Okay, more fun stuff.
I’m going to talk about the health
maintenance for children and adolescents
and I’ll be using guidelines to
talk about how to keep them healthy
along with some personal experience
with best practices for
children and adolescent care.
So you always want to establish
a good history for kids
so you’re going to want to
ask about a birth history
but that doesn’t mean every single
aspect of the birth history
or how the child felt as
they were being delivered,
they’re probably not going to be able
to answer that question too well.
But you do want to know how old
was mom when you were born,
any problems during pregnancy,
at what gestational age
was the child born,
and any problems after delivery.
I think those are really the key
points that you want to elucidate.
Getting a birth weight is
important during infant year,
not so much after they pass two
years of age, it’s not as critical.
You’re going to want to ask
about child development,
and so asking the parent or caregiver about
development and developmental stages.
That should be part of your records so
that’s just easy to go through a list.
I find it, because I
have a varied practice,
difficult to remember all of the different
milestones at different stages.
But the other thing I
would recommend doing is
certain things the child can
actually do for you right there.
Can the child tell time?
Well, that’s one of the
reasons I have a watch
with hands on it instead
of a digital watch.
That’s why I wear a watch at all.
You can't just show them the
phone, they’ll read the numbers.
Can they tell their left
from their right side,
can they put on their shoes,
can they hop, skip, and jump?
These are kind of fun things
you can do in the office
just to cross-check the development.
It doesn’t mean you don’t
believe the parents,
but it allows for more time,
and speaking of that, watch
that home environment,
that’s at many times reflected
in the clinical encounter.
So while I’m sitting back and
taking all this history,
I’m actually doing
an exam as well.
Even though I’m sitting there and
the child’s with the caregiver
on the other side
of the room maybe,
I’m watching how they interact.
I’m watching how the child interacts
with me, the environment, its siblings,
and therefore, I think it’s
giving me some conclusions
as to maybe this
child is withdrawn.
Maybe there’s some negative interaction
that I see between the parent,
maybe there’s a tension there.
And that can clue in as to maybe the
kid’s not doing as well in school
or having more accidents.
So watching that interaction, it’s a
nice chance just to observe a child.
ADHD is another good example, is
the child hyperactive in the room
I have stories about, you know, “Oh, he can’t
be controlled” and “Billy’s going wild.”
And then you look at poor Billy,
you know, the five-year-old, who’s just
sitting there with hands on his lap
kind of looking like
this down at the floor
and you realize it may not be the problem
with the kid so much as the parent.
And that’s critical as well for
thinking about school readiness.
To me, I work in a setting
with low-income patients.
I think the biggest risk I see to this
child’s health and wellbeing overall
isn’t tuberculosis or anemia or even
obesity, as important as that is for kids.
It’s failure to progress well in school.
And so I always -- starting certainly
in those developmental stages,
and then focusing a lot once they get
to pre-K, prekindergarten education,
I’m talking about what they’re doing in
school and how much they’re reading,
because getting -- you know, not
just passing through school.
So many kids that I see are
very happy with Cs and Ds
because they’re just passing
on to the next grade.
But that’s not going to
keep them competitive
and get them where they
want to be by the time
they reach in junior
high and high school.
So talking about school readiness
is important really at every stage.
Diet, spend a lot of
time on diet with kids.
The things that I really focus on for healthy
diet and prevention of obesity are two.
One, if there’s some intake of fruits and
vegetables, at least some on a regular basis,
and if they’re avoiding
between those two things
you can avoid a lot of
pitfalls when it comes to obese kids.
Of course, you want to asses a full diet,
but that’s one thing -- a
pearl I like to share.
The other, physical activity, it’s usually
not a problem for younger children
because they want to go out and play,
you just need to give them the
environment to go out and play.
If that is a problem because
of the physical environment,
parents try to get
that kid out there,
and what’s good for the kid
is good for the family.
So oftentimes when I see
an obese four-year-old,
they have an obese nine-year-old
sibling, and mom and dad are obese too.
So it’s good for that kid walking, you
know, around the block six times a day
at a good rate is a good
for the family too.
The other pitfall with physical activity
that I find is particularly among girls
and particularly when they
turn around 11 years old,
that desire to play and the social
acceptability of that goes down.
And, you know, what’s important, well,
it’s socializing, and that is important.
But sitting, texting, talking,
that doesn’t necessarily help with in
terms of reducing the risk of obesity.
Boys, it is a little different and I’m sorry
it’s a cultural bias, but it is there,
that still many are in sports and they play
sports as their form of socialization,
if girls don’t have that outlet.
And it can be sports, it can also be things
like dance or other forms of activity,
but really I try to watch girls in particular
because I think that’s a critical period
where they can start
Sleep, important for
kids, most kids I find,
the younger kids are getting
enough sleep and doing it right;
of a challenge.
They want to stay up till midnight,
they want to sleep in till 10 AM,
therefore, they might
be skipping breakfast,
which goes back to nutritional
issues that are concerning.
So really, I try to
stay on to ensure that
they have a good environment
for sleep as well.
So a head-to-toe exam, I’m just
going to highlight a few things.
Every child gets a body
mass index at each visit.
Cardiac exam is one of the
more important exams you
can do particularly for a
for a child that’s
going in to a sport
You’re going to want to do both the
full cardiac exam including palpation,
auscultation while sitting and
standing, assessment for a heave,
assessment of the PMI, all that,
So a complete exam for those kids.
Hips get checked for laxity
through age two years, so
that’s a critical one.
And genitalia, kids may feel embarrassed
but it’s important to continue to check
and this is just a quick
inspection for boys,
you know, making sure the testicles
are descended bilaterally.
But it is important, it’s
part of the physical nature
of the exam so we should
make sure that gets done.
All right, what about recommended
screening exams among children?
This is good fodder for your exam as well.
The maximum time or the
highest point prevalence
for anemia in childhood
is at one year old,
so absolutely they should have a
hemoglobin check at that time.
Many of us continue
to check annually
during a high-risk period
between one and five years old,
these are for average-risk kids,
all of these recommendations.
But after five years old, if they’ve
had normal hemoglobin levels,
it’s not really a strong imperative
to continue to check it.
Hearing and vision, try to
check it at age four years.
The kids may or may
not be cooperative,
but usually, if you’re
a little bit patient,
they will give you a good
hearing and vision check.
Fluoride varnish I think is miraculous, I
think of it like vaccines for the teeth.
And again, this is from
I know that dental care among the
toddler set is a real challenge,
getting them to brush twice daily,
getting them to floss even worse.
Fluoride varnish kind of has my back
in that it’s going to be
protective against dental carries.
So it’s a great idea.
And so make sure they’re
visiting the dentist every six months.
So the American Academy of Pediatrics
recommends lipid screening
between 9 and 11 years of age
and again in late adolescence.
I do believe in that because getting
the result and getting the number
could show who’s at risk and therefore be
motivational for kids to change their diet.
And then for all kids,
considering lead and tuberculosis
screening in those at-risk,
particularly those who have immigrated
here from low-income countries.
Vaccinations. Just to cover a
few pearls on vaccinations,
not meant to be comprehensive in
the review of vaccinations today.
That would take a long time.
But we give the acellular
because it’s associated
with less side effects,
particularly seizures versus
the whole cell vaccine.
However, what’s becoming more
and more evident is that
the immunity induced by the acellular
pertussis vaccine is not as strong
and that’s why there’s now a booster
recommended for kids routinely
at age 11 to 12 years after the usual
booster between four and six years of age.
And the overall protective effect of
these vaccines may only be a few years.
In several outbreaks of
pertussis in California,
children who are up-to-date in their
vaccination still acquired pertussis,
although the severity of infection tends not
to be as bad when you’ve been vaccinated.
Human papilloma virus vaccine, this is a
tremendous advance in the use of vaccines.
It’s a vaccine that can actually prevent
cancer, yet it remains underused.
I think it’s something along the lines of
60% of females are receiving the vaccine,
and much lower rates of
coverage among males.
But it is recommended
between ages 9 and 26 years
for both boys and girls and I try to
give it earlier rather than later.
The vaccine is a lot less effective after an
individual has initiated sexual activity,
so give it beforehand.
I’m an advocate in healthy kids of
trying to get it on board at age nine.
And then some vaccines are
vaccination can prevent a
terrible outcome of invasive
So, that one is at age
11 to 12 and 16 to 18.
And don’t forget the influenza vaccine,
important in kids, and that’s every fall.
So another area that’s somewhat
controversial is screening for autism
because the United States
Preventive Services Task Force
found insufficient evidence that
screening for autism is effective,
but the American Academy of Pediatrics
recommends using a validated
tool at age 18 and 24 months.
The most commonly used is the Modified
Checklist for Autism in Toddlers.
This was associated with a
high false-positive rates.
They went back to the drawing board and
came out the M-CHAT Revised with Follow-up,
and that two-stage screening process
improved on the specificity.
And one of the reasons to screen is that
we now know with autism spectrum disorders
that early intensive therapy
has significant improvements
in language, cognition, and adaptability,
critical outcomes in
patients with autism.
All right, among adolescents
again, the body mass index really
should be conducted at every exam,
every well child exam.
For sexually active females, they should
be screened for chlamydia and gonorrhea
that does not involve
Urine test with DNA analysis is sufficient.
And a screening for depression
among adolescents between
12 and 18 years old is recommended as
long as there’s follow up available.
Things we don’t screen for, and
this might come up on your exam.
We don’t screen routinely
for scoliosis anymore,
nor do we screen for cervical
cancer until age 21 years.
So it’s really not part of
adolescent medicine right now.
Instead, what I’d recommend is this
mnemonic for assessing adolescents.
Looking at their home and environment,
looking at education and employment
and they start to become employed,
what kind of activities are
they doing outside of school,
and then some risk factors:
drugs, sexuality, and the risk
of suicide and depression.
All those are critical issues during
adolescence that you want to be aware of.
Let’s talk about risky
behaviors among adolescents.
Let’s start with sexual activity.
And there’s a picture for you.
It’s romance down
by the dirty creek,
in the mud, with a bunch
of sticks lying around.
So in the next two minutes this
couple will be attacked by ants,
and yet oh young love, it’s awesome.
And about half of adolescents
report being sexually active,
overall, the rate of sexual activity
among adolescents is actually falling.
And even better, the
adolescent pregnancy rate
has declined precipitously in the last
10 to 15 years, and that’s great.
So the keys to maintaining a healthy
sexual being during adolescence is good,
open communication with the
adolescent about what they’re doing
and having an open discussion about
different family planning options
and those should absolutely include
contraceptive methods because
that’s what really makes, I
think, pregnancy rates fall
when it comes to adolescent
So let’s focus no on alcohol use.
Keys to curbing alcohol use and
particularly risky alcohol use
which is higher among adolescents is just
be open and direct about the subject.
Really try to emphasize that alcohol
is going to impair judgment
and I think a lot of adolescents are
cognizant of the fact how it affects driving
and the risk for drinking and driving, at
least intellectually they understand this.
But it also is a risk
regarding sexual choices
and that might resonate with adolescents
a little more that I found.
And then you want to try
to get a commitment
and maybe that’s absence from
alcohol and that’s great,
but certainly you want to avoid those
risky behaviors, drinking and driving.
Make a commitment that the
adolescent has to call their parents
if they ever are
impaired due to alcohol,
and make sure the parent understands
that when that call comes
they can’t be overly punitive
on their adolescent.
At least the adolescent did the right thing
and called them instead of
getting behind the wheel
or getting in another
With that, I hope this was
helpful in thinking about
the care of children
There are a lot of pearls for
clinical practice there,
but if you look at those guidelines,
there are also a lot of questions
you’re going to see on your exam.