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FROM WAAAH!

TO AAAH!

An Evidence-Based Update to the Well-Child Check

Madeleine Sanford, FNPOHSU Department of Family Medicine

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AAP Periodicity Schedule

ObjectivesFor each well-child check topic, the participant will be able to:

WCC Screening

Update

Summarize the epidemiology and risk factors

Describe the impact of the problem

Integrate the recommendation into practice

Choose Your Own Adventure!Well Child Check Topic Choices

Obesity/ Dyslipidemia

Oral Health Screening/ Topical

Fluoride in Office

Adolescent Depression/ Substance Abuse

Iron Deficiency / Lead Exposure

Developmental / Autism Screening Matters

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3 2 1

7 64

0

5

10

15

20

25

Age 0-2 Age 3-5 Age 6-11

IDA Iron Deficiency

Iron Deficiency: The ProblemUS Prevalence

1012

1720

0

5

10

15

20

25

% US Children

% Iron Deficiency in High Risk Toddlers

Poorer cognition in adulthood

SOCIAL• Low income

• Low literacy

• Race

SPECIAL NEEDS

LEAD EXPOSURE

HX PREMATURITY

• NUTRITIONBreastfeeding > 4 mos without

iron

• Weaning to milk/ non-iron

rich foods

• Obesity

Risk Factors for Anemia

Anemia Screening

WHEN:

USPSTF: I (insufficient)

AAP: 12 months universal, after based on risk factors

HOW:Hgb <11

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PreventionIron Deficiency

• Preterm <37 wks

• Age 2-4 wks iron rich foods

Breastfed > ½

Age 4 mos iron-rich foods

Marginally LBW

Age 8 wks iron-rich foods

High Risk age 6-12

mosGrade B Evidence

AAP USPSTF

AAP AAP

Nutrition counseling

Lead ExposureWhy It Matters

Pb>2

ADHD

Lower IQ

Anti-social

CV Effects

Motor skills

• NO safe levels• Chelation

doesn’t improve neurocognitive scores

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Lead Exposure in OregonThe Problem

Results for Oregon children screened for lead

<2

64%

2 to 5

22%

5 to 10

12%

10+

2%

(Oregon Department of Human Services Childhood Lead Poisoning Prevention Program, 2010)

PRE-1978

HOUSING / DAYCARE

MINORITY PARENTAL / SIBLING

LEAD EXPOSURE

RECENT IMMIGRANTS

POVERTY

Risk Factors for Lead Exposure

Lead Screening / Prevention

WHEN:

USPSTF: I (insufficient)

AAP: Risk assessment 6 mos- 6 yrs

Medicare: 12 and 24 mos*

PREVENTION / counseling

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Adolescent Depression Screening

Adolescent Depression

Suicide is Oregon's number two cause of death among youth

Oregon Health Division (2008)

01

02

03

04

Adolescent DepressionWhy It Matters

Girls > Boys

4%-9% of adolescents

(Biros MH et al., 2008)

20% admitted to ED met criteria for depression

poor academic performance, legal problems

substance use, early pregnancy, family disruption

Sequelae

Most depressed adolescents receive no treatment

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POVERTYPARENT WITH DEPRESSION CIGARETTE

SMOKING

MAJOR NEGATIVE

LIFE EVENT

OBESITY

Risk Factors for Adolescent Depression

Adolescent Depression Screening

WHEN:

USPSTF

AAP: Yearly, age 11-21

HOW:

PHQ-A

PHQ-A: Same as PHQ-2 with 2 extra questionsJust like the PHQ-9, but with 2 extra questions:

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Adolescent Depression

Fluoxetine (Prozac) and escitalopram(Lexapro) are approved for use in children.

0 10 20 30 40

First drank alcohol before age 13

Alcohol in past 30 days

5+ drinks past 31 days

Drinking + driving past 30 days

Marijuana past 30 d

Ever took rx drug that wasn't theirs

% US Teens, 2011

Adolescent Substance AbuseThe Problem

(CDC Youth Risk Behavior Surveillance System, 2011)

Adolescent Substance Abuse Screening

WHEN:

USPSTF: I (Insufficient)

AAP: Yearly risk assessment age 11-21

HOW:

CRAFFT

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Adolescent Substance Abuse ScreeningCRAFFT: Car, Relax, Alone, Forget, Friends, Trouble

Adolescent Substance Abuse ScreeningCRAFFT: Car, Relax, Alone, Forget, Friends, Trouble

Childhood ObesityThe Problem

• 17% aged 2 -19 years are obese

• Improving in 2-5 year age range (13% down to 9%)

• Higher among Hispanics (22.4%) and non-Hispanic blacks (20.2%) than among non-Hispanic whites (14.1%).

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GENETIC• Self-regulation

of food via FTO gene

PRENATAL SWEET BEVERAGES

• juice

SEDENTARY• Screen time

• POVERTY

Risk Factors for Pediatric Obesity

Pediatric Obesity Screening / Intervention

WHEN:

USPSTF:

AAP: Every visit, starting age 2

HOW:

BMI

Dyslipidemia Screening

WHEN:

USPSTF:

AAP: Once age 9-11, again age 17-19

HOW: Direct LDL (non-fasting)

BMI

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Dyslipidemia Intervention per AAP

• <1% qualify for statin• Primarily genetic• LDL > 190 after 6 mos trial

lifestyle change• LDL > 160 with fam hx 1st

degree premature CV disease• Lifestyle modification

Oral Health Screening / Topical Fluoride

Oral Health: The Problem

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Pediatric Oral Health Screening

WHEN:

USPSTF

AAP:

Risk assessment and visual screen age 6 - 30 mos, refer to dental home by age 1

Oral Health Risk Assessment

Topical Fluoride Application

1. Dry teeth w/ gauze2. Paint fluoride on teeth

Counsel:• No food for 1 hr (drinks ok)• Soft foods for next meal• No sticky foods today• Don’t brush teeth today• Yellow discoloration fades

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Fluoride

Remineralization of enamel

Inhibits demineralization of enamel

Makes cariogenic bacteria less able to produce acid from carbohydrates.

TOPICAL (most important)

Fluoride paste at WCC or at dentist every 3-6 months (CDC Grade IA)

Fluoride toothpaste for all (CDC Grade 1A)– Smear for < 2

– Pea-size age 2-5

SYSTEMIC – age 6 months- 16 years– CDC Grade I IA evidence fluoride 6 mos-5 yrs, Grade IA 6 -16 yr

– ADA & USPSTF Strength of recommendation :B

NO chance of fluorosis after age 6, most likely 15-30 months

CDC Grade I IA evidence fluoride

Why Developmental/ Autism Screening Matters

Jee, et al (2010), Hix-Small (2007)

ASQ

http://agesandstages.com/age-calculator/

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Adjust for prematurity if :• Born <37 weeks

and• Current age <2

41

35 (score)/

5 (answered) = 7

Scoring ASQ-3

Avoid pass/fail terms

• “Above Cutoff”

• “Near Cutoff”

• “Below Cutoff”

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43

GET CONSENT DURING

VISIT

SIGN HERE

FAX COPY

OF ASQ/

MCHAT

Autism Screening

Without screening, mean age 1st eval 48 mos, mean age dx 61 mos

– Parents usually notice something wrong by 18 mos

M-CHAT revised w/ follow-up

– TWICE between 16 and 30 months (18 & 24)

– Why twice?

MCHAT/ MCHAT-R

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MCHAT: Positive Screen

Simultaneously refer to:– Early Intervention

– CDRC • COUNSEL PARENTS: 9+ month wait AFTER

family gets paperwork back

– Audiology

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Bibliography

Committee on Childhood Lead Poisoning Prevention. (2012). Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention (p. 65)/www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdfAmerican Academy of Pediatrics. (2008). Recommendations for Preventive Pediatric Health Care-- Periodicity Schedule. Retrieved from https://www.aap.org/en-us/professional-resources/practice-support/Pages/PeriodicitySchedule.aspx

Baker, R. D., & Greer, F. R. (2010). Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age). Pediatrics, 126(5), 1040–1050. http://doi.org/10.1542/peds.2010-2576Biros MH, Hick K, Cen Y, & et al. (2008). Occult depressive symptoms in adolescent emergency department patients. Archives of Pediatrics & Adolescent Medicine, 162(8), 769–773. http://doi.org/10.1001/archpedi.162.8.769Brotanek, J. M., Gosz, J., Weitzman, M., & Flores, G. (2007). Iron Deficiency in Early Childhood in the United States: Risk Factors and Racial/Ethnic Disparities. Pediatrics, 120(3), 568–575. http://doi.org/10.1542/peds.2007-0572Brotanek JM, Gosz J, Weitzman M, & Flores G. (2008). Secular trends in the prevalence of iron deficiency among US toddlers, 1976-2002. Archives of Pediatrics & Adolescent Medicine, 162(4), 374–381. http://doi.org/10.1001/archpedi.162.4.374CDC National Center for Environmental Health. (2013). CDC - Lead - State and Local Programs - Oregon Data, Statistics and Surveillance. ://www.cdc.gov/nceh/lead/data/state/ordata.htm

Centers for Disease Control and Prevention. (2002). Iron Deficiency --- United States, 1999--2000. MMWR Weekly, 51(40), 897–899.

Committee on Environmental Health. (2005). Lead Exposure in Children: Prevention, Detection, and Management. Pediatrics, 116(4), 1036–1046. http://www.cdc.gov/nchs/data/databriefs/db191.htm

Bibliography, continued

Committee on Substance Abuse. (2011). Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians. Pediatrics, 128(5), e1330–e1340.

Dye, B., Thornton-Evans, G., & Li, X. (2015). Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011–2012 (NCHS Data Brief No. 191). CDC.

Final Recommendation Statement: Iron Deficiency Anemia: Screening - US Preventive Services Task Force. (2011). Retrieved May 26, 2015, from http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/iron-deficiency-anemia-screening

Gilbert, S. G., & Weiss, B. (2006). A rationale for lowering the blood lead action level from 10 to 2 μg/dL. Environment and Neurodevelopmental Disorders22nd International Neurotoxicology Conference, 27(5), 693–701. http://doi.org/10.1016/j.neuro.2006.06.008Jones, R. L., Homa, D. M., Meyer, P. A., Brody, D. J., Caldwell, K. L., Pirkle, J. L., & Brown, M. J. (2009). Trends in Blood Lead Levels and Blood Lead Testing Among US Children Aged 1 to 5 Years, 1988–2004. Pediatrics, 123(3), e376–e385. http://doi.org/10.1542/peds.2007-3608

Lozoff, B., Jimenez, E., Hagen, J., Mollen, E., & Wolf, A. W. (2000). Poorer Behavioral and Developmental Outcome More Than 10 Years After Treatment for Iron Deficiency in Infancy. Pediatrics, 105(4), e51–e51.

Lozoff, B., Jimenez, E., & Smith, J. B. (2006). Double burden of iron deficiency in infancy and low socio-economic status: a longitudinal analysis of cognitive test scores to 19 years. Archives of Pediatrics & Adolescent Medicine, 160(11), 1108–1113. http://doi.org/10.1001/archpedi.160.11.1108

Navas-Acien, A., Guallar, E., Silbergeld, E. K., & Rothenberg, S. J. (2007). Lead Exposure and Cardiovascular Disease—A Systematic Review. Environmental Health Perspectives, 115(3), 472–482. http://doi.org/10.1289/ehp.9785

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Bibliography, continued

Oregon Department of Human Services Childhood Lead Poisoning Prevention Program. (2010). State of Oregon Childhood Lead Poisoning Elimination Plan Update. Oregon Department of Human Services. Retrieved from http://library.state.or.us/repository/2010/201010181442551/index.pdfSuicide-in-Oregon-report.pdf. (2011). Retrieved May 26, 2015, from http://www.oregon.gov/oha/amh/CSAC%20Meeting%20Shedule/Suicide-in-Oregon-report.pdf

Whitlock, E., O’Connor, E. A., & Williams, S. B. (2010). Effectiveness of Primary Care Interventions for Weight Management in Children and Adolescents - NCBI Bookshelf. Rockville, MD: Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK36416/

Williams, S. B., O’Connor, E. A., Eder, M., & Whitlock, E. P. (2009). Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventive Services Task Force. Pediatrics, 123(4), e716–e735. http://doi.org/10.1542/peds.2008-2415