Case 3

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Case 3 3-Year-old well child check - Benjamin Author: Ardis Author: Ardis Olson, M.D., Dartmouth Medical School, and David Kwee, M.D., Morehouse School of Medicine

Learning Objectives 1. Describe the key components of a toddler well-child visit, including: The importance of identifying parent concerns in order to set priorities for the visit effectively. The role of the physician in guiding parenting skills through affirming and validating parent's efforts and recommending and facilitating modifications in parenting and behavior. Nutritional assessment and recommendations for diet and feeding behaviors. Assessment of dental health and common factors leading to childhood caries. Methods for performing developmental assessment screening tests and developmental surveillance. Methods for performing a physical examination tailored to the age and mood of the child. Topics for anticipatory guidance, such as safety. 2. List key developmental milestones for children between the ages of 3 and 5 years old. 3. Identify eczema and discuss first-line therapy. 4. Discuss the common causes and work-up of anemia in an otherwise healthy child, as well as first-line therapy of i ron-deficiency anemia. Summary of clinical scenario: scenario : This case focuses on the health maintenance visit of a preschooler. Benjamin is a picky eater with a poor diet, dental caries, and iron- deficiency anemia. He is also discovered to have atopic dermatitis.

Key Findings from History

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Inadequate vitamin and iron intake Excess milk and juice intake

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Control battles about food Bottle at bedtime Gun in the home

Atopic dermatitis on trunk and antecubital

Key Findings from Physical Exam

fossae Caries

Anemia due to: Iron deficiency Chronic blood loss Lead poisoning

Differential Diagnosis

Chronic illness (such as collagen vascular disease, malignancy, or HIV) Hemoglobinopathy Decreased marrow production ncreased destruction of red cells or precursors Atopic dermatitis vs. psoriasis

Key Findings from Testing

Final Diagnosis

Fingerstick hemoglobin: 10 grams/deciliter (g/dL), indicating anemia

Iron-deficiency anemia Atopic dermatitis

Case highlights: The case teaches how to conduct a preschool-aged maintenance visit, including counseling on nutrition, dental health, and behavior issues. Skills for assessing strabismus are discussed and treatment of atopic dermatitis is covered.

Key Teaching Points Knowledge Atopic diathesis: Each of the following may occur in isolation, but given a history of one, you should ask questions to determine the presence of the other conditions: Eczema Allergic triggers Asthma symptoms

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Atopic dermatitis/eczema (“the itch that rashes”): Thickening and inflammation of skin Tends to be familial, but with multifactorial inheritance Often environmental (allergic) triggers Anything leading to itching can exacerbate eczema. Health maintenance visit: Ensure child’s comfort and cooperation. Gather interval and family history (including maternal depression). Review immunizations. Screening: Tuberculosis (TB): Assess risk If there is a risk factor, a purified protein derivative (PPD) should be placed and read by a medical professional in 48 to 72 hours. Lead : Assess risk (mouthing objects, pre-1950s housing, housing near busy interstate, or recent immigrant) Anemia: Typically screened for at 12 months and again at preschool or kindergarten entry (if there are risk factors, then testing may be done at any visit). The initial 12-month window coincides with a period in development when diet, particularly iron sources, is often in flux. Anticipatory guidance: Nutrition: Inadequate vitamin and iron intake due to poor diet: One study found that preschool-aged children consumed 80% of the recommended fruit servings/day and 30% of the recommended vegetable servings/day. Many of the vitamins preschoolers consume come from fortified foods. Vitamin D: Children should receive vitamin D supplementation, as it is very difficult to attain the recommended daily allowance through nutritional sources or from sun exposure. Iron: A central nervous system co-catalyst, essential for normal development. Predominant sources in toddlers are meat, legumes, and iron-fortified cereals. Excess milk and juice intake: Diminishes appetite for other foods and results in a diet that lacks iron. Can add substantial calories to a diet and contribute to the

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development of early obesity. AAP recommends only one or two servings of fruit juice a day. Can result in early dental caries: Recommended discontinuation of the bottle by age 12 to 15 months. Exercise: Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity. Dental : Controversy about when first dental visit should occur: American Association of Pediatric Dentists (AAPD) and the American Academy of Pediatricians (AAP) both state that all children should be seen within six months of the first tooth eruption or by one year of age. However, many communities lack pediatric dentists, and many general dentists feel that the first visit should be at age 3 years. AAP states additionally that all children should be screened by six months for risk of caries. Safety : In the toddler years, overall safety issues become increasingly important because of the increased independence, inquisitiveness, and motor skills of preschoolers. Injuries are a major morbidity in the preschool years.The Injury Prevention Program (TIPP) is a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries. Car seats: Older than 24 months, or have outgrown height/weight limits on their car seat, use forward-facing car seat in car's back seat. Older children stay in a booster seat until they reach a height of 4 feet 9 inches (142 centimeters). Firearms in the home: Preferably remove. If cannot, use safety lock, store in locked cabinet, keep ammunition in separate locked cabinet. Study showed that 52% of parents who owned guns think their children are "too smart" or "know better"; also showed that, when given the opportunity, boys 8–12 years will handle a gun (76%) and pull the trigger (48%). Consider potential suicide risk for teenagers. Fire safety Poison control Car accidents Risk of lead poisoning Behavior/temperament: Temper tantrums

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Toilet training: Requiring assistance toileting at age 3 years is not a clear sign of developmental delay, but may preclude attendance at child care or preschool. Eating habits: Food rewards and punishment may promote obesity by interfering with children's ability to regulate their own food intake. Developmental surveillance and screening: Especially important in preschoolers so physician can intervene early if necessary. Involves physician observation and parental history. Parents' Evaluation of Developmental Status (PEDS) is an evidence-based surveillance and screening tool for children birth to 8 years that elicits and addresses parents’ concerns about their child’s development, behavior, and mental health. Modified Checklist for Autism in Toddlers (M-CHAT) is a validated tool for screening toddlers between 16 and 30 months of age to assess risk for autism spectrum disorders (ASD). General pediatricians do not conduct official developmental assessments but do practice developmental surveillance and screen for areas of concern during each visit. However, evidence suggests that developmental surveillance by itself is not enough to pick up developmental problems. States are mandated to provide developmental assessments and services for children < 3 years at risk for developmental delays by experts such as early interventionists, developmental-behavioral pediatricians, child psychiatrists, child psychologists, and/or early childhood learning specialists. For children 3 to 5 years, the school systems provide services to help them catch up to their peers. Expected developmental milestones (from AAP’s Bright Futures):

3-year-old

4-year-old

5-year-old

Knows gender and age

Social/ behavioral

Dresses self Feeds self

Is friendly to other children

Listens and attends

Plays with toys Engages in fantasy play

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Articulates well

Speaks in 2–3 word sentences Communication 75% understandable

States first and last names Sings a song Most speech clearly understandable

Tells a simple story using full sentences Appropriate use of tenses and pronouns Counts to 10 Follows simple directions

Cognitive

As children get ready for school, Names colors the Aware of gender developmental Knows name and milestones shift use of “cup, ball, Plays board to more spoon, crayon” games cognitive processes. Draws a person Asking parents with 3 parts about pre-k performance is important.

Balances on one foot, hops, and skips Hops on one foot Builds tower of 6–8 cubes Physical development

Throws a ball overhand Rides a tricycle Copies a circle

Ties a knot Balances on one leg for 2 seconds Mature pencil grasp Copies a cross Draws a person Pours, cuts, and with ! 6 body mashes own parts food Prints some Brushes teeth letters and numbers Copies squares

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and triangles Undresses and dresses with minimal assistance

Skills History: Approach child in a way that will ensure his/her comfort and cooperation. Establish a connection with the family and understand their social dynamics in order to successfully gather key information and provide anticipatory guidance at well child checks. Ask about stresses and family change in a non-threatening way. Physical exam: If exam needs to be truncated due to child's behavior, focus on: Neurodevelopment Monitoring previously recognized findings New findings identified by parents Physical problems common in preschoolers for which intervention can help Start with the least invasive parts of the exam (e.g., listen to heart and lungs), and move on to increasingly invasive ones (ears). Vital signs Temperature, heart rate, respiratory rate, blood pressure Plot height and weight and body mass index (BMI) on growth chart. HEENT Mouth: Caries Ears: Middle ear effusions may persist after earlier upper respiratory infection and affect hearing Eyes: Strabismus: Eyes not properly aligned with each other Hirschberg light reflex: Screening test for strabismus. Cover tests: Determines presence and amount of ocular deviation.

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Neck Enlarged thyroid is rare in children. “Shotty” (pea or marble-sized, nontender, and easily mobile) nodes in cervical and inguinal chains are normal in children and may persist for many years. Cardiac Murmurs Most murmurs will be functional New murmurs of congenital heart disease are unlikely Murmurs of atrial septal defect (ASD) sometimes are appreciated only in older children Lungs Yield likely to be low in a healthy child, but may hear subtle wheezing in a child with history of allergies Abdomen Palpate for organomegaly and masses: Most common: Stool Occasional: Enlarged kidney Very rare: Abdominal tumor (Wilms' or neuroblastoma) Musculoskeletal Observe for gait variants. In-toeing is most common variant seen at this age: Usually due to tibial torsion, with or without femoral anteversion. Tibial torsion usually spontaneously resolves by age 8 years (often well before). Careful history required to rule out potentially treatable causes. Often walking will strengthen anterior leg muscles and allow correction. Persistence has been associated with joint problems later in life. If in-toeing does not resolve by age 4 years, referral to orthopedic surgeon may be warranted. Genitals Check for hernias. Use opportunity to teach about who can appropriately examine the child. Girls at this age may have nonspecific vulval erythema due to underdeveloped self-hygiene skills. Neurological Assess muscle tone, strength, coordination, reflexes.

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Look at overall neurodevelopmental status—achievement of gross and fine motor skills, language, social skills.

Differential diagnosis Likely diagnoses Anemia: 1. Iron deficiency Most likely acquired cause of anemia in a 3-year-old child with poor nutritional intake. 10% of low-income preschoolers have iron-deficiency anemia, versus 7% of other preschoolers. Unclear whether cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk for iron deficiency. 2. Chronic blood loss May be caused by food allergies or gluten enteropathy 3. Lead poisoning 4. Chronic illness, such as collagen vascular disease, malignancy or other illness 5. Hemoglobinopathy Thalassemia, G6PD deficiency, or sickle cell disease More commonly found in those of Mediterranean, Asian or African descent Less likely diagnoses: Decreased marrow production (e.g., aplastic anemia), hemolytic anemias, and vitamin deficiencies (e.g., folate and B6) are rare in children and present with a more severe anemia (hemoglobin < 9 g/dL). Rash: 1. Psoriasis Can occasionally look like eczema Rare in children this young When present, occurs as a generalized rash known as guttate (droplet-shaped) psoriasis, and usually precipitated by a strep infection 2. Seborrheic dermatitis Unusual to have new case of seborrheic dermatitis at age 3 years, but should be part of the differential diagnosis, especially in early infancy (e.g., cradle cap). 3. Atopic dermatitis (eczema)

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Anemia screening: Fingerstick hemoglobin May be done in the office Rapid result Spun hematocrit relies on blood volume and hydration status can affect result Normal hemoglobin between 6 months and 6 years is 10.5–14 g/dL. Allergy testing: Radioallergosorbent test (RAST) Blood test used to determine to which substances a person is allergic

Management Advice for addressing eating problems: 1. 2. 3. 4. 5.

Jointly discard the bottle in the trash. Limit eating to three meals and two snacks per day. If child is thirsty, give her/him water. No bargaining or cajoling. Hunger should drive food choices, and only healthy options should be provided. 6. Dessert should never be used as an incentive for “good” eating. 7. Change diet content by gradually introducing new foods child is likely to try and slowly decreasing the quantity of old favorites. Anemia: Oral iron supplementation: If the anemia is mild, many providers will provide a trial of iron rather than do further workup. If hemoglobin recovers to within normal range, that is sufficient evidence of iron-deficiency anemia: Elemental iron 2–4 mg/kg divided once or twice daily Atopic dermatitis: Lubricate extensively Anti-inflammatories in short bursts: Topical hydrocortisone: Alternate a higher concentration for severe flares with a lower concentration for minor bouts. Newer topical anti-inflammatories such as calcineurin inhibitors are effective, but safety concerns with these are not fully resolved. Anti-histamines to reduce itching: Newer, non-sedating: Loratidine (Claritin) Cetirizine (Zyrtec) Traditional, with sedative side effects: Diphenhydramine (Benadryl)

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Hydroxyzine (Atarax, Vistaril) Treat associated skin infections aggressively. Back to Top

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