8/6/2019 Health Guidance 2

1/6

CASE 4

Concerns1. Is Andrew ready to start school?

a. Here are a few developmental challenges that Andrew will face in thetransition to Kindergarten. Andrew has already participated in

Preschool therefore he has already interacted with other children andhas been separated from his parents and other caregivers.

History

Andrew and his family have just moved to Ft. Lewis from Virginia.

After having several ear infections in his second year of life

Andrews language development was delayed due to mild

conductive hearing loss that resolved without surgical treatment.

During that time he participated in an early intervention program

between ages 2 and 3 and then received supplemental speech

8/6/2019 Health Guidance 2

2/6

and language therapy in preschool until about a year ago. Now

that kindergarten is approaching, his parents want to make sure

hes ready for school. Since they are new to the area, this is the

first healthcare visit Andrew has had at Madigan.

Developmental History

Andrew sat at 6 months, walked at 15 months, spoke single words

by 18 months and used two-word phrases a few months after he

turned two. His language, while initially delayed, improved with

early intervention and speech and language therapy, and by age 4

no delays were evident. He attended preschool and day care in

Virginia, and the family hopes to find an after-school program

here. He has been toilet trained during the day since he entered

preschool at age 3, but he still wets the bed most nights.

It affects one out of every four children at age five, one in five at

age seven years, and about one in twenty at age ten years. Boys

make up two-thirds of this group, and often there is a family

history of bedwetting(usually in the father). It may be related to

the time it takes different children to develop control over thenervous, muscular, and nighttime full bladder sensation that

needs to be subconsciously suppressed. If your child wets at night,

here are some possible causes:

y Slow development to awaken when the bladder is full

y Constipation, which can cause extra pressure on the bladder from therectum

y An early sign of diabetes mellitus, a urinary tract infection, or emotionaldistress caused by an upsetting event or unusual stressbut only ifwetting began suddenly after an extended dry period.

If your child continues to wet frequently, or if you notice any of the followingsignals, talk with your pediatrician:

y Wet underpants, nightclothes, and bed linens, even when the child

8/6/2019 Health Guidance 2

3/6

regularly uses the toilet

y Unusual straining during urination, a very small or narrow stream ofurine, or dribbling after urination

y Cloudy or pink urine, or bloodstains on underpants or nightclothes

y Redness or rash in the genital area

y Hiding underwear to conceal wetting

y Daytime as well as nighttime wetting

y Explain the problem to your child, emphasizing that you understand andknow its not his fault.

y Discourage him from drinking fluids during the two hours before bedtime.

y Reward dry nights, but dont punish wet ones. This is very important,since this is an emotional issue for both of you.

What can you tell me about alarm training versus medication as a

way to address it?

Anticipatory guidance for Andrew

y Mental Healtho Continue family routines, assign chores,

o show affection/respect, model anger management/self discipline

o use discipline for teaching not punishingo Solve conflict/anger by talking, going outside and playing or walking

away

y Nutrition and physical activity

o Eat breakfast and 5 servings of fruits/veggies per dayo limit candy/soda/high fat snacks

o @ least 2 cups low fat milk/day

o Play 60o Limit TV to 2 hours/day

y Oral Healtho Help with brushing if needed

o Dentist 2 times/yr

o Brush twice daily/floss oncey Safety

o Safe street habits, wearing helmetand safety pads when ridingbike

o Booster seat in back seato Teach to swim/supervise around water

o Safety w/ adults no secrets b/t adults

8/6/2019 Health Guidance 2

4/6

no interest in private parts no helping adults with their private parts

o Smoke detectors/CO detectors

o Remove guns or store unloadedand locked with ammunitionlocked separately

CASE 5

Concerns

Mom is concerned about his school performance and he is concerned about his

height.

History:

Andrew was born 5 weeks early. Otherwise, he hasbeen fairly healthy, except for 4 or 5 ear infections inhis first two years of life. He used inhalers on severaloccasions for a night-time cough 3 years ago, buthas not used them again since that time. He has hadno surgeries and no hospitalizations.

Environment

Andrew is now 10 years old as mentioned previously.He lives with his mother

(army nurse), father (science teacher/admin), sister Lydia who is 13 and a 5 yearold sister who was adopted from Russia.He is planning on attending a 2 week musiccamp in July for violin.He is also in preparation to move to Germany for his mothers

PCSing to Landstuhl in August.

Anticipatory Guidance

y Schoolo Ask teacher about help if there are concerns about school performance

o Create a quiet space for homeworko Get help from trusted adult/teacher in reference to bullying

y Development and Mental Health

o Promote independence, self responsibility, assign chores, providepersonal space@ home

o be a positive role model, discuss respect & anger managemento know your childs friends and supervise activities with peers

o anticipate new adolescent behaviors

o Answer questions about puberty and sex

y Nutrition/Physical activity

o Encourage nutritious foods.

8/6/2019 Health Guidance 2

5/6

o Play 60

o Limit non academic screen time to two hours

y Oral Health

o Wear mouth guard with sportso Dentist 2 times/yr

o Brush twice daily/floss oncey Safety

o back seat is the safest placeo use safety equiptment

o use sunscreen

o counsel about tobacco, alcohol and drugs

y 1.What aspects of Andrews diet can you praisehim for?The fact that he eats a variety of foods and chooses to eat veggies. Also, he stays

away from candy.

y 2.What aspects of Andrews diet could beimproved?He does not voluntarily eat fruit and he eats McDonalds every day after school.

y 3.How will you prioritize your advice for Andrew,and how will you educate him about his diet?

In reference to his fast food eating, it is alright to eat at fast

food restaurant. A plain burger could have the same

nutritional value as something that is made at home. Also,many of these restaurants have salads and eating a salad with

low calorie dressing and low fat cheeses helps to limit high

caloric food intake. Also, snacks are not bad but healthy

choices are best. Eating veggies and fruit rather than a

cheeseburger would be beneficial.

y 4.How will you counsel him about his growth?I would tell him to continue eating healthy, making sure that he is maintainingadequate caloric intake.One method of calculating the Estimated Energy

Requirement is the following equation for 9-18 years of age:

EER = 135.3-30.8 * Age + Physical Activity Level * (10 * weight [kg] + 934 * height

[m] ) +25

He is not falling off of the growth curve and seems to be maintaining in the 10th

percentile. I would be more concerned if he was falling off of the curve.

8/6/2019 Health Guidance 2

6/6

Does Andrew need a PPD placed today?Yes, seeing that he has had contact with some one who is suspected to have

tuberculosis with a positive TST and being treated empirically with anti-Tb

medication.

In reference to him not wanting to move to Germany. I would talk to him about how

he moved from VA to Ft.Lewis and was able to make new friends. I am sure that hewill be able to do the same in Germany. Also, he will be able to experience a different

culture, something most children and even adults never get to experience.