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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 Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship 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.

Last updated: 29 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Mode of delivery and complications (if any)
  • Gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care at time of birth
  • Birth weight
  • Results of screenings:
    • Hearing
    • Cyanotic congenital Congenital Chorioretinitis heart disease
    • State metabolic and genetic testing Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies

Social history Social History Adult Health Maintenance

  • Parental status/involvement
  • Household members
  • Special custody or guardianship
  • Age and number of siblings
  • Daycare/childcare attendance
  • Relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient 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 Developmental milestones Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. Developmental Milestones and Normal Growth should be screened for at each visit through school age.
    • Verbal history
    • Demonstration and observation
    • Fine motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology skills
    • Gross motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology 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 Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes intake.
  • Discuss intake of fats Fats The glyceryl esters of a fatty acid, or of a mixture of fatty acids. They are generally odorless, colorless, and tasteless if pure, but they may be flavored according to origin. Fats are insoluble in water, soluble in most organic solvents. They occur in animal and vegetable tissue and are generally obtained by boiling or by extraction under pressure. They are important in the diet (dietary fats) as a source of energy. Energy Homeostasis and sweets.
  • Encourage mealtime routine.

Physical activity

  • Types of activities
  • Number of hours per day

Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep

  • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep environment
  • Hours and duration

Bowel and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess habits

Screen time

  • Hours per day
  • Content restrictions/supervision

Menstrual history, if age-appropriate

  • Preparation of prepubescent girls for menarche Menarche The first menstrual cycle marked by the initiation of menstruation. Menstrual Cycle 
  • Discussion regarding duration and intensity of periods as well as pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

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:
  • Age 2 through adolescence:
    • Weight
    • Height
    • BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity

Examinations

  • Blood pressure for ≥ 3 years of age
  • General appearance:
  • Head:
  • Eyes:
  • Ears:
  • Nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose and Nasal Cavity: Anatomy:
    • Midline
    • Nostril patency
  • Throat Throat The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy:
    • Uvula Uvula A fleshy extension at the back of the soft palate that hangs above the opening of the throat. Peritonsillar Abscess midline
    • Trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea: Anatomy midline
  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) exam:
    • Murmurs
    • Point of maximum impulse
    • Check the pulse in at least 2 locations
  • Abdominal exam:
  • Genitourinary exam:
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions:
    • Birthmarks
    • Signs of abuse
  • Musculoskeletal:
    • Ortolani and Barlow hip maneuvers (through age 2 years)
    • Gait Gait Manner or style of walking. Neurological Examination
    • Scoliosis Scoliosis Scoliosis is a structural alteration of the vertebral column characterized by a lateral spinal curvature of greater than 10 degrees in the coronal plane. Scoliosis can be classified as idiopathic (in most cases) or secondary to underlying conditions. Scoliosis assessment at ages 10 and 12 for girls and age 13 for boys
  • Neurologic:
    • Tone
    • Appropriate level of consciousness 
    • Primitive reflexes Primitive Reflexes Primitive reflexes are involuntary motor responses that can be elicited after birth. Although these reflexes are important for survival, they gradually disappear within the 1st year of life due to their inhibition by the developing frontal lobe. Primitive Reflexes

Immunizations

Immunizations provide children and adolescents protection against multiple vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination-preventable infectious Infectious Febrile Infant diseases.

Table: Immunization schedule
Vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination 18 months 19–23 months 2–3 years 4–6 years 7–10 years 11–12 years 13–15 years 16 years 17–18 years
Hepatitis B Hepatitis B Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus (Hep B) ← 3rd dose 6–15 →
Diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus–acellular pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough) ( DTaP DTaP Combined vaccines consisting of diphtheria toxoid; tetanus toxoid; and an acellular form of pertussis vaccine. At least five different purified antigens of b. Pertussis have been used in various combinations in these vaccines. Bordetella) ← 4th dose → 5th dose
Inactivated poliovirus Poliovirus Poliomyelitis is an infectious disease caused by the poliovirus. This virus is a member of the Picornaviridae family. It is a small, single-stranded, positive-sense RNA virus without a lipid envelope. Transmission occurs through the fecal-oral route and, occasionally, through respiratory aerosols. Poliovirus/Poliomyelitis (IPV) ← 3rd dose → 4th dose
Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza (IIV) Annual vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination: 1 or 2 doses Annual vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination: only 1 dose
Measles Measles Measles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus mumps Mumps Mumps is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. Mumps is typically a disease of childhood, which manifests initially with fever, muscle pain, headache, poor appetite, and a general feeling of malaise, and is classically followed by parotitis. Mumps Virus/Mumps rubella Rubella An acute infectious disease caused by the rubella virus. The virus enters the respiratory tract via airborne droplet and spreads to the lymphatic system. Rubella Virus ( MMR MMR A DNA repair pathway involved in correction of errors introduced during DNA replication when an incorrect base, which cannot form hydrogen bonds with the corresponding base in the parent strand, is incorporated into the daughter strand. Excinucleases recognize the base pair mismatch and cause a segment of polynucleotide chain to be excised from the daughter strand, thereby removing the mismatched base. Lynch syndrome) 1st dose (12–15 months) 2nd dose
Varicella (VAR) 1st dose (12–15 months) 2nd dose
Meningococcal vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination 1st dose 2nd dose
Tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria–acellular pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough) (Tdap: ≥ 7 years) Tdap
Human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV)) 2 doses, ≥ 6 months apart
Pneumococcal conjugate vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (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 Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza)
  • If vaccinations are missed:
    • Catch-up schedules: reduced time interval needed between vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination doses
    • Do not have to start series over if it was already started

Screenings

Surveillance Surveillance Developmental Milestones and Normal Growth and screening Screening Preoperative Care for additional physical and psychosocial problems are an essential component of child and adolescent care.

  • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types screening Screening Preoperative Care:
    • Hemoglobin at age 12 months
    • Risk factor assessment annually 
    • Screen only individuals with risk factors.
    • Universal hemoglobin screening Screening Preoperative Care for menstruating females is controversial.
  • Hearing screening Screening Preoperative Care:
    • Newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn auditory brain stem Brain Stem The brain stem is a stalk-like structure that connects the cerebrum with the spinal cord and consists of the midbrain, pons, and medulla oblongata. It also plays a critical role in the control of cardiovascular and respiratory function, consciousness, and the sleep-wake cycle. Brain Stem: Anatomy response test
    • At health maintenance visits for ages 4–21 years
    • Repeat screen if risk factors are present.
  • Vision Vision Ophthalmic Exam screening Screening Preoperative Care;
    • Photoscreening annually ages 12 months–4 years
    • Eye chart screening Screening Preoperative Care should be performed during health maintenance visits for ages 5–21 years
  • Lipid screening Screening Preoperative Care:
    • Ages 9–11 years
    • Again in late adolescence
  • Oral health screening Screening Preoperative Care:
    • From ages 6 months–5 years
    • Fluoride Fluoride Inorganic salts of hydrofluoric acid, hf, in which the fluorine atom is in the -1 oxidation state. Sodium and stannous salts are commonly used in dentifrices. Trace Elements 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 Lead poisoning Poisoning that results from chronic or acute ingestion, injection, inhalation, or skin absorption of lead or lead compounds. Metal Poisoning (Lead, Arsenic, Iron) screening Screening Preoperative Care:
    • 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 TB Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis screening Screening Preoperative Care
    • Risk factor assessment annually starting at age 12 months
    • Tuberculin Tuberculin A protein extracted from boiled culture of tubercle bacilli (Mycobacterium tuberculosis). It is used in the tuberculin skin test (tuberculin test) for the diagnosis of tuberculosis infection in asymptomatic persons. Type IV Hypersensitivity Reaction skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions test or interferon-γ release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology assay, if risk factor present
  • Autism spectrum screening Screening Preoperative Care:
    • Modified Checklist for Autism in Toddlers (M-CHAT)
    • Ages 18 and 24 months
  • Mental health/depression screening Screening Preoperative Care:
    • Patient Health Questionnaires 2 and 9 assessment
    • Annually starting at age 12 years
  • Alcohol and substance use screening Screening Preoperative Care:
    • CRAFFT (C ar AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation, Relax, Alone, Forget, Friends, Trouble) questionnaire
    • Annually starting at age 12 years
  • STIs STIs Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (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 Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns
    • Bike safety
    • Car safety
    • Cyber safety
    • Water safety
  • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of 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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