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DOS Course 2017 1 Oxtober 2010 1 Confidential Pediatric Issues and Updates Cheryl Cairns, DNP CPNP Community Pediatrics Pediatric Institute © Cleveland Clinic 2017

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DOS Course 20171 Oxtober 20101Confidential

Pediatric Issues and Updates

Cheryl Cairns, DNP CPNP Community Pediatrics

Pediatric Institute

© Cleveland Clinic 2017

• Participants will be able to discuss pediatric screening

guidelines for primary care

• Participants will be able to discuss anticipatory guidance

for parents of children in the primary care setting

• Participants will be able to identify crucial aspects of the

first primary care visit for an adopted child

Objectives

DOS Course 20172

• AAP Bright Futures

– Set of principles, strategies and tools used to improve health and

well-being of children

• Periodicity Schedule

– Published annually

– https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

AAP Screening Guidelines

DOS Course 20173

• Recommended for all expectant families

– Establishing a positive family-provider relationship

– Anticipatory guidance

– Anticipation of any high risk concerns

– Gathering information

– Concerns

– History

– Social

– Medical

– Family

https://www.healthychildren.org/English/ages-stages/prenatal/Pages/Preparing-for-Delivery.aspx

Prenatal Visit

DOS Course 20174

• Full visit

– First pregnancy

– For adolescent and other young parents

– Pregnancy complications or newborn problems are anticipated

– When parents are unusually anxious for any reason

• Brief office visit

– Parents who are still deciding on a pediatrician

– 5-10 minutes

– Introduction to office

• Phone contact visit

– Get basic information / send out information

• Group visit

– Encourages mutual support

Prenatal Visit Types

DOS Course 20175

• 0.5 to 5 in every 1000 neonates and infants - congenital

sensorineural deafness or severe-to-profound hearing

impairment

• Permanent hearing loss identified by newborn hearing

screening program were:

– ~1/1000 (Brazil, bilateral; and Sweden)

– 1–3/1000 (China, bilateral) and ~5/1000 (China, unilateral)

– 1.6/1000 (Germany, bilateral) and 0.7/1000 (Germany, unilateral)

– 1.61/1000 of at-risk infants (India, bilateral)

– 1/1000 (Serbia, bilateral) and 0.3/1000 (Serbia, unilateral)

– 1.05/1000 (United States, Colorado, bilateral) and 0.45/1000

(United States, Colorado, unilateral)

Hearing Loss

DOS Course 20176

• 1.Definition targeted hearing loss

– Congenital permanent bilateral, unilateral sensory, or permanent

conductive hearing loss

– Neural hearing loss - infants admitted to the NICU

– NICU infants admitted for more than 5 days

–Auditory brainstem response (ABR) included as part of their screening

so that neural hearing loss will not be missed

– Those who do not pass ABR evaluated by an otolaryngologist

– Genetics consultation should be offered

Hearing Loss

DOS Course 20177

• Newborn evaluation after birth

– Breastfeeding should be encouraged and instruction and support

should be offered

• Infant should have an evaluation within 3 to 5 days of

birth and within

– 48 to 72 hours after discharge from the hospital

– Evaluation for feeding and jaundice.

– Breastfeeding infants should receive formal breastfeeding

evaluation, and their

– Mothers should receive encouragement and instruction

Newborn Exam

DOS Course 20178

• Screening

– Patient Health Questionnaire-2 (PHQ-2) | Instructions

– Patient Health Questionnaire-9 (PHQ-9)Instructions

– Edinburgh Postnatal Depression Scale

• May have lasting impact on a child’s health and well-

being if left untreated

– When parents are depressed it can negatively

– Impact a child’s development

– Impede their ability to learn

– Effects that can last into adulthood

Maternal Depression

DOS Course 20179

• Level A recommendation

– Back to sleep for every sleep

– Use a firm sleep surface

– Room-sharing without bed-sharing is recommended

– Keep soft objects and loose bedding out of the crib

– Pregnant women should receive regular prenatal care

– Avoid smoke exposure during pregnancy and after birth

– Avoid alcohol and illicit drug use during pregnancy and after birth

– Breastfeeding is recommended

– Consider offering a pacifier at nap time and bedtime

– Avoid overheating

– Do not use home cardiorespiratory monitors as a strategy for

reducing the risk of SIDS

Safe Sleep

DOS Course 201710

• Expand the national campaign

• Major focus on the safe sleep environment

• Reduce the risks of all sleep related infant deaths

– SIDS

– Suffocation

– Accidental deaths

– Pediatricians, family physicians and other primary care providers

should actively participate in this campaign

• Level B recommendations

– Infants should be immunized in accordance with

recommendations of the AAP and CDC

Safe Sleep

DOS Course 201711

• Vitamin D

– encourage parents of infants who are either breastfed or

consuming <1 L/day of infant formula to give their infants an oral

vitamin D supplement.

• Iron supplementation in breast fed infants

– Begin at 4 months

– Until iron containing foods in diet, and meat is better than iron

fortified cereals

Nutritional Supplementation

DOS Course 201712

• Safety first

• Accept help from others

• Need routine

• Adjust their schedules

• Rest

• Enjoy

Anticipatory Guidance First Year

http://images.mentalfloss.com/sites/default/files/styles/article_640x430/public/baby_0.jpg

DOS Course 201713

• Physical

– Raises head and chest when on stomach

– Stretches and kicks on back

– Opens and shuts hands

– Brings hand to mouth

– Grasps and shakes toys

• Social

– Begins to develop social smile

– Enjoys playing with people

– More communicative

– More expressive with face and body

– Imitates some movements and expressions

0-3 months

DOS Course 201714

• Physical

– Rolls both ways

– Sits with and without support of hands

– Supports whole weight on legs

– Reaches with one hand

– Transfers object from hand to hand

– Uses raking grasp

• Social

– Enjoys social play

– Interested in mirror images

– Responds to expressions of emotions

• Cognitive

– Finds partially hidden object

– Explores with hands

4-7 months

http://static.guim.co.uk/sys-

images/Guardian/About/General/2010/8/16/1281977987910/B

DOS Course 201715

• Physical

– Gets to sitting position without help

– Crawls forward on belly

– Assumes hands-and-knees positions

– Gets from sitting to crawling position

– Pulls self up to stand

– Walks holding on to furniture

• Social

– Shy or anxious with strangers

– Cries when parents leave

– Enjoys imitating people in play

– Prefers certain people and toys

– Tests parental response

8-12 months

DOS Course 201716

• Clinical impression rather than formal screening-

children's developmental status are much less accurate

• Survey at every well child exam

• Screen at 9, 18 or 30 months or when concern expressed

– PEDS

– ASQ

• Perform Autism-specific screening at 18 and 24 months

– MCHAT

Developmental Surveillance and Screening

DOS Course 201717

Developmental Screening Workflow

http://pediatrics.aappublications.org/content/118/1/405.full

DOS Course 201718

• Motor skills advancing

• Visual and hearing abilities.

• Early communication skills emerging

• Autism traits - may be recognizable in the first year of life

– Lack of eye contact,

– Orienting to name being called

– Pointing

9 Month Developmental Screen

DOS Course 201719

• Delays in communication and language development are

often evident by 18 months of age

• Mild motor delays more apparent at 18 months of age

• Medical interventions for motor disorders have been

shown to be effective in children at 18 months of age

• Effective early intervention for delayed language

development is also available

• Symptoms of autism are often present at this age

18 Month Developmental Screen

DOS Course 201720

• Most motor, language, and cognitive delays may be

identified with screening instruments

• Evaluation of and intervention for those children with

delayed development

Thirty Month Developmental Screen

DOS Course 201721

• Parent-completed

• 19 age-specific categories

• Communication

• Gross motor

• Fine motor

• Problem-solving

• Personal adaptive skills

• 10-15 minutes

• Pass/fail score

• English, Spanish, French and Korean versions available

Ages and Stages (ASQ)

DOS Course 201722

• PEDS

• Parent-interview form

• 10 questions

• 2-10 minutes

• Developmental and behavioral problems needing further

evaluation

• English, Spanish, Vietnamese, Arabic, Swahili,

Indonesian, Chinese, Taiwanese, French, Somali,

Portuguese, Malaysian, Thai and Laotian

Parents' Evaluation of Developmental Status

DOS Course 201723

• M-CHAT

• Parent-completed

• Risk of autism

• 23 items

• 5-10 minutes

• Pass /fail

Modified Checklist for Autism in Toddlers

DOS Course 201724

• Apply beginning with first tooth eruption

• Does not cause fluorosis

• Position

– For an infant or very small child, use the knee to knee position and

have the caretaker lower the child’s head onto the provider’s lap

– A young child or infant may be placed on an exam table; the

provider may work from above and behind the head

Fluoride Varnish

https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Recommends-Fluoride-to-Prevent-Dental-Caries.aspx#sthash.ULuVVz1y.dpuf

DOS Course 201725

• Open the child’s mouth using finger

• Remove excess saliva and plaque from the teeth

– Gauze sponge

– Teeth should be as dry as possible

• Use your fingers and the sponges to isolate the teeth and

keep them dry

– Work on one quadrant of teeth at a time

– Apply a thin layer of varnish to all surfaces of the teeth

– Fluoride varnish will set upon contact with saliva.

Fluoride Varnish Application

DOS Course 201726

• Physical

– Walks alone

– Pulls toys behind when walking

– Begins to run

– Stands on tiptoe

– Kicks a ball

• Social

– Imitates behavior of others

– Aware of herself as separate from others

– Enthusiastic about company of other children

• Cognitive

– Finds objects even when hidden 2 or 3 levels deep

– Sorts by shape and color

Toddler (1-3 years)

http://1.bp.blogspot.com/y+w

alking.jpg

DOS Course 201727

• Safety First

• Meal times should be with family

– Limit grazing

– Provide healthy choices

– Toddlers are picky

• No screen time for children younger than 24 months,

except for video chats with family

• Encourage independence

• Toilet training (parents will survive )

Toddler Anticipatory Guidance

DOS Course 201728

• Physical

– Climbs well

– Walks up and down stairs, alternating feet

– Kicks ball

– Runs easily

– Pedals tricycle

– Bends over without falling

• Social

– Imitates adults and playmates

– Show affection for familiar playmates

– Can take turns in games

– Understands "mine" and "his / hers”

Preschool

http://www.koreaittimes.com/images/children%20playing%20in%20mud.jpg

DOS Course 201729

• Cognitive

– Makes mechanical toys work

– Matches an object in hand to picture in book

– Plays make believe

– Sorts objects by shape and color

– Completes 3 - 4 piece puzzles

– Understands concept of "two

• Tips for parents

– Yell less, love more

– Label behavior

– Give child your full attention in frequent, small doses

– Redirect with creativity

– *Screen time one-hour limit for children ages 2 to 5

Preschool

DOS Course 201730

• Nutrition

– Vegetables: 3-5 servings per day

– Fruits: 2-4 servings per day

– Bread, cereal, or pasta: 6-11 servings per day

– Protein foods: 2-3 servings of 2-3 ounces

– Dairy products: 2-3 servings per day

• Fitness

– 1 hour per day

• BMI

– <5th percentile Underweight

– 5th–84th percentile Healthy weight

– 85th–94th percentile Overweight

– ≥95th percentile Obesity

School Age Healthy Living

DOS Course 201731

• Depression

– Only 50% of adolescents with depression are diagnosed

before they reach adulthood

– In primary care as many as 2 in 3 depressed youth are not

identified

– Even when diagnosed by PC physicians only half

of these patients are treated appropriately

• http://www.glad-pc.org/

Adolescent Depression

http://i.ytimg.com/vi/-YbSs6A6gNw/hqdefault.jpg

DOS Course 201732

• Ages 12-18

• PHQ 2

• PHQ 9

Depression Screening

http://www.psy-world.com/images/phq-9.jpg

DOS Course 201733

Depression Workflow

http://pediatrics.aappublications.org/content/pediatrics/120/5/e1299.full.pdf

DOS Course 201734

• Dyslipidemia

– Fasting lipid profile before puberty and in late adolescence

– Consider screening in younger children with a family h/o

hypercholesterolemia

– Once b/w 9-11 yrs

– Once b/w 17-21 yrs

• Hearing

– Include higher frequencies

–6000 and 8000 Hertz in screening audiogram

– Counsel regarding risk of hearing loss due to environmental

exposure

Adolescence

DOS Course 201735

• Tobacco, Alcohol and Drug Use

– Provide interventions, education and counseling to prevent

initiation of tobacco use in adolescents

• SBIRT (Screening, brief intervention, referral, treatment)

– assesses the severity of substance use and identifies the

appropriate level of treatment.

– Brief intervention focuses on increasing insight and awareness

regarding substance use and motivation toward behavioral

change.

– Referral to treatment provides those identified as needing more

extensive treatment with access to specialty care

• http://www.sbirttraining.com/node/2374

• http://files.hria.org/files/SA3541.pdf

Adolescence

DOS Course 201736

• HIV

– USPSTF - Screen all 15-65 year olds, and younger/older at risk

– CDC/AAP – Screen once b/w 16-18

• Chlamydia

– Screen all sexually active females <= 24 yrs

• Gonorrhea

– Screen all sexually active females <= 24 yrs

– Screen young men who have sex w/ men

• Syphilis

– Screen individuals at increased risk of infection

Adolescence STI

DOS Course 201737

• Who are the Children

– Orphanage care

– Foster Care

– Prenatal adversity

– Substance exposures, malnutrition, stress

– Malnutrition, abuse, neglect, abandonment

– Complex special medical needs

– May or may not have received needed care

Adoption

DOS Course 201738

• Most families travel to adopt

– International travel safety & health needs

–Vaccines & travel health needs

–CDC traveler’s health website: http://wwwnc.cdc.gov/travel

– Siblings: to take them or not?

–Needs of siblings left at home

– Infectious diseases brought home by new child

Adoption Process for Families

DOS Course 201739

Question 1

• Which of the following vaccines is recommended for all

close personal contacts of a newly adopted child?

• HAV

• HBV

• Varicella

• Pertussis

DOS Course 201740

• Hepatitis A

– 1-6% of new adoptees with acute Hepatitis A

– CDC recommends HAV for all unvaccinated persons who will

have close personal contact with a child arriving from a country

with endemic Hepatitis A

– First dose at least two weeks before arrival

• Hepatitis B

– 5-6% new adoptees HBsAg +

–Known special need, or surprise

– Household contacts should have HBV series

Preparing for Infectious Risks

DOS Course 201741

• Help families to assess their own abilities to meet hardest

possible needs

• Help families to locate community resources to meet

predictable needs

• Preparation for & support during travel

– First aid & urgent health problems while abroad

• May be best left to adoption medical specialists

– http://www2.aap.org/Sections/adoption/directory/map-adoption.cfm

– http://eclevelandclinic.org/adoption

Pre-Adoption Medical Review

DOS Course 201742

• Feeding and sleep

• Attachment and bonding

• Behavior

• Family adjustments

• Anticipatory guidance

The First Office Visit

DOS Course 201743

The First Office Visit

DOS Course 201744

• Review of known medical history

– Include any new information

• Document growth - Ht, Wt and OFC

– Early assessment of age

• Careful, detailed physical examination

– Identify scars, physical anomalies, signs of illness, malnutrition,

past abuse

• Hearing and vision

Initial Medical Evaluation

DOS Course 201745

• Detailed assessment of current development

– Standardized tools often not useful yet

–Child never exposed to most test items

– Detailed history & observations of child’s skills in all

developmental domains

– Allows assessment of catch-up rate over next several months

Initial Medical Evaluation

DOS Course 201746

• CBC

• Lead level

• Stool O&P (3)

• RPR or VDRL

• HGsAg

• HCV

• HIV I&II

• PPD (or IGRA>5yr)

– Re-check these after 6 mos to r/o recent infection

Initial Medical Evaluation Labs

DOS Course 201747

• Also consider:

– HAV IgG and IgM

– If any GI sx, jaundice

–Older children, & those from endemic countries

– Chagas Disease, Strongyloides, Schistosomiasis, Malaria

– TFT’s if unusually small/delayed, or not improving rapidly over first

months home

– Ca, PO4, Alkaline Phosphatase if from northern climate or severe

malnutrition

Initial Medical Evaluation Labs

DOS Course 201748

• Different from immigrant children who come to US with

their original families, where:

– Parents can verify vaccines

– Medical facilities meet WHO standards

• If records meet timing standards, then can check titers

(for children > 12 mo.) or start series over

– Parental preference

– Easiest for child

• Check titers for:

– Tetanus, Diptheria

– Measles, Mumps, Rubella, Varicella

– Hepatitis A & B

– Polio neutralizing antibodies

Immunizations

DOS Course 201749

• Prioritize medical needs

– Balancing emergency, urgent, and non-urgent needs with child

and family’s emotional and bonding needs

• Prioritize developmental needs

– Urgent or can wait 1-2 months

– Most children make huge progress in first several months

Completing the First Visit

DOS Course 201750

• See them early and often

– E/M visits, to follow-up identified medical needs, nutrition,

developmental delays, immunization catch-up, and child and

family adjustments to adoption

–Attachment

–Feeding

–Sleeping

–School transition

• Routine Well Child Care schedule as issues resolve

The First Year Home

DOS Course 201751

Thank You

Questions???

Conclusion

DOS Course 201752

• http://pediatrics.aappublications.org/content/124/4/1227.full

• http://www.who.int/blindness/publications/Newborn_and_Infant_Heari

ng_Screening_Report.pdf

• http://pediatrics.aappublications.org/content/120/4/898.full

• http://pediatrics.aappublications.org/content/118/1/405.full

• https://www.aap.org/en-us/advocacy-and-policy/state-

advocacy/Documents/MaternalDepressionScreeningGuidance.pdf

• http://pediatrics.aappublications.org/content/pediatrics/early/2011/10/

12/peds.2011-2284.full.pdf

References

DOS Course 201753

DOS Course 201754