"#$% &' &()%#*(+,- .%,,(/01,- /0%/2 ( 3%45#614 Morehousee School of Medicine Medicin e David Kwee, M.D. Morehous Health maintenan m aintenance ce visit of o f a preschooler. presch ooler. Models M odels how to conduct cond uct a preschooler’s pres chooler’s visit and counsel parents pa rents about health promotion, nutrition, dental health, and behavior issues. The di fferential diagnosis and treatment of atopic dermatitis are also covered.
Final Diagnoses: Diag noses: Iron Iro n deficiency, defici ency, den tal caries, caries , eczema
7%#*4148 +95%/:1;%$ 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. 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 iron-deficiency anemia. • •
• • • • •
Important Review Topics for a Three-year-old's Health Maintenance Visit Social The social environment plays a major part in how children develop. • •
It is necessary to understand the family context before giving advice. To enter this arena, ask about changes and family stressors in a non-threatening way.
Nutrition •
Pre-schoolers can suffer from poor nutrition. Inadequate fruit, vegetable, and iron intake is quite common.
•
Calcium, and vitamin D deficiencies also are common.
•
Children should receive vitamin D supplementation as it is very difficult to attain the recommended daily allowance through nutritional sources or from sun exposure.
Exercise •
According to the American Academy of Pediatrics (AAP) guideline "Active Healthy Living: Prevention of Childhood Obesity through Increased Physical Activity": "Toddlers should be allowed to develop enjoyment of outdoor physical activity and unstructured exploration under the supervision of a responsible adult caregiver. Such activities include walking in the neighborhood, unorganized free play outdoors, and walking through a park or zoo."
•
Having quality play environments is optimal at this age.
•
Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity.
Toilet Training •
•
Toddlers at age 3 may not have achieved full toilet "independence"--especially toddlers with intense, willful temperaments. Requiring assistance toileting is not a clear sign of developmental delay at this age, but may preclude attendance at child care or preschool.
Dental •
The American Association of Pediatric Dentists (AAPD) and the AAP both state that all children should be seen within 6 months of the first tooth eruption or by one year of age. Additionally, the AAP states that all children should be screened by 6 months to see if they are at a higher risk of developing caries. Your community, however, may not have a pediatric dentist. Also, many general dentists feel that the first visit should be at age 3 years. This is an unresolved issue between general and pediatric dentists.
•
See the AAPD policy statement about "early childhood caries," the diagnostic term that has replaced "baby bottle tooth decay" or "milk bottle caries." Also see the AAPD policy statement about "the dental home," advocated for children at higher risk of dental caries.
Safety •
•
•
•
•
Car seats are often used inappropriately; toddlers are moved too soon to booster seats. The National Transportation Safety Board advises that toddlers older than 24 months or who have outgrown the weight and height limits on their car seats should be in a forward-facing car seat in the car's back seat. Older children should stay in a booster seat until they reach a height of 4' 9" (142 cm). 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.
<$$%$$148 -%;%,+=6%4: "#$%& '()%*(++* ,-.-%+/0-12#% 344-440-12 Developmental assessment of most preschoolers is a process of both observing the child and taking a history from the parent.
Developmental Surveillance • • • •
•
A form of developmental assessment--often in the form of play activities--incorporated into the exam. Helps to determine areas of concern, prompting further evaluation, if necessary. Performed at every encounter with the family. The experienced pediatrician takes a "mental snapshot" of the child's development and compares it to predicted norms. Evidence continues to mount that developmental surveillance alone inadequately identifies developmental delays.
One standard, recognized source for health maintenance information for children is Bright Futures from the American Academy of Pediatrics. This excellent, comprehensive document provides evidence-based synthesis of the best available information on what to expect at each age. Remember, the behaviors identified for each age in Bright Futures are what MOST kids at that particular age will do; but these are simply descriptions of expected behaviors, not a developmental screening test.
,-.-%+/0-12#% 344-440-12 Pediatricians do not, in general, perform definitive developmental assessments, but do perform screening tests to determine which children must be fully assessed. Less than 3 years: Children of this age with suspected developmental problems should be evaluated by one or more of the following (the choice may be determined by which specialists are available in the community): •
• • •
Early Intervention (each state is mandated to provide developmental assessments and services for those children at risk for or determined to have developmental delays) A developmental-behavioral pediatrician A child psychiatrist or child psychologist Early childhood learning specialists.
Ages 3 to 5 years: If problems are detected early, services provided by the school system for 3- to 5-year-olds can often help these children catch up to their peers. Reference: Hagan JF, Shaw JS, Duncan P, Eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition, American Academy of Pediatrics. 2008
,-.-%+/0-12#% 5)%-42+1-4 6+$ 789 :89 #1* ;8&-#$8+%*4 <& ,+0#)1 3-year-old
4-year-old •
Socio-emotional
• •
•
Communication •
Dresses self Feeds self
Speaks in 2- to 3-word sentences 75% understandable
•
•
•
• •
• • •
Cognitive
Knows name and use of "cup, ball, spoon, crayon"
•
•
•
•
•
Physical
•
• •
Builds tower of 6-8 cubes Throws a ball overhand Rides a tricycle Copies a circle
•
Knows gender and age Friendly to other children Plays with toys/engages in fantasy play
States first and last name Sings a song Most speech clearly understandable
Names colors Aware of gender Plays board games Draws person with 3 parts Copies a cross
Hops on one foot Balances for 2 seconds
5-year-old
• •
•
• •
•
• •
Pours, cuts, and mashes own food
• •
Brushes teeth
Articulates well Tells a simple story using full sentences Uses appropriate tenses and pronouns Counts to 10 Follows simple directions
As children get ready for school, the developmental milestones shift to more cognitive processes. Asking the parents about school performance is as important as the following milestones: • • •
• • •
•
Listens and attends Can tell difference between real and make-believe Shows sympathy/concern for others
• •
Draws a person with > 6 body parts Prints some letters and numbers Copies squares and triangles
Balances on one foot Hops and skips Ties a knot Has mature pencil grasp Undresses/dresses with minimal assistance
>1*$: /+4:#/: !"#$%&'(
The first priority is to establish the relationships between you and Benjamin and his mother in order to have a productive well-child visit. How would you proceed? (There is no single right answer.) Multiple Choice Answer: A: O Tell Benjamin, "I understand that you are scared. This is not going to hurt you, though, so you have nothing to fear." B: O Ask Benjamin, "Would you like to be on your mother's lap, so that you are more comfortable?" C: O Give a toy to Benjamin. "Benjamin, why don't you relax and play for a minute, while I talk with your mother." D: O Tell Benjamin's mother, "Sometimes even 3-year-olds have bad behavior at the doctor. We will do the best that we can. Fortunately, most illness in 3 year olds is found not only on physical, but with symptoms." *($+#, - '..#(%
At 3 years of age, some children can be cooperative at the pediatrician's office, some are wary still, and some still need a lot of parental reassurance. Smiling and talking with Benjamin in a pleasant, reassuring, calm voice, smiling is an outstanding strategy, rather than just talking and interacting with his mother. Giving the pre-schooler a fun activity to do while obtaining a medical history is effective; just giving a couple of crayons and drawing on the table exam paper can engage the child so that he is cooperative. Many parents are embarrassed when their children act up at the office, but reassuring that it is normal childhood behavior will allow the parent to relax more.
3%45#614?$ *#$0
Eczema (Atopic Dermatitis) Benjamin has a typical eczema eruption with thickening of his skin and inflammation.Eczema has been called "the itch that rashes," because there is a cycle of irritation leading to scratching, leading to the rash.Educate parents that anything leading to itching (even a child's rubbing his face on Mom's sweater) can exacerbate eczema. Eczema and Allergies Although eczema often occurs without a history of allergies, such a history would support an atopic diathesis and should prompt you to ask additional questions about allergic triggers and asthma symptoms. (Benjamin's mother says that he does not have allergies and has never had any wheezing.) Family History While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear environmental (allergic) triggers. Treatment The basic tenets of treatment are: • • •
Protecting skin by lubricating extensively Using anti-inflammatories in short bursts, and Treating associated skin infections aggressively.
Pharmacological Treatment Prescribe topical hydrocortisone, alternating a higher concentration for severe flares with a lower concentration for minor bouts. Often over-the-counter hydrocortisone is inadequate. Newer anti-inflammatory topicals, including the calcineurin inhibitors, have proven effective, although safety concerns have not been fully resolved in this class of medications. Remember that sometimes simply prescribing antihistamines can help with the itch: •
•
The non-sedating antihistamines approved for children, loratidine (Claritin) and cetirizine (Zyrtec), may be effective. Traditional antihistamines (with sedative side effects) such as diphenhydramine (Benadryl) and hydroxyzine (Atarax or Vistaril) are often used at bedtime to decrease itch.
In developing an effective treatment plan, it is important to understand what treatment has been used already. (Benjamin's mother tells you she has applied hydrocortisone intermittently, saying she uses it only when the rash is "really bad.") Differential Diagnosis Sometimes eczema may be confused with the other common inflammatory rashes: •
•
Psoriasis: Although psoriasis can occasionally first look like eczema, it is rare in children this young. When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection. Seborrhea: While it is unusual to have a new case of seborrheic dermatitis at age 3, this should also be part of the differential diagnosis, especially in early infancy (e.g., cradle cap).
@*+9,%6$ .1:0 /A**%4: -1%: !"#$%&'(
Considering the information Benjamin's mother has just given you, what do you believe are the most important nutritional issues for Benjamin?
*($+#, - '..#(%
The most important nutritional issues for Benjamin are: Inadequate Nutrition From the history, Benjamin is likely to be lacking vegetable and fruit intake. One study of preschool-aged children 2 to 3 years old found that these children consumed, on average, about 80% of the recommended fruit servings/day, but only 30% of the recommended vegetable servings/day. Iron intake in toddlers occurs predominantly from meat, legumes, and iron fortified cereals, of which Benjamin eats little. Iron is of crucial importance to normal development in this age group due to its role as a CNS co-catalyst. Milk and Juice Intake Recent studies suggest that 100% fruit juice intake and milk may be deficient in many preschoolers diets, with substitution of fruit drinks or other high-fructose corn syrup-sweetened beverages. For young children already at risk of overweight or obesity, excess intake of fruit juices, especially juice drinks with sweetened high-fructose corn syrup, can add substantial calories to a child's diet and contribute to the development of early obesity. The AAP recommends no more than 4-6 ounces of juice per day. Early Childhood Caries Bathing teeth throughout the day with milk or juice from a bottle can result in early dental caries. Early childhood caries typically have a lag time before visible decay. Thus the patterns established when a child is 1 to 3 years old may result in caries when the child is 3 to 5 years old. Although constant use is most damaging, even routine bedtime use of the bottle can lead to cavities. It is recommended that parents discontinue the bottle by the time the child is 12- to 15-month-olds. In older toddlers, it becomes more difficult if the bottle has become their transition object or "lovey." Control Battles About Food Benjamin is a determined child, and his mother has set up a pattern of negative interaction about eating. Because she has allowed Benjamin control over what he eats, Mom is unlikely to be able to promote healthy food habits. Food rewards and punishment in preschoolers may promote obesity by interfering with children's ability to regulate their own food intake. References: Fox MK, Condon E, Briefel RR, Reidy KC, Deming DM. Food consumption patterns of young preschoolers: are they starting off on the right path? J Am Diet Assoc . 2010 Dec;110(12 Suppl):S52-9. Baker RD, Greer FR; Committee on Nutrition. American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010 Nov;126(5):1040-50. Epub 2010 Oct 5. Faith MS, Dennison BA, Edmunds LS, Stratton HH. Fruit juice intake predicts increased adiposity gain in children from low-income families: weight status-by-environment interaction. Pediatrics. 2006 Nov;118(5):2066-75. Committee on Nutrition: The Use and Misuse of Fruit Juice in Pediatrics Pediatrics. 2001 107:1210-1213. Baughcum, A.E. Maternal feeding practices and childhood obesity. Pediatrics and Adolescent Medicine 1998; 152 (10):1010-1014.
B,%6%4:$ +C :0% %D#6 Physical Exam of the Toddler General Tips Listen with your stethoscope first in case he/she starts crying. I f the exam needs to be truncated due to the child's behavior, then you should focus on: • • • •
Neurodevelopment Monitoring previously recognized findings New findings identified by parents, and Physical problems common in preschoolers for which intervention may be helpful.
Exam Area
HEENT
Eyes
Possible Findings
•
Mouth: Caries Ears: Middle ear effusions that may persist after earlier URI and affect hearing.
•
Strabismus (see below for how to examine)
•
• •
Neck
•
Cardiac
Lungs
•
• •
•
Abdomen
•
An enlarged thyroid is rare in children. Many children have "shotty" nodes (pea or marble-sized, nontender, easily mobile lymph nodes that are not fixed to surrounding structures) in the anterior and occasionally posterior cervical chain. These are normal in the cervical and inguinal chains in children and may persist for years. Most murmurs will be functional. New murmurs of congenital heart disease are unlikely, but signs of atrial septal defect sometimes are appreciated better in older children. Yield likely to be low in a healthy child. May hear subtle wheezing in a child with a history of allergies. Palpation for organomegaly and masses is appropriate. While the most common mass will be stool, children this age occasionally have an enlarged kidney or, very rarely, an abdominal tumor such as Wilms' or neuroblastoma.
Several gait variants occur at this age. The m ost common is in-toeing due to tibial torsion with or without femoral anteversion:
Musculoskeletal
• • •
Most spontaneously resolve by age 8 years. Often walking will strengthen anterior leg muscles and allow correction. Persistence has been associated with joint problems later in life.
Careful history and examination for potentially treatable causes of intoeing is appropriate. (For most cases, reassurance and follow-up is all that is necessary, but if intoeing does not
spontaneously resolve by 4 years of age, referral to an orthopedic surgeon is warranted.) Link to images and an explanation of tibial torsion . • •
Genitals •
•
Neurologic
•
Hernias are sometimes seen. This segment of the exam also provides the opportunity to teach about who can appropriately examine the child. Some girls show nonspecific vulval erythema due to poor hygiene once they are toilet trained and caring for themselves in the bathroom. Assessment of overall muscle tone, strength, and coordination is appropriate. In general, the neuro exam at this age is more focused on assessing a child's achievement of overall neurodevelopmental status, including gross and fine motor, along with language and social-skills milestones.
Reference: Broderick P. Pediatric vision screening for the family physician. AFP. Sept. 1, 1998. http://www.aafp.org/afp/980901ap/broderic.html Accessed August 17, 2011.
Examining for Strabismus Two methods of assessing presence and degree of strabismus: • •
The Hirschberg light reflex The cover/uncover test
"+4:14A148 :0% BD#6 !"#$%&'(
Which of the following safety issues are important to discuss with the parents of a 3-year-old?
*($+#, - '..#(%
Car accidents (C), swimming pools (D), falls (E), firearms (F), poisonings (G), and fires (H) are all important causes of injury in a child of Benjamin's age and should be reviewed with parents. The Injury Prevention Program (TIPP) was started in 1983 by the AAP to help pediatricians prevent injuries in their patients. "TIPP is designed to provide a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries-behaviors that are effective and capable of being accomplished by most families." The program includes an AAP policy statement, safety surveys for parents to complete, age-appropriate safety information for parents, and a schedule of safety counseling for pediatricians. At age 3, a child should be put in a front-facing car seat in the back seat (A). By definition, SIDS (B) affects children under one year of age (infants). To view the TIPP information that should be provided to Benjamin's mother, go to this link: http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-2-to-4-Years.aspx
< 8A4 14 :0% 0+A$% !"#$%&'(
What advice would you give about guns in the home?
Non-evaluated freetext Preferably, remove the gun from the home. Put a safety lock on the gun. Keep the gun in a locked cabinet. Keep the ammunition separate and locked.
*($+#, - '..#(%
Parents may have incorrect expectations of their school-aged child's ability to reason appropriately about guns. In a study from 2003, the authors found that 52% of parents who owned guns thought that their children were "too smart" or "knew better," even though only 40% had given specific instructions to their children regarding guns. In this survey only 12% of parents who owned guns locked them. Another study from 2001 found that, when given the opportunity, boys 8-12 would handle a gun (76%) and pull the trigger (48%). Parents' opinions about whether or not their child would handle a gun were not predictive of which boys would handle the gun. Even when the child is as young as Benjamin, it is important to provide parents with these brief facts. Fortunately, you had observed Dr. Harris counsel a parent in a similar situation earlier this week. You learn from Mrs. Jones that, because she and Benjamin live alone, she purchased the gun recently for self-protection. While you understand the feeling that Ms. Jones has about protecting her child, this is a significant safety concern. Parents who possess guns for protection from crime are likely unwilling to place the gun in one locked cabinet and ammunition in another. While this recommendation may be excellent for families with hunters, you advise her that while you understand her concern, households with preschoolers in them are at increased risk for injuries from guns and she must balance the need for self-protection with the risk of injury to her child. You tell her that the only foolproof way to prevent accidental injury due to the gun is to remove the gun from the house and seek additional security such as a home alarm or "burglar bars." Benjamin's mother tells you that she was in fact somewhat worried about bringing the gun into the home and will think about your advice. References: Connor SM, Wesolowski KL. They're too smart for that: Predicting what children would do in the presence of guns. Pediatrics. 2003;111(2):E109-14. Jackman GA et al. Seeing is believing: what do boys do when they find a real gun? Pediatrics. 2001;107(6):1247-50.
E66A41F#:1+4$ #4- ,#9 :%$:$ !"#$%&'(
Which evaluations are appropriate today? (Select all that apply.)
"#$%&'$( )*+&,( -./0(12 -2 3 4&.5(1/%&,6 *(7+5$+8&.9*(7:%+,1&% ;2 < );) )2 < =(:> $(?($ @2 < A:>&+:$$(15+/+18(.% %(/% BA-CDE
*($+#, - '..#(%
Due to Benjamin's history of poor diet, the most appropriate evaluation today is an evaluation for possible anemia with a fingerstick hemoglobin/hematocrit (A).
Anemia Screening • •
• • •
Typically, screening for anemia is done at 12 months and again at preschool or kindergarten entry. The initial 12-month window coincides with a period in development when diet, particularly iron sources, is often in flux. If there are risk factors for anemia, then testing may be done at any visit. Results of a screening hemoglobin can be known immediately. Spun hematocrit still relies on blood volume, and hydration status can falsely affect the result.
A CBC (B) is more test than you need now. It provides information about anemia, but is more costly and inconvenient than a hemoglobin test. Plus, it takes longer to obtain the results, possibly delaying treatment. Lead screening (C) was already done when Benjamin was younger, and the results were normal. He does not have any risk factors for lead poisoning: • • •
Unlike younger children, developmentally at age 3 Benjamin is no longer mouthing objects He does not live in at-risk housing Nor is he an immigrant -- significant because children born in certain countries outside the U.S. are at increased risk for lead poisoning.
If he is anemic, you may need to reassess environmental exposures. A radioallergosorbent test (RAST) (D) is a blood test used to determine to which allergens a person is sensitized. Although this information might help his mother avoid exposure to allergens that trigger his eczema, RAST testing is not indicated at this time. For some younger children, food allergy can contribute to eczema, but this is less common by the preschool years. For most children a clear allergen is never found.
"#A$%$ +C #4%61# !"#$%&'(
Of the following causes of anemia, select the most likely causes in this child:
"#$%&'$( )*+&,( -./0(12 -2 3 F1+.G>(H&,&(.,I :.(7&: ;2 < -$'*: %*:$://(7&: )2 < JKL@ >(H&,&(.,I @2 3 =(:> '+&/+.&.5 M2 < )*1+.&, &$$.(// 42 < )*1+.&, 8$++> $+// J2 < N(7+$I/&/ N2 < @(,1(:/(> 7:11+0 '1+>#,%&+. F2 < 4+$:%( >(H&,&(.,I O2 < ;K >(H&,&(.,I
*($+#, - '..#(%
Given Benjamin's poor nutritional intake, the most likely cause of anemia in this otherwise healthy child isiron deficiency (A).
Iron-Deficiency Anemia Epidemiology Nationally among preschoolers deficient iron stores may occur in up to 35% of low-income children (versus only 7% in other preschoolers), with up to 10% having iron-deficiency anemia. Association with Cognitive Difficulty With respect to the association between iron deficiency anemia and cognitive difficulties, it is unclear whether cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk for iron deficiency. Given iron's role as a co-catalyst in CNS processes, it is reasonable to be concerned about iron deficiency being a potential cause of his anemia. Causes • •
Lack of iron intake is the most likely acquired cause of iron-deficiency anemia. In rare cases, iron stores are decreased from chronic GI blood loss (e.g., food allergies and gluten enteropathy).
Lead poisoning (D) is also on the differential diagnosis, however, as Benjamin's hemoglobin was normal at 12 months: his anemia has to be acquired. Lead poisoning would be higher on the differential diagnosis if Benjamin lived in pre-1970s housing, lived near a busy interstate, or was a recent immigrant. Benjamin shows no symptoms of chronic or severe illnesses (E) that cause anemia -- such as collagen vascular disease, malignancy, or other chronic illness. These are unusual acquired causes of anemia. In this child of northern European descent, a hemoglobinopathy (e.g., alpha thalassemia (B), G6PD deficiency (C) or sickle cell disease) would not be high on the differential. It does need to be considered in children of Mediterranean, Asian or African descent. (And, of course, he would have been anemic at 12 months of age and his newborn screening hemoglobin electrophoresis would also have been abnormal, with hemoglobin "Barts" present.) Decreased marrow production (e.g., aplastic anemia) (H), hemolytic anemias (G) and vitamin deficiencies (e.g., folate and B6(J)) are rare in children and present with a more severe anemia (Hgb less than 9 g/dL (90 g/L)). In patients like Benjamin whose anemia is mild, many providers will provide a trial of iron rather than do any further workup at this point. If the hemoglobin recovers to the normal range after a trial period, that is sufficient evidence of iron-deficiency anemia. References: Eden AN. Preventing iron deficiency in toddlers: A major public health problem. Contemporary Pediatrics. 2003;20(2):57-67. Falk H. International environmental health for the pediatrician: Case study of lead poisoning. Pediatrics. 2003;112(1):259-264
GA66#*1F148 #4- .+*2148 :+ /0#48% C++- 9%0#;1+*$ Counseling Parents About Children's Eating Habits You can make long-term differences in a child's health only by working as a team with the parent. In two-parent families, or when extended families are also caring for the child, all members must be engaged and educated about necessary changes. Rather than focusing on the details of the child's diet, try to leverage a few key changes involving the eating process. To change a child's nutrition patterns: • •
•
L1+?&>( %*( ':1(.% 0&%* /%1:&5*%H+10:1>P /&7'$( /%1:%(5&(/ %*:% ,:. 8( &7'$(7(.%(> /(Q#(.%&:$$IR L1+?&>( /#''+1% :.> 1(://#1:.,( %*:% %*( ,*&$>S/ 1(:,%&+./ 0&$$ /#8/&>( &H %*( ':1(.%S/ :''1+:,* 1(7:&./ ,+./&/%(.%R D1I %+ '1(':1( %*( ':1(.% H+1 *:.>$&.5 H#%#1( ,*:$$(.5(/R
The child will benefit by having a loving, predictable environment with appropriate boundaries. And, of course, always offer availability to assist the family in developing additional strategies if needed.
!"#$%&'(
What practical steps would you take today in addition to oral iron treatment (given as 2-4 mg/kg/day of elemental iron divided once or twice daily)?
Non-evaluated freetext Among the things to prescribe for Benjamin's mother are to stop giving a bottle to him, limit his eating to mealtimes, don't bargain with him, and gradually introduce new iron-rich foods.
*($+#, - '..#(%
A seasoned pediatrician would prescribe four specific steps to interrupt Benjamin's current behavior around food: •
•
•
•
Stop the bottle now. It is helpful to actually have Benjamin and his mother jointly discard the bottle in the trash to show him it's gone for good. Usually children stop their requests for the bottle after a few days. (You recall that Mrs. Jones has already been able to do this once.) Limit Benjamin's eating to 3 meals and 2 snacks, stopping the food and drink grazing. If he is thirsty, give him water, not juice. Limiting the amount of juice a toddler drinks may improve his nutrition in several ways. For one, when he is drinking juice or milk, his appetite for solids is blunted. He needs adequate solids for energy and vitamins. No bargaining or cajoling. Benjamin is to eat at time-limited meals. He needs to have his hunger ultimately drive his choices, and only healthy options should be provided. Dessert should never be held as an incentive for "good" eating. Gradually change his diet content by introducing new foods he is likely to try and slowly decrease the quantity of old favorites.
H%C%*%4/%$ 1. 2.
3. 4.
5.
6. 7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17. 18.
19. 20. 21. 22.
American Academy of Pediatrics. Family Pediatrics: Report of the Task Force on the Family.Pediatrics 2003;111(6):1541-1571S. Baker RD, Greer FR;Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Committee on Nutrition. American Academy of Pediatrics.Pediatrics. 2010 Nov;126(5):1040-50. Epub 2010 Oct 5. Baughcum AE. Maternal Feeding Practices and Childhood Obesity. Pediatrics and Adolescent Medicine 1998;152(10):1010-1014. Beltran-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, Griffin SO, Hyman J, Jaramillo F, Kingman A, Nowjack-Raymer R, Selwitz RH, Wu T; Centers for Disease Control and Prevention (CDC). Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis--United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. 2005 Aug 26;54(3):1-43. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm Bright Futures, American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Available at http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf . Last accessed August 18, 2010. Broderick P. Pediatric Vision Screening for the Family Physician. American Family Physician. Sept. 1, 1998. http://www.aafp.org/afp/980901ap/broderic.html CDC Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50 (RR-14). Committee on Nutrition. The Use and Misuse of Fruit Juice in Pediatrics. Pediatrics 2001 107: 1210-1213. Connor SM, Wesolowski KL. They're too smart for that: Predicting what children would do in the presence of guns. Pediatrics 2003; 111 (2):E109-14. Dawson G. et al. Preschool Outcomes of Depressed Mothers: Role of Maternal Behavior, Contextual Risk, and Children's Brain Activity. Child Development 2003; 74(4):1158-1175. Dennison BA, Rockwell HL, Baker SL. Fruit and vegetable intake in young children. Journal of the American College of Nutrition. Aug 1998; 17(4):371-8. Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, February 2002. Freely available on the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s11c01.html Eden AN. Preventing iron deficiency in toddlers: A major public health problem.Contemporary Pediatrics 2003; 20(2):57-67. Faith MS, Dennison BA, Edmunds LS, Stratton HH. Fruit juice intake predicts increased adiposity gain in children from low-income families: weight status-by-environment interaction.Pediatrics. 2006 Nov;118(5):2066-75. Fox MK, Condon E, Briefel RR, Reidy KC, Deming DM Food consumption patterns of young preschoolers: are they starting off on the the right path?. J Am Diet Assoc. 2010 Dec;110(12 Suppl):S52-9 Falk H. International environmental health for the pediatrician: Case study of lead poisoning.Pediatrics. 2003;112(1):259-264. Fox MK, Condon E Breifel RR, Reidy KC, Deming DM. Food Consumption Patterns of Young Preschoolers: Are They Starting Off on the Right Path? J Am Diet Assoc. 2010;110(12 suppl);S52-9. Georgia Dept. of Community Health. Tuberculosis (TB) Risk Assesment. http://health.state.ga.us/pdfs/tb/CH.Risk&Inst.09.Eng.pdf Glaser DW. "Anemia in Case Based Pediatrics For Medical Students and Residents". Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, February 2002. Freely available on the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s11c01.html Green M et al. (eds) National Center for Education in Maternal and Child Health. Georgetown University. 2002. Hughston Sport Medicine Foundation site on In-Toeing in Children: http://www.hughston.com/hha/a_12_3_2.htm Jackman GA et al. Seeing is believing: what do boys do when they find a real gun? Pediatrics 2001;107(6):1247-50. Lewis M. Child and Adolescent Psychiatry. Philadelphia: Williams and Wilkins, 1996:450.
23. Sass P, Hassan G. Lower Extremity Abnormalities in Children. American Family Physician 2003; 68 (3):461-468. 24. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US children, 19891991. Pediatrics. Oct 1998;102(4 Pt 1):913-23. 25. Wasserman RC. Screening for vision problems in pediatric practice. Pediatrics in Review. Jan 1992;13(1):4-5. Other Sources: 1. 2. 3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14.
American Academy of Pediatric Dentistry's policy on early childhood caries: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113 American Academy of Pediatrics TIPP safety screening report: http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-2-to-4-Years.aspx AAD Guidelines for Atopic Dermatitis http://www.aad.org/research/_doc/ClinicalResearch_Atopic%20Dermatitis%20Part%20I.pdf CDC information on 13-serotype pneumococcal conjugate vaccine: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5909a2.htm Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Hirschberg Light Reflex: http://eyeontechs.com/new/?p=218 Iron in Diet: http://www.nlm.nih.gov/medlineplus/ency/article/002422.htm Reach Out and Read program: http://www.reachoutandread.org/ Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm The development of drawing skills in children: Bright Futures, 2002.http://www.brightfutures.org UpToDate, the online clinical information resource. Burton D. Rose, MD, and Joseph M. Rush, MD, founders. 2004. Victor Lowenfeld and Betty Edwards' Web site on the development of drawing in children: http://www.learningdesign.com/Portfolio/DrawDev/kiddrawing.html Preventing Early Childhood Caries: http://www.thecommunityguide.org/oral/caries.html Abnormal Cover/Uncover Test Video - http://www.mrcophth.com/
