Pediatric Heath Maintenance

Aka: Pediatric Heath Maintenance, Health Maintenance in Children, Well Child Visit

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II. History: All Ages

  1. Consider pre-visit questionnaire
    1. Bright Futures (AAP) Toolkit
      1. https://toolkits.solutions.aap.org/bright-futures/core-forms
  2. Interval History
    1. Emergency Department Visits
    2. Hospitalizations
    3. Surgeries
  3. Living situation (split families, step-siblings... )
    1. Home safety
  4. Dietary intake
    1. See Nutrition Guidelines
    2. Food insecurity (esp. children living in poverty)
      1. Hunger Vital Sign
    3. Safe drinking water
    4. Consider introducing highly allergic foods (peanuts, eggs) age <1 to prevent food allergies
    5. Healthy Diet
      1. Maximize vegetable and fruit intake
      2. Whole grains
      3. Low fat and nonfat dairy products
      4. Beans, fish and lean meats
      5. Avoid fast food, Simple Sugars, highly processed foods
    6. Obesity prevention
      1. See high BMI management as below
      2. Avoid solid food introduction age <6 months
      3. Avoid juice <1 year old
      4. Limit 100% juice to 4 oz/day at 1-3 years, 4-6 oz/day at 4-6 years
  5. Exposures
    1. Second-hand smoke exposure
  6. Toileting
    1. Urination Problems
    2. Defecation Problems
  7. Physical Activity
    1. Encourage at least 60 minutes of moderate to vigorous aerobic exertion (active free play) daily
    2. Provide safe community places to play
  8. Screen Time (television, computer, video games)
    1. Avoid screen use in under age 18 months (except video chatting)
    2. Educational applications may be used starting at 18 to 24 months
    3. At age 2-5 years limit Screen Time to 1 hour
    4. For older children limit Screen Time to <1-2 hours of high quality programming daily
    5. Keep screens out of bedrooms and avoid use within one hour of bed
    6. Screen Time averages 7.5 hours daily in the U.S.
      1. Over 4 hours of daily Screen Time is associated with Obesity
      2. High Screen Time is associated with poor sleep, depression, Myopia, worse school performance
    7. Adopt a Family Media Use Plan
      1. https://www.healthychildren.org/English/media/Pages/default.aspx
  9. Sleeping
    1. See Crib Safety
    2. Infants should sleep on their back on a firm mattress for the first year (no blankets, soft objects)
    3. Average school aged child sleeps more than 9 hours per night (9-12 hours per night is ideal)
    4. Inadequate sleep is associated with behavioral problems, poor school performance, Hypertension, Obesity
    5. See Sleep Problems in Children
    6. See Obstructive Sleep Apnea in Children
  10. Dental care practices
    1. See Oral Health in Children
    2. Wean bottle by age 12 months
    3. Avoid juices under age 12 months
    4. Young children see a dentist every 2 years, then start twice per year in school aged children
    5. Brush twice daily with pea-sized amount of fluoride-containing toothpaste
    6. Flouride varnish applied to Primary Teeth at clinic visit
    7. Start flossing once 2 teeth touch one another
  11. Social
    1. Monitor child's internet use
    2. Parents should be aware of possible Bullying of their child
    3. Ask about and get to know your child's friends
  12. Unintentional Childhood Injuries (leading cause of death among children)
    1. Most common causes of pediatric death are MVA, Drowning, gun shot wounds, Burn Injury
    2. Car and Bike Safety
      1. Car Seats
      2. Car Safety (no sitting in front seat age <13, and no riding in flat bed of pick-up truck)
      3. No all terain vehicle operation age <16 years
      4. Teach safe street crossing
      5. Seat Belts
      6. Bicycle helmets
      7. Helmets for football, lacrosse, hockey, Skiing, snow boarding, horse back riding
      8. Helmets when skate boarding and riding a scooter
    3. Home safety
      1. Stair gates and railings
      2. Window locks or guards
      3. Cabinet locks
      4. Crib Safety
      5. Furniture anchors
    4. Fire, Smoke and Burn Injury prevention
      1. Smoke Alarms (installed on each floor near bedrooms)
      2. Fire escape plan
      3. "Stay low and crawl" when encountering a smoke filled room
      4. "Stop, drop and roll" if clothing catches on fire
      5. Carbon Monoxide detectors (installed near sleep areas)
      6. Water heaters set to maximum of 120 F (49 C)
    5. Gun Safety
      1. Assure guns in the home are safely secured, locked and unloaded, separate from ammunition)
      2. Firearms are in one of three U.S. households
    6. Other
      1. Drowning Prevention
        1. Learn to swim at age 5 years
        2. Use personal floatation device while boating
        3. Continuous adult supervision around water, and surround pools with fence
      2. Poisoning Prevention
      3. Choke Hazards
  13. Skin protection
    1. Sunscreen (minimum of SPF 15)

III. History: Infants

  1. Birth history
    1. Gestational age
    2. Pregnancy and delivery complications
    3. Newborn Screening results
  2. Infant Feeding Problems
    1. Breast Feeding
    2. Formula Feeding
  3. Postpartum Depression (screen at 1, 2, 4 and 6 month visits)
    1. Edinburgh Postnatal Depression Scale
    2. PHQ-2 with reflex to PHQ-9

IV. History: School Age (age 5- 12 years)

  1. School performance and concerns
    1. See Learning Disorder
    2. See ADHD Diagnosis
    3. See Truancy
    4. See Bullying
  2. Cognitive, Emotional and Behavioral health
    1. Mood Disorder (Major Depression, Anxiety Disorder)
      1. Start screening at age 12 years (per AAP/USPTF, see adolescents below)
      2. Start screening for Anxiety Disorder at age 8 years (per USPTF)
    2. Behavioral Disorder
    3. Pediatric Symptom Checklist or Pediatric Symptom Checklist-Youth (5 min screening tool)
      1. https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf

V. History: Adolescents (age 12 to 18 years)

  1. Interview children in the room without their parents
  2. Mood Disorder screening
    1. Major Depression affects 2% of boys and 4% of girls ages 8 to 15 years old
      1. Of those with Major Depression ages 5-13 years old, 10% attempt Suicide
    2. Screen for Major Depression age 12 to 18 years with PHQ-2 (per AAP, USPTF)
    3. Also screen for Anxiety Disorder age 8 to 18 years (per USPTF)
    4. See Adolescent Depression
    5. See Childhood Depression
  3. Substance Abuse Screening (start discussing at age 11 per AAP)
    1. See CRAFFT questionnaire
    2. See Adolescent Chemical Dependency
    3. By age 13, 16% have tried Alcohol, 10% Cigarettes and 7% Marijuana (U.S., 2017)
    4. Tobacco Abuse
    5. Alcohol Abuse
    6. Drug Abuse
  4. Sexual activity screening
    1. Annual Chlamydia and Gonorrhea testing (urine Chlamydia PCR and urine Gonorrhea PCR testing)
    2. Consider HIV Test and Syphilis test (e.g. multiple partners, high risk sexual behavior)
    3. Pap Smears start at age 21 regardess of sexual activity

VI. Exam: Vital Signs

  1. Body Temperature (until after age 18 months)
  2. Blood Pressure (annual screening starting at age 3 years of age per AAP)
    1. See Hypertension Criteria
    2. Screen annually after age 3 years for most children
    3. Screen at each visit for those children with higher risk conditions
      1. Obesity
      2. Kidney disease
      3. Aortic arch obstruction
      4. Aortic Coarctation
      5. Diabetes Mellitus

VII. Exam: Growth (review on growth curves at each visit)

  1. See Growth Assessment
  2. See Height Measurement in Children
  3. See Weight Measurement in Children
  4. Head Circumference (until age 2 years)
  5. Body Mass Index annually starting at age 2 years old (age 6 years per USPTF)
    1. Overweight and Obesity Screening at Well Child Visits is a high yield activity (affects 32% of children and teens in U.S.)
    2. BMI >85% for age and gender is considered Overweight (>95% is Obesity)
    3. See Childhood Obesity for management
    4. Refer to comprehensive, intensive behavioral interventions (>25 contact hours)

VIII. Exam: General

  1. See Newborn Exam
  2. Complete physical examination
    1. Overall yield is low in healthy, asymptomatic children with normal growth
    2. Observe for signs of abuse (~1 Million children affected annually in U.S.)
    3. Scoliosis screening
      1. Visual screening at age 10 and 12 years in girls, 13-14 years in boys (per AAP)
      2. Not recommended by USPTF
    4. Testicular exam is recommended annually by AAP starting at age 11 years old (but not USPTF)
      1. Documenting descended Testicles pre-Puberty is critical (Cryptorchidism risk)
      2. Assess for sexual maturity and Precocious Puberty starting at age 7 years
      3. Evaluate for Testicular Masses, Hydrocele, Inguinal Hernia, Varicoceles
  3. Eye Exam
    1. Red Reflex (until after age 2 years)
    2. Strabismus testing such as cover-uncover (until after age 2 years)
    3. Vision (AAP)
      1. See Pediatric Vision Screening
      2. Instrument based screening (Autoscreening, Photorefractors) at age 12 and 36 months
      3. Formally check Vision (Snellen Chart) annually starting at age 4 years (per AAP, AAOS)
        1. Minimum Vision Screening once between age 3 and 5 years (USPTF)
        2. Obtain at age 5, 6, 8, 10 and 12 years
      4. Refer if visual acquity worse than 20/40
  4. Hearing Exam
    1. Subjective Hearing screening until age 3 years, then formal Hearing screening
    2. See Pediatric Hearing Screening
    3. Hearing screening (Audiometry) at age 5, 6, 8 and 10 years, and once between age 11 and 14 years
  5. Skin Exam
    1. See Nonaccidental Trauma Signs (physical abuse)

IX. Evaluation: Developmental Screening

  1. General Screening (at each schedule well visit or at 9, 18 and 30 month visits)
    1. Age 2-4 months: Edinburgh Questionnaire or INI Questionnaire
    2. Age 4-18 months: ASQ Questionnaire, PEDS Questionnaire or INI Questionnaire
    3. Age 18-60 months: ASQ Questionnaire, PEDS Questionnaire or CDR Questionnaire
  2. Specific Screening: Perform for all children at specific visits
    1. Modified Checklist for Autism in Toddlers (M-CHAT): Perform at 18 and 24 months (AAP)
    2. ASQ: SE Behavioral Screening: Perform at 6,12, 18, 24, 30, 36, 48 and 60 months
  3. School readiness (age 4-5 years)
    1. Social and emotional development are key to success
    2. Assess ability to follow directions, attention
    3. Consider referral for support services
    4. Avoid delaying school entry (not helpful and may exacerbate behavioral problems)
      1. Byrd (1997) Pediatrics 100(4): 654-61 [PubMed]
  4. As needed screening in school age children
    1. School performance
    2. See Learning Disorder
    3. See ADHD Diagnosis
    4. Mood Disorder (Major Depression, Anxiety Disorder)
    5. Behavioral Disorder

X. Labs

  1. Newborn Screening (review results at first Well Child Visit)
  2. Hemoglobin At 9-12 months (AAP)
  3. Serum Lead level
    1. Screen high risk children between ages 6 months and 6 years old (AAP:)
  4. Lipid panel
    1. Obtain once between ages 9 and 11 years old (AAP)
      1. Goal was early identification of Familial Hypercholesterolemia missed by Family History alone
    2. USPTF and AAFP do not recommend (False Positives, and unknown longterm Statin safety in children)

XI. Management: Immunizations

  1. See Pediatric Vaccination for schedule
    1. National Vaccination compliance is excellent until after age 6 years old in the U.S.
      1. Primary Series at 2, 4, 6, 12, and 15-18 months, as well as 4-6 years
    2. More than 60% of adolescents are not up-to-date on their Vaccines as of age 11 years old
      1. Tdap (Adacel, Boostrix)
      2. Meningococcal Vaccine (Menactra)
      3. HPV Vaccine (Gardasil)
  2. Influenza Vaccine
    1. October to March
    2. Give second dose in first season

XII. Management: Medications

  1. Iron Supplementation
    1. Preterm Infants starting at 1 month of age
    2. Exclusively Breast fed infants starting at 6 months of age
  2. Fluoride Supplementation
    1. Flouride varnish applied to Primary Teeth at clinic visit
    2. Fluoride Supplementation if inadequate fluoride in drinking water (0.6 ppm or less) for age 0.5 to 16 years
  3. Vitamin D 400 IU daily (more if deficient)
    1. Vitamin D Deficiency may approach 50% Incidence (especially in northern latitudes)
    2. Vitamin D Supplementation 400 IU daily in exclusively Breast fed infants
    3. Consider Vitamin D Deficiency screening

XIII. Management: Referrals

  1. Dental visits starting at age 3 years
    1. See Oral Health in Children

XIV. Management: Anticipatory Guidance Education

  1. Newborn: Jaundice, eating, sleep, maternal bonding
  2. Month 2: Colic, growth, sleep, sibling adjustment
  3. Month 4: Childcare, sleep, solid introduction
  4. Month 6: Child proofing
  5. Month 9: Child proofing, stranger anxiety
  6. Month 12: Discipline, shoes, walking, turning Car Seat
  7. Month 15: Discipline, Time-Out
  8. Month 18: Temper tantrums, sleep problems
  9. Month 24: Toilet Training, sleep problems, speech development
  10. Month 36: Eating patterns, socialization, books
  11. Month 48: Speech, school readiness
  12. Month 60: Behavioral consequences

XV. Resources

  1. Recommendations for Preventive Pediatric Health Care (AAP, Bright Futures)
    1. https://www.aap.org/en-us/Documents/periodicity_schedule.pdf
  2. AAP Screening Tools
    1. https://screeningtime.org/star-center/#/screening-tools

XVI. References

  1. Neale (2008) Park Nicollet Primary Care Update Lecture, St. Louis Park, MN
  2. Riley (2019) Am Fam Physician 100(4):213-8 [PubMed]
  3. Riley (2019) Am Fam Physician 100(4):219-26 [PubMed]
  4. Riley (2011) Am Fam Physician 83(6): 689-94 [PubMed]
  5. Riley (2011) Am Fam Physician 83(6): 683-8 [PubMed]
  6. Turner (2018) Am Fam Physician 98(6): 347-53 [PubMed]

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