaningful paragraphs and stories
• Deficit Difficulty expressing feelings and
  using words for self-defense, with resulting
  frustration and physical acting out struggling
  during circle time and language based subjects
• Levine MD Developmental-Behavioral
  Pediatrics. Nelsons 2004
• 
  

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References

• Bright Futures, Health Supervision III Guidelines
  2008 AAP Publication
• Caring for your Baby and Young Child AAP
  Publication
• Nelsons Textbook of Pediatrics 2004
• Pediatrics A Primary Care Approach,
• Carol Berkowitz, MD, FAAP, 2008

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General Approach to the Well Child Visit

• Interval History/Behavioral Observation
• Nutrition
• Elimination
• Sleep Patterns
• Development/Behavior/School Performance
• Physical Exam
• Anticipatory Guidance
• Disease Prevention, Health Promotion, Injury
  Prevention

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8 9 Year Old Visit

• Interval History/Interview with Behavioral
  Observations
• Child How are things going?
• Parent Have there been any changes in your
  childs health?
• Middle childhood is marked by considerable
  development in academic skills, physical
  abilities, social interactions and emotional
  regulation. School success and home life are
  both important for self-esteem.
• Nutrition
• Child How is your appetite? What do you eat
  for breakfast?
• Parent How is your childs appetite?
• Encourage child to eat breakfast daily
• Reinforce need for balanced diet avoiding junk
  food
• With a balanced diet and exercise there should be
  no need for dieting

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8 9 Year Old Visit

• Elimination
• Child How often do you have bowel movements?
• Parent Do you have any concerns about your
  childs toilet habits?
• Enuresis Defined as normal voiding that occurs
  at an inappropriate time or involuntarily in a
  socially unacceptable setting.
• Defined as occurring at least 2 per week for at
  least 3 consecutive months
• Diagnosis is reserved for girls older than 5 and
  boys older than 6
• Diurnal enuresis occurs during the day
• Nocturnal enuresis occurs at night
• Primary enuresis refers to kids who have never
  achieved sustained dryness
• Secondary enuresis refers to kids whose urinary
  incontinence occurs after 3 to 6 months of
  dryness
• 75 to 80 of kids with enuresis have primary
  enuresis
• Incidence of secondary enuresis increases with
  age and makes up 50 by age 12
• Causes of primary enuresis include faulty toilet
  training, maturational delay, small bladder
  capacity, sleep disorders, nocturnal polyuria
• Causes of secondary enuresis include UTIs,
  diabetes mellitus and insipidus, genitourinary
  anomalies, seizure disorder, medication use

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8 9 Year Old Visit

• Sleep Patterns
• Child What time do you go to bed at night? How
  many hours do you sleep on a school night?
• Children age 8 frequently sleep 9 to 12 hours per
  night.
• School
• Child What subjects do you like? What do you
  think about your grades?
• Parent How are your childs reading and writing
  skills? What did you learn at the parent-teacher
  conference?
• If school failure is suspected discuss need for
  comprehensive approach involving parents, school
  and pediatrician.

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8 9 Year Old Visit

• Development and Behavior
• Child What do you like to do for fun? How many
  hours each day do you watch T.V?
• Parent What are your expectations for your
  child in terms of sports and extracurricular
  activities? How does your child get along with
  friends and peers at school?
• Parents should encourage peer play outside the
  home, i.e. clubs, camps or athletic teams.
• Parents should consider giving an allowance to
  encourage independence and responsibility.
• Recommend fair, understandable rules about
  chores, T.V., outside activities, homework and
  bedtime.
• Encourage follow through with stated consequences
  when rules are broken.
• Consider discussing puberty.

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8 9 Year Old Visit

• Physical Exam
• Height
• Weight
• Blood Pressure
• Look for signs of puberty
• Screening
• Hemoglobin, PPD if high risk
• Injury Prevention/ Health promotion/ Disease
  Prevention
• Discuss participation in team sports where
  emphasis is fun and not winning
• For those children that dont like team sports,
  encourage individual sports like swimming,
  tennis, dance or gymnastics
• Trampoline use should be discouraged
• Children can learn CPR at this age
• Gun Safety
• Smoke detectors in the home

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10 11 Year Old Visit

• Interval History/ Interview with Behavioral
  Observations
• Speak to child alone during some portion of the
  visit
• Explain confidentiality to the child and parents
• At this age peer groups become an increasingly
  important influence on style, attitudes and
  values. They may begin risk-taking behaviors
  such as cigarette smoking or drinking alcohol.
• Nutrition
• Child What is meant by a well balanced diet?
• Parent Is there a history of elevated
  cholesterol in your family?
• Encourage child to eat breakfast before school
• Encourage regular exercise
• Advise parent and child about adequate hydration
  during warm climate sports or outdoor activities

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10 11 Year Old Visit

• Elimination
• Child Do you experience pain or burning with
  urination?
• Sleep Patterns
• Child How do you feel when you wake up in the
  morning?
• Parent How much sleep does your child get at
  night?
• Children this age should still get at least 9
  hours of sleep per night
• Development/ Behavior
• Child Where do you spend your time after
  school?
• Parent What are the most enjoyable activities
  you do together? What activities are most likely
  to cause friction or problems?
• Age 10 is a prime year for sports competition.
  Year round participation in multiple sports my
  reduce over-use injuries of same muscle groups.
• Strength training is appropriate with proper
  supervision.
• Parents should discuss tobacco, alcohol and
  illicit drug use.
• Encourage parents to prepare girls for menarche.

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10 11 Year Old Visit

• Physical Exam
• Height
• Weight
• Blood Pressure
• Make sure to include assessment for scoliosis,
  Tanner staging and exam of genitalia
• Screening
• Hemoglobin for menstruating females
• Urine dipstick should be done between 11 and 21
• Cholesterol and PPD for high risk kids
• Injury Prevention
• Seat belts
• No power tools unless supervised
• Water activities should be supervised
• Children this age should not operate personal
  watercraft
• Sunburn protection

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School Failure

• Failure in school can have lifelong consequences.
  The causes of school failure are often multiple
  including chronic illness, behavioral,
  emotional and social issues
• Background
• 10 15 of school age children repeat or fail a
  grade
• More likely among males, minorities, low
  socio-economic status and single parent
  households
• Children with disabilities are nearly 3 times as
  likely to repeat a grade as those with no
  disability
• Disability
• Learning
• Speech or language impairment
• Mental retardation
• Emotionally disturbed
• Children who are small for gestational age are
  nearly twice as likely to experience school
  failure

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School Failure

• Background
• Grade failure is linked strongly to subsequent
  dropping out of high school
• 10 of drop-outs had no failures
• 22 of drop-outs failed one grade
• 39 of drop-outs failed 2 grades
• Grade failure causes children to be older than
  their same-grade peers
• Old for grade high school students are more
  likely to report smoking regularly, chewing
  tobacco, alcohol use, driving in a car with
  someone who has been drinking, using alcohol
  prior to a sexual experience and using cocaine or
  other illicit drugs.
• They have more suicidal ideations, risky sexual
  behavior and violent behaviors
• Grade retention alters peer group formation
• Grade retention has a negative impact on
  self-esteem, social adjustment, behavior,
  self-confidence, attitudes towards school and is
  stressful for children

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School FailureConditions and Associated Factors

• Endogenous Factors
• Chronic disease
• Anemia
• Asthma
• Sleep Apnea
• Cystic Fibrosis
• SLE
• Crohns Disease
• Acute conditions causing school absence
• Sensory impairment
• Vision
• Hearing
• Perinatal conditions
• Prematurity
• FAS
• In utero drug exposure
• Maternal conditions affecting pregnancy
• Neurologic disorders
• Brain injury

• Endogenous Factors
• Learning disability
• Language and Speech Disorder
• Phonologic language
• Expressive language
• Receptive language
• Stuttering
• Learning disorder
• Reading
• Writing
• Mathematics
• Mental Retardation
• Communication disorders
• ADHD
• Autistic spectrum disorders
• Genetic disorders Fragile x
• Endocrine disorders Hypothyroidism
• Psychiatric disorders
• Oppositional defiant disorder

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School FailureConditions and Associated Factors

• Exogenous Factors
• Family
• Divorce/Separation/conflict
• Poverty
• Frequent moves
• Substance abuse
• Depression
• Attitudes towards education
• Low level of family support
• Inadequate accommodations for studies at home
• Neglect/Abuse
• Environment
• Neighborhood/housing
• TV/computers
• Peers
• Peer pressure for low performance
• Substance abuse

• Exogenous Factors
• Competing priorities excessive extramural
  activities
• Social
• Work
• Sports
• School
• Mismatch between student and teacher
• Unrealistic expectations
• Inadequate school environment
• Violence/safety
• Classroom size
• Transitions
• Third grade
• Elementary school to middle school
• Increases in testing standards without increasing
  educational support
• Excessive testing

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School FailureMedical Assessment and Subsequent
Interventions

• History
• Developmental history
• Motor milestones
• Language milestones
• Regression
• Social skills
• Temperament
• Current Medical Conditions
• Acute
• Chronic
• Medications
• Past medical history
• Head trauma
• CNS conditions
• Sleep history
• Social history
• Peer group
• Family stress poverty, conflict, single parent
• Family orientation toward education

• History
• School history
• Details of current difficulties
• School setting
• Educational support
• School absences
• Achievement
• Onset of problems
• Results of educational testing
• Preschool performance
• Communication with the school
• Attention profile
• Attention
• Hyperactivity
• Impulsivity
• Family history
• Educational achievement and difficulties
• Mental retardation
• ADHD

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School FailureMedical Assessment and Subsequent
Interventions

• School Failure Interventions
• As indicated by assessment (e.g., treatment of
  hypothyroidism)
• Advocate for more complete assessment
• Attend school meetings
• Advocate for IEP that consists of more than
  simply having a child repeat the grade that was
  failed
• Advocate for alternatives to grade retention
• Mixed-age classes
• Individualized instruction
• Tutoring
• Home assistance program
• Smaller class size
• Alternative education settings
• Guidance counseling

• Help families get more involved in their childs
  education
• Assist families with peer group issues
• Improve environment for learning at home
• Limit amount of television watching
• Provide a quiet place to do homework
• Help develop childs strengths
• Assess siblings for school problems and take the
  opportunity to promote school readiness prior to
  the failure of a younger sibling

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School FailureMedical Assessment and Subsequent
Interventions

• Prevention
• Promote school readiness during health
  supervision visits
• Assess childrens strengths and weaknesses
• Assess educational progress at all health
  supervision visits
• Implement some interventions listed previously
  before failure occurs
• Assess peers, activities, and health-impairing
  behaviors