Child and Adolescent Care

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 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 Fine Motor Developmental Milestones and Normal Growth skills
  • Gross motor Gross Motor Developmental Milestones and Normal Growth 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

• Consistency Consistency Dermatologic Examination 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 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:
  • Weight
  • Length
  • Head circumference Head Circumference Physical Examination of the Newborn
• 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:
  • Nourishment
  • Tone
  • Congenital Congenital Chorioretinitis anomalies
• Head:
  • Anterior fontanelle Fontanelle Any of six membrane-covered openings between the cranial sutures in the incompletely ossified skull of the fetus or newborn infant. The fontanelles normally close sometime after birth. Skull: Anatomy
  • Head shape/plagiocephaly
• Eyes:
  • Extraocular movements
  • Red reflex Red Reflex Cataracts in Children
  • Strabismus Strabismus Strabismus is the misalignment of the eyes while fixating the gaze on an object. Strabismus can be idiopathic, but it may also be caused by cerebral palsy, uncorrected refractive errors, and extraocular muscle or cranial nerve dysfunction. Strabismus
  • Accommodation Accommodation Refractive Errors
• Ears:
  • Check for low-set ears Low-set ears DiGeorge Syndrome.
  • Check for ear tags or pits.
  • Check for patency.
• 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 exam:
  • Murmurs
  • Point of maximum impulse
  • Check the pulse in at least 2 locations
• Abdominal exam:
  • Masses
  • Hepatosplenomegaly Hepatosplenomegaly Cytomegalovirus 
  • Hernias
• Genitourinary exam:
  • Tanner stage Tanner stage Sexual Physiology
  • Boys:
    • Urethral meatus placement
    • Testicular descent
• 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-preventable infectious diseases.

• 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 Hearing Screening Infant Care:
  • Newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn auditory brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification stem 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 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 screening Screening Preoperative Care:
  • Depression:
    • Patient Health Questionnaires 2 and 9 assessment
    • Annually starting at age 12 years
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder:
    • Recommended for ages 8–18 years
    • Multiple screening Screening Preoperative Care tools available (e.g., Child Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder Related Disorders, Patient Health Questionnaire Patient health questionnaire A self-administered version of the primary care evaluation of mental disorders (prime-md), a diagnostic tool containing modules on multiple mental health disorders including anxiety, alcohol, eating, and somatoform modules. The patient health questionnaire (phq-9) is designed specifically for mood/depression scoring each of the 9 dsm-iv criteria based on the mood module from the original prime-md. The generalized anxiety disorder scale (gad-7) scores 7 common anxiety symptoms. Psychiatric Assessment–Adolescent)
• 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)
• Cardiovascular screening Screening Preoperative Care (preparticipation examination for athletics):
  • Evaluate for history of:
    • Chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, tightness, or pressure with exertion
    • Unexplained syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope or near-syncope Near-Syncope Syncope (not thought to be vasovagal)
    • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea or fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia associated with exercise
    • Heart murmur
    • Elevated blood pressure
    • Previous restriction from sports
    • Previous cardiac testing by a physician
    • Family history Family History Adult Health Maintenance of premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis death (before age of 50 years) attributed to heart disease
    • Family history Family History Adult Health Maintenance of disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment from heart disease (before the age of 50 years)
    • Family history of cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types, long QT syndrome Long QT syndrome Long QT syndrome (LQTS) is a disorder of ventricular myocardial repolarization that produces QT prolongation on electrocardiogram (ECG). Long QT syndrome is associated with an increased risk of developing life-threatening cardiac arrhythmias, specifically torsades de pointes. Long QT Syndrome, ion channelopathies, Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome, or arrhythmias
  • Examination:
    • Heart murmur (not thought to be innocent)
    • Femoral pulses
    • Signs of Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome
    • Brachial artery Brachial Artery The continuation of the axillary artery; it branches into the radial and ulnar arteries. Cubital Fossa: Anatomy blood pressure in both arms

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