Well Child Care
1-4 years old
Med Peds Rounds
September 8, 2010
Debra Lotstein, MD, MPH
What is Ideal Well Child Care?
• A transformational shift from acute to
preventive care
• Incorporates a lifespan perspective in health
care
• An opportunity for engagement with other
health producing sectors of society
– Education
– Social services
Outcomes of WCC at Age 5:
Physical Health and Development
• No undetected hearing or vision problems
• No undetected birth defects/congenital
anomalies
• No chronic health problems with a
management plan
• Immunizations complete for age
• No undetected lead poisoning
• Good nutritional habits and no obesity
Outcomes of WCC at age 5:
Development
• No unrecognized or untreated delays
– Emotional, social, cognitive, communication
• Ready for school
– Child recognizes relationship between letters and
sounds
– Child has positive social behaviors with peers and
adults
Outcomes of WCC at age 5:
Family Capacity
• Parents are knowledgeable about child’s
physical health and needs
• No unrecognized maternal depression,
violence, substance abuse
• No undetected early warning signs of child
abuse and neglect
• Parents feel valued and supported in role
• Parents understand and are able to fully use
well child care services
A Systematic Approach to
Well Child Care
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Diet
Elimination
Sleep
Development
Home
School
Safety
Vaccines
Anticipatory Guidance
Guidelines for WCC 1-4 yo
• The first priority is to attend to the parents’
concerns
• Be sure to cover each area but avoid having a
“spiel” for everything
• Use clinical practice tools to help you
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4.
5.
Preventive Services Prompting Sheet
Standardized screening tools
Vaccine registry/charts
Reach out and Read
Community Resource Guide
1. Preventive Services Prompting Sheet:
Based on CHDP periodicity,
AAP guidelines
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12 months
15 months
18 months
2 years
3 years
4 years
2. Standardized Screening Tools
• Surveillance:
– general process of identifying children at risk for
developmental problems
• Screening:
– use of standard tools for identifying those at risk
• Evaluation:
– complex process to identify specific disorders
Routine Use of Structured Developmental
Screening Tools
• Used if concerns arise AND periodically at well
visits (9 (or 12),18,30 month visit per AAP)
• Easy to use tools with good sensitivity (75%) and
specificity (at least 75%) for problems needing
referrals
– PEDS
– Ages and Stages Questionnaires
– MCHAT for autism (at 18 and 24 mos)
• Promotes conversations and parent engagement
in their child’s development
2. Standardized Screening Tools
• Development
– PEDS/ASQ
• Family Stressors
– Domestic Violence
– Maternal Depression
• Lifestyle Log for Overweight/Obese
– After 2 years old
3. Vaccine Registry and Charts
• Catch up missed vaccines
• Live vaccines
• Boosters
4. Reach out and Read
• National program started in Boston
• Using books as a way to
– Promote child’s readiness for reading
– Promote social/emotional development
– Use as a tool in the exam room to assess
development, parenting skills, can use to model
how to share books
– Assure there are books in the home
5. Community Resource Guide
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Special Needs
Child care and early education
Mental Health
Other
Approach to the Physical Exam 1-4 yo
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Approach the child indirectly
Keep child with parent as much as possible
Use parent as example
Use distraction
A Systematic Approach to
Well Child Care: Routines/ Concerns to Discuss
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Diet
Elimination
Sleep
Development
Home
School
Safety
Vaccines
Anticipatory Guidance
Diet: Feeding
• Child should be in control of eating
– Avoid forcing/struggles about food
• Give up on a well rounded “adult- like” diet until
3 years old
• Diet 1 through 3 years old:
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Approx 16 oz whole milk a day (end meal with milk)
3-4 oz protein
Iron rich foods
Fruits
Variety of cooked vegetables/leafy greens
• Need to offer multiple times
Diet: Obesity Prevention
• Plot height and weight on growth curve
• Plot BMI on curve from 2 years old on
• Assess diet and activity
– See lifestyle log for those overwt (85-95) or
obese (>95%)
• 5-4-3-2-1
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5 servings fruits and vegetables per day
4 glasses of water
3 servings dairy products
2 or hours or less screen time per day
1 hour or more of exercise per day
Elimination: Toilet Training
• Developmentally need to:
– Feel urine or BM coming, hold onto it, walk to
toilet, sit down, produce, and let them be flushed
away
• Avoid struggles over toileting
• Likely to be more ready at end of second year
(just before turning 2)
Sleep
• Bedtime routines/rituals are key
– Rocking chair, bedtime story, transitional object
• Goal is to teach self-soothing
• More night time awakenings can be expected
with learning to walk
• 2 naps a day decrease to 1 nap round 15
months
Development
• “Touchpoints” theory (Brazelton)
• With each developmental growth spurt comes
with predictable struggles and also
regressions
• Helping parents understand and anticipate
these normal progressions helps prevent
family conflict and promote positive
development of the child
Development
• Motor milestone of walking (12-14 mos) is
accompanied by emotional development of
urge for independence
• In the second year new independence at 1 yo
comes ambivalence and fears
– “Do I want to walk away, or don’t I?”
– This “inner turmoil” underlies outer “negativism”
and temper tantrums, peak 2nd and 3rd years of
life
Discipline
• Its about teaching, not punishing
• Setting limits so that eventually the child can
learn self-control and respect for others
• Save discipline efforts for the important things
(e.g. safety of self or others)
– Pick your battles
Discipline
• First control the environment
– Avoid the avoidable
• “Acting out” is often worst at predictable times:
end of day (when tired), when parent is
distracted, or if child over-excited (public place)
• Use quiet “time out” or hug to break the cycle of
buildup
– when quiet, can explain “I’ll have to stop you until you
learn to stop yourself”
Development: Language
Age Range
Receptive Language
Expressive Language
12-15 months
Shakes head no
Follows one-step commands
5-10 words
Says Mama, dada
Imitates sounds
Points to 2-4 body parts
Uses jargon mixed with
real words
15-18 months
Shakes or nods to question
Recognizes pictures when named
3-20 words
18-24 months
Points to body parts
Understands personal pronouns
100-200 words
24-36 months
Follows 2 step directions
Responds to yes/no questions
Up to 900 word vocabulary
3-4 word phrases
50-75% speech is
understood
36-48 months
Identifies 4 colors
Understands negatives
4 or more word sentences
75% speech is understood
Relates experiences
Language Delay
• A wide range of normal speech and language development
between 1-3 yo
• Consider referral if:
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No first words by 15 months
No consistent words by 18 months
No word combinations by 24 months
Speech is difficult for parents to understand at 24 months
Speech is difficult for strangers to understand at 36 months
• Some will be familial late talkers: increase in males, family history
• Where to refer:
– < 3yo Regional Center (speech rx, other stimulation)
– >3yo: School
• Home
– Who lives at home with you? Any changes?
• School
– Who is with child during the day? Day care?
Thinking of daycare or preschool?
• Safety
– Car Seats
• 0-1 :rear –facing until 1 year AND 20 lbs
• 1-4: Car seat until 4 yo AND 40 lbs
• 4-6 : Booster seat until 6 yo AND 60 lbs (or 8 and 80)
Official BF3 Table Images
12 Month Visit
29
Official BF3 Table Images
Use for Presentations
15 Month Visit
30
Official BF3 Table Images
Use for Presentations
18 Month Visit
31
Official BF3 Table Images
Use for Presentations
2 Year Visit
32
Official BF3 Table Images
Use for Presentations
2 ½ Year Visit
33
Official BF3 Table Images
Use for Presentations
3 Year Visit
34
Official BF3 Table Images
Use for Presentations
4 Year Visit
35
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