ࡱ> U bjbjnn aac:::::| jh`#$$$$%x'(`ggggggg$jmh:)%%))h::$$$h%/%/%/)R:$:$g%/)g%/%/2[Q`$ m)%].g:h0jhS]:ns*h:n\Q`Q`:n:!a))%/)))))hh,J)))jh)))):n)))))))))B : Pediatrics Table of Contents (ctrl+click on text to go directly to section) CLINICAL PROTOCOLS Well Child/Pediatric Preventive Health Care  HYPERLINK \l "Birth15m" Birth through 15 Months 1  HYPERLINK \l "M16m10y" 16 Months through 10 Years 3  HYPERLINK \l "M11y21y" 11 Years through Birth Month of 21st Year 5 CASE MANAGEMENT  HYPERLINK \l "clinical_protocols" Clinical Protocols for Management of Abnormal Screenings 10 WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE (Birth through 15 months) AGE01 M 1 M2 M4 M6 M9 M12 M15 MHISTORY 1,2 (Comprehensive initial and interval history including medical, dietary, developmental, lead, TB, Fluoride and oral health, and health risk assessment. as described in HP13 and 14)XXXXXXXXDEVELOPMENTAL ASSESSMENT 3XXXXXX*XXPHYSICAL EXAM 4 (comprehensive)XXXXXXXXMEASUREMENTSHEIGHT/WEIGHTXXXXXXXXHEAD CIRCUMFERENCEXXXXXXXXTEMPERATUREXXXXXXXXRESPIRATIONSXXXXXXXX HEART RATEXXXXXXXXBLOOD PRESSURERRRRRRRRTESTICULAR EXAMXXXXXSENSORY SCREENINGVISIONOSSSSSSSHEARINGOSSSSSSSIMMUNIZATIONS6XXXXXXXXLABORATORY (routine)METABOLIC SCREENING7 XSSSICKLE CELL DISEASE7XSSLEAD5RRXRHCT/HGBXURINALYSISLABORATORY (patient at risk)FLUORIDE SUPLEMENTATION8RRRRRRRRTUBERCULINRRRRRRRRQUANTITATIVE HEPATITIS C RNARRHEALTH EDUCATION9 (age appropriate)XXXXXXXXRECOMMENDED DENTAL REFERRAL8SSSRECOMMENDED Fluoride Varnish at eruption of first tooth and at 6 month intervals to age 6 years. 8SSSX or RS X=TO BE PERFORMED S=SUBJECTIVE BY HX O=OBJECTIVE BY A STANDARD TESTING METHOD R=TO BE PERFORMED FOR AT RISK PATIENTS X*= AAP recommends (not required) use of a standardized developmental screening tool at these times Footnotes refer to the key on the following page. The shaded area is the range during which a service may be provided, with X indicating the preferred age for service. A history and physical exam can help determine whether an infant and toddler are developing normally or otherwise. If on completion of history and physical exam parameters are noted outside of normal ranges for any conditions, the child should be referred for further evaluation; follow Clinical Protocols for Management of Abnormal Screenings in the Case Management Section for critical abnormalities. A comprehensive history should be completed on the initial visit that identifies medical, immunization, dietary/nutritional, developmental, lead, TB, mothers hepatitis B and hepatitis C status, fluoride, and oral health risks. An interval history should be completed each visit after the initial visit; the HRA for these periodic pediatric visits is to include the dietary questions, risks for SHS, lead, TB, fluoride, oral health, and abuse and neglect. The WIC-75 dietary information may be used in addition to the HRA but is only required for the WIC Certification visit and not every pediatric periodicity visit. For infants born to mothers confirmed to be infected with hepatitis C virus (HCV) (e.g., positive HCV RNA confirmation test), provide Quantitative HCV RNA testing at ages two months or four months and provide age-appropriate immunizations including hepatitis B (HepB) immunizations. Quantitative HCV RNA testing should then be repeated at a subsequent visit in four to six months, independent of the initial HCV RNA test result if the first test is reported as negative. An anti- HCV antibody test (anti-HCV) can be an alternative but should be provided no sooner than age 18months because anti-HCV from the mother can interfere with those test results until that age. See the 5-Screening and Referral Guidance for Infants Born to Mothers with Hepatitis C Virus (HCV) Infection. A comprehensive pediatric preventative visit shall include assessment of the parents developmental/behavioral concerns with the history, and assessment for age-specific developmental benchmarks during the physical exam, according to the age-appropriate benchmarks in this section. Assessment of the developmental benchmarks by history and exam should be documented as part of the patients record. If developmental delay is suspected based on an assessment of a parents developmental/behavior concern or if delays are suspected after a screening of developmental benchmarks, a written referral is made to the appropriate source for further evaluation. (See Clinical Protocols for Management of Abnormal Screening in this section.) A Comprehensive physical examination should be done at appropriate intervals by appropriate staff, and according to the age specific preventive health guidelines for services. The exam should include and document: General Appearance, Nutritional Status, vital signs, Mental status, head-to-toe physical exam including all systems see Chapter on Physical exam in the CCSG. At every health visit, all children 6 months to 6 years of age are evaluated, using the questions on the Verbal Risk Assessment for Lead Poisoning to determine their exposure to and risk of poisoning. (See Lead Section). If an infant or toddler comes under care for the first time at any point of the Well Child EPSDT schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date. Immunizations should be brought up to date according to the Recommended Childhood and Adolescent Immunization Schedule (See Immunization section). For infants born to mothers confirmed to be infected with HCV, provide age appropriate immunizations, including Hepatitis B vaccinations.. For guidance regarding metabolic/sickle cell screening, refer to Newborn Metabolic Screening Section in the Administrative Reference. Infants or Toddlers who are not drinking fluoridated water or who are not taking vitamins with fluoride should be given a fluoride supplement. Fluoride Varnish should be applied at eruption of the first tooth and at 6-month intervals to age 6 years. Families should be counseled for risk factors for dental caries are: bottle weaning after 12 months of age, excessive/long-term use of sippy cup with sugary beverages, white spot lesions on teeth. Age appropriate Health Education/Anticipatory Guidance for issues regarding General Health, Nutrition, Safety, and Psychosocial Issues should be given with each patient contact. The Well Child Care provider should provide Basic Nutritional Counseling. Parents and caregivers should be advised to place infants on their backs, in a separate bed, free of soft bedding, in a smoke-free environment when putting infants to sleep. Anticipatory guidance should follow AAP Bright Futures for this age grouping and includes but is not limited to safe sleep, abusive head trauma, infant car seats, second hand smoke, choking hazards, falls, home safety, and other topics according to risk. Referrals for Medical Nutritional Therapy should be made to a Registered Dietitian for the following conditions: Metabolic/Genetic Conditions, Failure to Thrive, Diabetes, Lead Poisoning, Obesity, Eating Disorders, Anemia, and Early Childhood Caries. WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE (16 months through 10 years) AGE18 M24 M30 M3 Y4 Y5 Y6 Y7 Y8 Y9 Y10 YHISTORY 1, 2 (Comprehensive initial and interval history including medical, dietary, developmental, lead, TB, Fluoride and oral health, and health risk assessment. as described in HP13 and 14)XXXXXXXXXXXDEVELOPMENTAL ASSESSMENT 3X*XX*XXXXXXXXPHYSICAL EXAM4 (comprehensive)XXXXXXXXXXXMEASUREMENTSHEIGHT/WEIGHTXXXXXXXXXXX BMIXXXXXXXXXXHEAD CIRCUMFERENCEXXTEMPERATUREXXXXXXXXXXXRESPIRATIONSXXXXXXXXXXXHEART RATEXXXXXXXXXXXBLOOD PRESSURERRRXXXXXXXXPELVIC EXAMTESTICULAR EXAMSENSORY SCREENINGVISIONSSSOOOSRSROHEARINGSSSOOOSRSROIMMUNIZATIONS6XXXXXXXXXXXLABORATORY (routine)SICKLE CELL DISEASE11LEAD5RXRRRRHCT/HGBRRRRRRRRRRLABORATORY (patient at risk)FLUORIDE7RRRRRRRRRRRGLUCOSE.9RRRRRRRRRRRHEPATITIS C antibody testRCHOLESTEROL.9RRRRRRRRRRRSTDTUBERCULIN.10RRRRRRRRRRHEALTH EDUCATION11 (age appropriate)XXXXXXXXXXXDENTAL REFERRAL7X or RX or RX or RXSSXSSSSRECOMMENDED Fluoride Varnish at eruption of first tooth and at 6 month intervals to age 6 years. 7SSSSSS X=TO BE PERFORMED S=SUBJECTIVE BY HX O=OBJECTIVE BY A STANDARD TESTING METHOD R=TO BE PERFORMED FOR AT RISK PATIENTS X*= AAP recommends (but not required) use of a standardized developmental screening tool at these ages Footnotes refer to the key on the following page. The shaded area is the range during which a service may be provided, with X indicating the preferred age for service. A history and physical exam can help determine whether an infant and toddler are developing normally or otherwise. If on completion of history and physical exam parameters are noted outside of normal ranges for any conditions, the child should be referred for further evaluation; follow Clinical Protocols for Management of Abnormal Screenings in the Case Management Section for critical abnormalities. A comprehensive history should be completed on the initial visit that identifies medical, immunization, dietary/nutritional, developmental, lead, TB, mothers hepatitis B and hepatitis C status, fluoride, and oral health risks. An interval history should be completed each visit after the initial visit; the HRA for these periodic pediatric visits is to include the dietary questions, risks for SHS, lead, TB, fluoride, oral health, and abuse and neglect. The WIC-75 dietary information may be used in addition to the HRA but is only required for the WIC Certification visit and not every pediatric periodicity visit. For infants born to mothers confirmed to be infected with hepatitis C virus (HCV) (e.g., positive HCV RNA confirmation test), provide Quantitative HCV RNA testing at ages two months or four months and provide age-appropriate immunizations including hepatitis B (HepB) immunizations. Quantitative HCV RNA testing should then be repeated at a subsequent visit in four to six months, independent of the initial HCV RNA test result if the first test is reported as negative. An anti- HCV antibody test (anti-HCV) can be an alternative but should be provided no sooner than age 18 months because anti-HCV from the mother can interfere with those test results until that age. See the 5-Screening and Referral Guidance for Infants Born to Mothers with Hepatitis C Virus (HCV) Infection. A comprehensive pediatric preventative visit shall include assessment of the parents developmental/behavioral concerns with the history, and assessment for age-specific developmental benchmarks during the physical exam, according to the age-appropriate benchmarks in this section. Assessment of the developmental benchmarks by history and exam should be documented as part of the patients record. If developmental delay is suspected based on an assessment of a parents developmental/behavior concern or if delays are suspected after a screening of developmental benchmarks, a written referral is made to the appropriate source for further evaluation. (See Clinical Protocols for Management of Abnormal Screening in this section.) A Comprehensive physical examination should be done at appropriate intervals by appropriate staff, and according to the age specific preventive health guidelines for services. The exam should include and document: General Appearance, Nutritional Status, vital signs, Mental status, head-to-toe physical exam including all systems see Chapter on Physical exam in the CCSG. A comprehensive history indicating lead exposure on a child, 6 months to 6 years of age, warrants a blood sample to be collected immediately. If lead level is less than 5ug/dL retest at next periodicity schedule only if risk factor changes. Refer to Lead Poisoning Prevention and Management Section. If a toddler or preschooler comes under care for the first time at any point of the Well Child/EPSDT schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date. For immunizations, refer to the Recommended Childhood and Adolescent Immunization Schedule United States, approved by the Advisory Committee on Immunization Practices (HYPERLINK "http://www.cdc.gov/nip/acip"www.cdc.gov/nip/acip) or the American Academy of Pediatrics (HYPERLINK "http://www.aap.org"www.aap.org) or the Immunization section Toddlers and pre-school children who are not drinking fluoridated water or who are not taking vitamins with fluoride should be given a fluoride supplement. Fluoride Varnish should be applied at eruption of the first tooth and at 6-month intervals to age 6 years. Families should be counseled for risk factors for dental caries are: bottle weaning after 12 months of age, excessive/long-term use of sippy cup with sugary beverages, white spot lesions on teeth. Recommend children receive dental sealant on their permanent molars as soon as the teeth come inbefore decay attacks the teeth. The first permanent molars called 6 year molars (2nd and 3rd grade) come in between the ages 5 and 7. The second permanent molars 12 year molars (6th grade) come in when a child is between 11 and 14 years of age. Intra and extra oral piercing, use of tobacco and frequent intake of sugary beverages are never recommended at any age. Recommend use of lip protectant with SPF of 15 or greater to be applied to the lips. Cholesterol and Glucose screens should only be completed for at risk patients. Refer to Clinical Protocols for Management of Abnormal Screenings in this section. A Tuberculin Skin Test (TST) should be administered to at-risk children with any of the High-Risk indicators on the Tuberculin Skin Test Recommendations. (See TB Section) Age appropriate Health Education/Anticipatory Guidance for issues regarding General Health, Nutrition, Safety, and Psychosocial Issues should be given with each patient contact. The Well Child Care provider should provide Basic Nutritional Counseling. Anticipatory Guidance for this age group should include but is not limited to child safety seats, second hand smoke, home safety, poisoning, bike/ATV safety, fire safety, falls, bullying, child abuse prevention and other topics according to risk. Referrals for Medical Nutritional Therapy should be made to a Registered Dietitian for the following conditions: Metabolic/Genetic Conditions, Failure to Thrive, Diabetes, Lead Poisoning, Obesity, Anemia, and Early Childhood Caries. WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE (11 Yrs through Birth Month of 21st Year) AGE11 Y12 Y13 Y14 Y15 Y16 Y17 Y18 Y19 Y20 Y21 YHISTORY1,2 (Comprehensive initial and interval history including medical, dietary, developmental, lead, TB, Fluoride and oral health, and health risk assessment. as described in HP13 and 14)XXXXXXXXXXXDEVELOPMENTAL ASSESSMENT3X*XX*XXXXXXXXPHYSICAL EXAM4 (comprehensive)XXXXXXXXXXXMEASUREMENTSHEIGHT/WEIGHTXXXXXXXXXXXBMIXXXXXXXXXXXHEAD CIRCUMFERENCETEMPERATUREXXXXXXXXXXXRESPIRATIONSXXXXXXXXXXXHEART RATEXXXXXXXXXXXBLOOD PRESSUREXXXXXXXXXXXPELVIC EXAM/PAP.7,9RRRRRRRRRRRBREAST EXAM10,11SSSSSSSSSXXTESTICULAR EXAM12XXXXXXXXXXXSENSORY SCREENINGVISIONSOSSOSSOSSSHEARINGSOSSOSSOSSSIMMUNIZATIONS.6XXXXXXXXXXXLABORATORY (Routine)SICKLE CELL DISEASELEADHCT/HGB8RRRRRRRRRRRLABORATORY (Patient at risk)FLUORIDE.13RRRRRRGLUCOSE.15RRRRRRRRRRRCHOLESTEROL.15RRRRRRRXSTD16RRRRRRRRRRRTUBERCULIN14RRRRRRRRRRRHEALTH EDUCATION (Age Appropriate.)17XXXXXXXXXXXDENTAL REFERRAL .13SSSSSSSSSSS X=TO BE PERFORMED S=SUBJECTIVE BY HX O=OBJECTIVE BY A STANDARD TESTING METHOD R=TO BE PERFORMED FOR AT RISK PATIENTS The shaded area is the range during which a service may be provided, with X indicating the preferred age for service. A history and physical exam can help determine whether an infant and toddler are developing normally or otherwise. If on completion of history and physical exam parameters are noted outside of normal ranges for any conditions, the child should be referred for further evaluation; follow Clinical Protocols for Management of Abnormal Screenings in the Case Management Section for critical abnormalities. A comprehensive history should be completed on the initial visit that identifies medical, immunization, dietary/nutritional, developmental, lead, TB, fluoride, and oral health risks. An interval history should be completed each visit after the initial visit; the HRA for these periodic pediatric visits is to include the dietary questions, risks for SHS, lead, TB, fluoride, oral health, and abuse and neglect. A comprehensive pediatric preventative visit shall include assessment of the parents developmental/behavioral concerns with the history, and assessment for age-specific developmental benchmarks during the physical exam, according to the age-appropriate benchmarks in this section. Assessment of the developmental benchmarks by history and exam should be documented as part of the patients record. If developmental delay is suspected based on an assessment of a parents developmental/behavior concern or if delays are suspected after a screening of developmental benchmarks, a written referral is made to the appropriate source for further evaluation. (See Clinical Protocols for Management of Abnormal Screening in this section.) A Comprehensive physical examination should be done at appropriate intervals by appropriate staff, and according to the age specific preventive health guidelines for services. The exam should include and document: General Appearance, Nutritional Status, vital signs, Mental status, head-to-toe physical exam including all systems see Chapter on Physical exam in the CCSG. A history and physical exam can help determine whether a pre-teen or adolescent is developing normally or otherwise. If on completion of history and physical exam parameters are noted outside of normal ranges, follow Clinical Protocols for Management of Abnormal Screenings in the Case Management Section for critical abnormalities. If a preteen or adolescent comes under care for the first time at any point of the Well Child/EPSDT schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date. For immunizations, refer to the schedule approved by the Advisory Committee on Immunization Practices (HYPERLINK "http://www.cdc.gov/nip/acip"www.cdc.gov/nip/acip) or the American Academy of Pediatrics (HYPERLINK "http://www.aap.org"www.aap.org) or the Immunization section. Pap smears are not suggested under the ACOG guidelines until age 21 unless the clinician thinks there is a reason to complete a pap smear during the pelvic exam. (Refer to the Cancer Screening/Follow-up Section for risk factors, screening, and follow-up information). Ideally, female adolescents HCT/HGB screen should occur after the onset of the 1st menses. All menstruating adolescents should be screened annually (regularity, dysmenorrhea, etc.). All females should be taught to do breast self-exam (BSE) beginning at age 20. The required method for performing the clinical breast exam and teaching BSE is the MammaCare Method. Counseling shall be documented in the medical record at the initial and annual visits. (Refer to Cancer Screening/Follow-up Section for risk factors, screening, and follow-up information). An adolescent with an abnormal breast exam should be referred for examination and/or follow-up treatment. (Refer to Cancer Screening/Follow-up Section) Testicular exams to identify undescended testicles are an important part of a physical exam for 1120 year old males and should be completed three times within this age span. If service is declined, documentation is required. If pre-teens and adolescents are not drinking fluoridated water or are not taking vitamins with fluoride, they should be given a fluoride supplement. Recommend children receive dental sealant on their permanent molars as soon as the teeth come inbefore decay attacks the teeth. The first permanent molars called 6 year molars (2nd and 3rd grade) come in between the ages 5 and 7. The second permanent molars 12 year molars (6th grade) come in when a child is between 11 and 14 years of age. Intra and extra oral piercing, use of tobacco and frequent intake of sugary beverages are never recommended at any age. Recommend use of lip protectant with SPF of 15 or greater to be applied to the lips. A TST should be administered to at-risk children with any of the High-Risk indicators on the Tuberculin Skin Test Recommendations. (See TB Section) Cholesterol and Glucose screens should only be completed for at risk patients. All sexually active patients should be screened for STD and offered HIV counseling and testing. Age appropriate Health Education/Anticipatory Guidance for issues regarding General Health, Nutrition, Safety, and Psychosocial Issues should be given with each patient contact. The Well Child Care provider should provide Basic Nutritional Counseling. Anticipatory Guidance for this age group should include but is not limited to safety belt and helmet use, smoking and substance abuse, second hand smoke, bullying, pregnancy prevention, STI, dating violence and stalking, and other counseling according to age and risks. Referrals for Medical Nutritional Therapy should be made to a Registered Dietitian for the following conditions: Metabolic/Genetic Conditions, Failure to Thrive, Diabetes, Lead Poisoning, Obesity, Eating Disorder, Anemia, and Dental Caries. PEDIATRIC AGE APPROPRIATE DEVELOPMENTAL BENCHMARKS 1 MO2 MO4 MO6 MO9 MO12 MOFINEMoves arms and legsEyes follow you and shows interest in objectsReaches for objects Follows you with his eyes.Reaches and transfers objects. Puts objects in mouth.Feeds self Bangs and throws objectsPoints with index finger. Drinks from a cup. Feeds selfGROSSLifts head for short time when on stomachLifts head and upper chest with support in the arms when on stomachHolds head erect but raises body on hands when on stomachRolls over, sits with support. Stands when placed in standing positionCan sit without supportPulls to stand May take a few steps aloneLANGUAGEMakes throaty noises Responds to sounds by blinking, crying, or startled movementsCoos and babbles in response to voicesLaughs and squeals out loudTurns to sound vocalizes single commands such as Dad, Ba-BaSays Mama and Dada Understands no-no and bye-byeCan say words in addition to mama and dadaSOCIALLooks at faces and follows movements with eyesShows pleasure in contact with adultsSmiles, squeals, blows bubblesMay have stranger anxietyResponds to name Plays peek-a-booPlays pat-a-cake, peek-a-boo15 MO18 MO2 YR3 YRFINEDrinks from a cup. Stacks 2 blocks. Feeds self with fingers.Scribbles and imitates drawing with a crayonCan stack 6 blocks, make straight or circular marks with a crayonCopies circle and a crossGROSSWalks well, stoops, climbs stairsWalks backwards, runs stiffly, throws a ballCan go up stairs one at a time. Can kick a ballJumps up and down, kicks a ball, rides a tricycleLANGUAGEHas vocabulary of 3-6 words. Indicates what he/she wants by pointing and gruntingMimics words and objectsHas a vocabulary of at least 20 words and uses 2 word phrasesKnows his name, age, and sex, colors Uses 3-4 word phrasesSOCIALMakes gestures and imitates others. Listens to a storyShows affection and blows kissesImitates adults and follows 2 step commandsCan feed and dress him/ herself. Shows easy imaginative behavior4 YR5 YR6 YRFINEBuilds a tower of 10 blocks, thumb wiggleCopies a square and a triangle Draw him/her selfDraws a 6-part personGROSSHops, jumps on 1 foot Throws an overhand ball Ride a tricycle with training wheelsBalances on one foot for 5 seconds Draws a 3-part person, prints and knows some letters, may be able to skipWrites letters, can do heel to toe stepsLANGUAGESings a song Can tell you his first and last nameKnows name, address, and phone #. Counts on fingersKnows all letters and countsSOCIALCan talk about daily activities and discuss thing in his/her name Differentiate fantasy/reality conceptsPlays make believe and dress-upUnderstands right and wrong PEDIATRIC AGE SPECIFIC/APPROPRIATE DEVELOPMENTAL BENCHMARKS LATE CHILDHOOD 810 YEARS STAGESIncreasing Awareness of Outside WorldPHYSICALHeight and Weight BMI (if available) Scoliosis Screening, Dental-mixed dentition (primary and permanent teeth) Tanner StagePSYCHO-SOCIAL MENTAL HEALTHPersonal competence and building confidence in self Same sex friends assume greater importance Seeking of increasing independence from family becomes obvious Easily influenced by peers with increase in risk-taking behaviorsEARLY ADOLESCENCE 1115 YEARS STAGESDramatic Physical Changes: Who am I Physically?PHYSICALHeight and Weight BMI (if available) Tanner Stage Acne and Common Dermatoses Dental, permanent teeth erupted Sexual Activity Substance AbusePSYCHO-SOCIAL MENTAL HEALTHDemand Privacy (modesty) Preoccupation with appearance Present/self oriented Morality driven by rules i.e., right/wrong, good/bad Anxious about large number of changes in lifeMIDDLE ADOLESCENCE 1518 YEARS STAGESSearch for Clearer sense of Self and to Find Place in Larger Community: Who am I?PHYSICALHeight and Weight BMI (if available) Tanner Stage Acne and Common Dermatoses Dental Sexual Activity Substance AbusePSYCHO-SOCIAL MENTAL HEALTHFriends assume greater importance and provide feelings of security/less time with family Extreme sensitivity to peer group social norms and fads Sexual identity (homosexual/heterosexual) Future oriented in thinking Broaden perspective to include societal issues/while seeking greater privacy Question rules and authority increases risk taking behaviors Opinionated and challenging increasing conflictsLATE ADOLESCENCE 1820 YEARS STAGESEmergency of Realistic Self Image and Adult Behavior: Where am I going?PHYSICALHeight and Weight BMI (if available) Tanner Stage Acne and Common Dermatoses Dental Sexual Activity Substance AbusePSYCHO-SOCIAL MENTAL HEALTHDecision about college/workforce, military Focuses on achieving greater autonomy from family/more accepting of parents Increased high-risk behaviors peak Development of mature sexual identity Seek mature emotional intimacy Draw from increasing life experiences for options and to make decision CLINICAL PROTOCOLS FOR MANAGEMENT OF ABNORMAL SCREENINGS (Birth through 20 years) The demographic, health and behavior information that is routinely collected using the HRA, Health History, and Physical Exam in preventive health care screening visits provides the health care provider with valuable information in determining the patients health status and potential health risk issues. If on completion of history and physical exam parameters are noted outside of normal ranges for any conditions, the child should be referred for further evaluation. The list below, while not all inclusive, provides guidance on critical referral points that must be addressed. Other abnormalities should be referred according to the clinical judgment of the practitioner providing the Health History/HRA, Physical, and Developmental Exam. CONDITIONCRITICAL REFERRAL POINTSACTIONSCHILD ABUSE/ NEGLECT (Emotional, Physical, Sexual, or Neglect)Signs of Physical Abuse: TEN-4 Rule -- Bruise anywhere on a child < 4 months; Bruise in the aggregate TEN (Torso, Ears, or Neck) region in child < 4 years Unexplained or recurring Cigarette Burns, Fractures, Abrasions/Lacerations, Bite Marks, or Scars on Body (anywhere) Vaginal Lacerations (External/Internal) Rectal Excoriations History of suspected abusive behavior by an Adult (physical, sexual, or mental)Assure child safety Report suspected abuse to Dept. for Community Based Services Refer and link to medical provider/ PCP Refer to mental health services as indicated ABNORMAL PATTERNS OF GROWTHLow Birth Weight (birth 2 years) FTT (birth 2 years Physical Indicators: Head Circumference: (Birth to 3 Years) <10 percentile or >90 percentile Height: (Birth to 10 Years) <10% or > 90% Delayed Growth Weight: < 10% or > 85 % Asymmetry of Extremities Involuntary Movement of Head or Extremities/Poor Hand Control Unsteady Gait Absence or Enlarged Thyroid/Thyroid Nodules Scoliosis/Kyphosis Inappropriate Tanner stage for ageRefer and link to PCP for medical evaluation Assist with obtaining specialty services as needed Refer LBW, FTT, or underweight or overweight children for Medical Nutritional Therapy Assure child is up to date on developmental screenings 3. Refer as appropriate to Social Services, Genetic Services, WIC, nutrition, parenting services as indicated SUSPECTED DEVELOPMENTAL DELAYFailure to pass developmental screening Congenital Anomaly(ies) and/or Genetic Syndrome Organic Disease Seizures/Convulsions/Epilepsy Deafness BlindnessRefer and link to a physician for medical evaluation Refer to First Steps for formal developmental screening test Consider referral to Commission for Children with Special Health Care Needs (CCSHCN) as appropriate Assess for maternal depression and refer as appropriate CLINICAL PROTOCOLS FOR MANAGEMENT OF ABNORMAL SCREENINGS (continued) CONDITIONCRITICAL REFERRAL POINTSACTIONSCARDIOVASCULAR DISEASE/ CHOLESTEROL (2 through 20 Years)Physical Indicators: Near Syncope Light headedness Unexplained seizures Overweight/obesity or diabetes with cardiac symptomsRefer and link to PCP for medical evaluation and follow-up Provide basic nutrition counseling and case management regarding food purchasing, food preparation habits and eating patterns. Evaluate progress at return visitsDENTAL/ORALPhysical Indicators: Cavities, Prolonged Bottle Use (>6 mo.) Red Swollen Gums, Leukoplakia, Gingivitis, Oral Cyst/Lesions, Pain, halitosis, loose teeth, Mal-alignment Smokeless Tobacco Unfluoridated Water.Referral for dental visit as indicated Apply fluoride varnish at the eruption of the first tooth and repeat every 6 months. Anticipatory guidance on weaning from bottle, no juice in bottles, nutrition, oral care/dental hygiene, and tobacco product use Test of home water for Fluoride as indicated, and providing Fluoride supplementation as indicatedGENETIC DISORDERSPhysical indicators including, but not limited to: Positive newborn screening White patch hair Heavy eyebrow Characteristics of eyes Unusual face/skull structure Webbed neck, cleft palate, lip Hirsutism (especially in females) Deafness Tall/short stature Pectus excavation/carinatum Unusual hands/feet; Extra/ missing digits/short digits; Webbing Structural Defects or Injuries: Deformed External/Internal Ear Confirmed diagnosis of genetic disorder Family historyRefer and link to PCP for medical evaluation Refer to Genetic Services as indicated for evaluation, diagnosis, counseling Refer to First Steps (birth3 years) if diagnosis is an established risk condition (chfs.ky.gov/dph/firststeps.htm) Refer for dental evaluation for palate, lip deformities Refer diabetes, metabolic disorders for medical nutrition therapy as indicatedHEARING LOSSPhysical Indicators: Discharge from Ears Enlarged Tender Lymph Nodes No Intelligible Speech by 2 years Failure to Localize Sound Imbedded Foreign Bodies Impacted Cerumen Recurring Otitis MediaRefer and link to PCP for medical evaluation First Steps (birth 3 years) with confirmed hearing loss diagnosis Anticipatory guidance on S/S of infections, antibiotic therapy, feeding position for infantsOCULAR PROBLEMSPhysical Indicators: Abnormal vision screening exam Eye Injury, Irritation or inflammation Tilts Head or Thrust Head Forward Setting sun sign Asymmetry in Corneal Reflex Absent Red reflex, Pupillary Light Reflex Marked Strabismus Suspected BlindnessRefer and link to PCP for medical evaluation Refer for Ophthalmology evaluation as indicated Refer to First Steps (birth to 3 years) if blindness confirmed CLINICAL PROTOCOLS FOR MANAGEMENT OF ABNORMAL SCREENINGS (continued) CONDITIONCRITICAL REFERRAL POINTSACTIONSDIABETESPhysical Indicators: The Three POLYS (Cardinal Symptom of Diabetes) particularly if associated with weight loss: Polyphagia Polyuria Polydipsia Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovaries)Refer and link to PCP for medical evaluation Diabetic/counseling as indicatedINJURIESAge Appropriate Issues: Unsafe sleeping environment Abusive Head Trauma Choking (All ages, especially <3 years) Food/Foreign Objects Medicine/Poisons Motor Vehicle Safety/Child safety restraints/ /Seat Belt Use (all ages) Water (all ages): Temperature, Drowning, Sunburns, Electrical Shock Others as indicated by the HRAIf child appears to be in an unsafe environment notify DCBS for possible neglect Assure counseling and education to family on age appropriate safety and Points to Remember EATING DISORDERS AND UNDERWEIGHTPhysical Indicators: < 10percentile weight for height Lower percentile than earlier measurement or major change in percentile Loss > 10% of previous weight Absence of Menarche after puberty Throat ulcers/ Teeth erosion and sensitivity Anorexia Nervosa/Bulimia: (1120 years) Distorted body image Dieting when not overweight, use of self-induced Emesis, Laxatives, and Diuretics to lose weightRefer and link to PCP for medical evaluation Refer to Medical nutrition therapy Refer for mental health services, dental evaluation as appropriate. Anticipatory guidance on health risk associated with eating disorders, healthy body image, oral health, & basic nutritionOVERWEIGHT/ OBESITYPhysical Indicators: >85% desired weight for height ( 85% Higher percentile than earlier measurements or major change in percentiles High non-fasting cholesterol >200 (1120 years)Refer and link for medical evaluation Refer for medical nutrition therapy Refer for mental health services if indicated Anticipatory guidance SUBSTANCE ABUSEPhysical Indicators including, but not limited to: Restlessness, Disoriented, Slurred speech Agitated/aggressive behaviors Dilated pupils Needle tracks/scars Oral pre-cancerous lesions on lips, tongue, or mucosa. Periodontal disease and/or numerous caries Admitted use of Tobacco, Alcohol, Drugs (prescribed/ street), Inhalants, Anabolic SteroidsAssure safety of child and staff Report suspected abuse/neglect to Dept. for Community Based Services Refer and link to PCP for medical/dental evaluation, as indicated Refer and link for mental health and substance abuse services Counseling & brief intervention for tobacco, alcohol, drugs as indicated CLINICAL PROTOCOLS FOR MANAGEMENT OF ABNORMAL SCREENINGS (continued) CONDITIONCRITICAL REFERRAL POINTSACTIONSRISK BEHAVIORSPhysical Indicators: (Female and Male) STD Evidence of sexual activity under age 16 Positive pregnancy screening Oral Human Papilloma Virus, oral lesions High-Risk Sexual Activity Behavior Non-condom use; Non-contraceptive use Multiple Sexual Partners Injecting drug user Desire for PregnancyRefer and link to PCP for medical evaluation if physical indicators Report sexual abuse of a minor to Department for Social Services or Kentucky State Police Follow protocols for STD and Family Planning programs Anticipatory guidance in abstinence, pregnancy prevention, STDs, and HIVPSYCHOSOCIALPhysical indicators: Non-congruent verbalization, mannerism, and expressions Aggressive behavior, acting out Flat affect Self-mutilation/Slash scars wrist/arms Rebellion, risk-taking Prolonged bereavement Depression/Suicidal ideation, threats, attempts Inappropriate parent/child interaction Signs of Emotional Abuse: Unusual/Inappropriate Child Behaviors: Conduct, Habit, & Neurotic, Withdrawn Poor Peer Relationship Psychosomatic ComplaintsAssure safety of child If suicidal ideation /self- mutilation is present, call Suicide Crisis Hotline with patient/parent still present (1-800-Suicide) Refer and link to PCP for medical evaluation Refer and link to mental health services and local support groups as indicated Refer to appropriate resources (grief counseling in bereavement, parenting classes, and social support groups)  References . Hagan JF, Shaw JS, Duncan PM, eds. 2008 Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.     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