Child and Adolescent Care

Child and adolescent care is the area of healthcare dedicated to individuals who are beyond the immediate neonatal age through adulthood. These individuals do not present a uniform group, but are a series of patient populations, each with evolving healthcare needs (both preventive and pathologic) unique to them. Appropriate care aims to ensure optimal overall health to promote the physical, emotional, and social well-being of these often-challenging populations. Primary care physicians are usually responsible for child and adolescent care. Well-child visits are scheduled yearly for this purpose. These visits are an opportunity to obtain a detailed clinical history, monitor physiologic and psychologic development, assess growth parameters, and perform a thorough physical examination. Age-specific screenings, counseling, and vaccinations should also be completed at these times.

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History

A comprehensive history should be obtained, particularly for individuals new to the physician.

Birth history

Birth history is usually obtained only at 1st visit, or if pertinent.

  • Mother’s age
  • Antenatal care
  • Complications during pregnancy
  • Mode of delivery and complications (if any)
  • Gestational age at time of birth
  • Birth weight
  • Results of screenings:
    • Hearing
    • Cyanotic congenital heart disease
    • State metabolic and genetic testing

Social history

  • Parental status/involvement
  • Household members
  • Special custody or guardianship
  • Age and number of siblings
  • Daycare/childcare attendance
  • Relationship with family and peers
  • Involvement in extracurricular activities
  • HEADSS interview for adolescents:
    • Home and environment
    • Education and employment
    • Activities
    • Drugs
    • Sexuality
    • Suicide/depression

Development

  • Developmental milestones should be screened for at each visit through school age.
    • Verbal history
    • Demonstration and observation
    • Fine motor skills
    • Gross motor skills
    • Language skills
    • Social skills
    • School readiness
  • School-aged:
    • Grade level
    • Performance
    • Teacher concerns

Diet

  • Ensure a variety of food groups.
  • Discuss appropriate portion sizes.
  • Ensure adequate calcium intake.
  • Discuss intake of fats and sweets.
  • Encourage mealtime routine.

Physical activity

  • Types of activities
  • Number of hours per day

Sleep

  • Sleep environment
  • Hours and duration

Bowel and bladder habits

  • Consistency and pattern
  • Daytime and nighttime control at appropriate age

Screen time

  • Hours per day
  • Content restrictions/supervision

Menstrual history, if age-appropriate

  • Preparation of prepubescent girls for menarche 
  • Discussion regarding duration and intensity of periods as well as pain

Physical Examination

As part of the comprehensive physical exam, special consideration should be given to the areas below.

Assessment of parent–child interaction

  • Look for appropriate contact/familiarity between caregiver and child.
  • Especially young children should be comfortable with caregivers and wary of strangers.

Growth parameters

  • Should be plotted on appropriate growth chart for comparison
  • Toddlers up to 2 years old:
    • Weight
    • Length
    • Head circumference
  • Age 2 through adolescence:
    • Weight
    • Height
    • BMI

Examinations

  • Blood pressure for ≥ 3 years of age
  • General appearance:
    • Nourishment
    • Tone
    • Congenital anomalies
  • Head:
    • Anterior fontanelle
    • Head shape/plagiocephaly
  • Eyes:
    • Extraocular movements
    • Red reflex
    • Strabismus
    • Accommodation
  • Ears:
    • Check for low-set ears.
    • Check for ear tags or pits.
    • Check for patency.
  • Nose:
    • Midline
    • Nostril patency
  • Throat:
    • Uvula midline
    • Trachea midline
  • Cardiac exam:
    • Murmurs
    • Point of maximum impulse
    • Check the pulse in at least 2 locations
  • Abdominal exam:
    • Masses
    • Hepatosplenomegaly 
    • Hernias
  • Genitourinary exam:
    • Tanner stage
    • Boys:
      • Urethral meatus placement
      • Testicular descent
  • Skin:
    • Birthmarks
    • Signs of abuse
  • Musculoskeletal:
    • Ortolani and Barlow hip maneuvers (through age 2 years)
    • Gait
    • Scoliosis assessment at ages 10 and 12 for girls and age 13 for boys
  • Neurologic:
    • Tone
    • Appropriate level of consciousness 
    • Primitive reflexes

Immunizations

Immunizations provide children and adolescents protection against multiple vaccine-preventable infectious diseases.

Table: Immunization schedule
Vaccine18 months19–23 months2–3 years4–6 years7–10 years11–12 years13–15 years16 years17–18 years
Hepatitis B (Hep B)← 3rd dose 6–15 →
Diphtheria–tetanus–acellular pertussis (DTaP)← 4th dose →5th dose
Inactivated poliovirus (IPV)← 3rd dose →4th dose
Influenza (IIV)Annual vaccination: 1 or 2 dosesAnnual vaccination: only 1 dose
Measles–mumps–rubella (MMR)1st dose (12–15 months)2nd dose
Varicella (VAR)1st dose (12–15 months)2nd dose
Meningococcal vaccine1st dose2nd dose
Tetanus–diphtheria–acellular pertussis (Tdap: ≥ 7 years)Tdap
Human papillomavirus (HPV)2 doses, ≥ 6 months apart
Pneumococcal conjugate vaccine (PCV13)4th dose (12–15 months)
  • Multiple vaccinations are routinely recommended for children.
  • Combination vaccines are often used to reduce the number of injections given.
  • Vaccines administered:
    • IM
    • SC
    • Intranasal spray (only yearly influenza)
  • If vaccinations are missed:
    • Catch-up schedules: reduced time interval needed between vaccine doses
    • Do not have to start series over if it was already started

Screenings

Surveillance and screening for additional physical and psychosocial problems are an essential component of child and adolescent care.

  • Anemia screening:
    • Hemoglobin at age 12 months
    • Risk factor assessment annually 
    • Screen only individuals with risk factors.
    • Universal hemoglobin screening for menstruating females is controversial.
  • Hearing screening:
    • Newborn auditory brain stem response test
    • At health maintenance visits for ages 4–21 years
    • Repeat screen if risk factors are present.
  • Vision screening;
    • Photoscreening annually ages 12 months–4 years
    • Eye chart screening should be performed during health maintenance visits for ages 5–21 years
  • Lipid screening:
    • Ages 9–11 years
    • Again in late adolescence
  • Oral health screening:
    • From ages 6 months–5 years
    • Fluoride varnish application from eruption of 1st tooth until 5 years old
    • Visit a dentist as soon as 1st tooth erupts and every 6 months thereafter.
  • Lead poisoning screening:
    • Risk factor assessment ages 6 months–6 years
    • Blood lead level ages 12 and 24 months
    • Additional blood lead levels if risk factors
  • Latent TB screening: 
    • Risk factor assessment annually starting at age 12 months
    • Tuberculin skin test or interferon-γ release assay, if risk factor present
  • Autism spectrum screening:
    • Modified Checklist for Autism in Toddlers (M-CHAT)
    • Ages 18 and 24 months
  • Mental health/depression screening:
    • Patient Health Questionnaires 2 and 9 assessment
    • Annually starting at age 12 years
  • Alcohol and substance use screening:
    • CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) questionnaire
    • Annually starting at age 12 years
  • STIs

Anticipatory Guidance

Age-appropriate topics should be discussed for guidance in the home setting.

  • Diet
    • Balanced food groups
    • Low fat intake
    • Avoid sweetened foods and beverages.
  • Exercise: Encourage free play or team sports rather than structured exercise.
  • Safety and injury prevention
    • Choking
    • Poisoning
    • Burns
    • Bike safety
    • Car safety
    • Cyber safety
    • Water safety
  • Sleep
    • Adequate hours per night for age
    • Avoid TV and other screens before bed.
  • Bullying
  • Parental support

References

  1. Centers for Disease Control. Immunization schedules. Retrieved March 24, 2021, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
  2. American Academy of Pediatrics. Recommendations for preventive pediatric health care. (2021). https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf
  3. Bright Futures. (2021). Performing preventive services. https://brightfutures.aap.org/materials-and-tools/PerfPrevServ/Pages/default.aspx
  4. Clark MB. (2020). All about fluoride: updated clinical report covers caries prevention in primary care. https://www.aappublications.org/news/2020/11/30/fluoride113020

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