ࡱ>  zbjbjss  $|9P}""("""$$,$|||||||.Ё|($$((|"" }!-!-!-(""|!-(|!-!-t{"P;Y+vH| }0P}vj,pj{j{$h%h!-%T$&$$$||!-$$$P}((((j$$$$$$$$$ : WELL CHILD/EPSDT PEDIATRIC AND ADOLESCENT PREVENTIVE HEALTH GUIDELINES Purpose/Policy The purpose of the Well Child/Pediatric and Adolescent Preventive Health Care program is to provide Comprehensive Health and History screening and assessment of the physical, mental, and social well being of children birth through 20 years of age. If a patient is currently receiving preventive healthcare from another provider, the patient should be referred back to that provider. If a patient is not currently receiving preventive health care from another provider, preventive health care should be offered/provided. The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents is the recommendation of The American Academy of Pediatrics. A registered Public Health Nurse or nurse practitioner must complete the state approved Pediatric Assessment/Well Child Certification program prior to performing pediatric screening services in a health department setting. APRN (Advance Practitioner Registered Nurse who are certified in pediatrics are exempt. All other APRNs must complete the course prior to performing pediatric services. Registered nurses and APRNs that participate in the Kids Smile: Fluoride Varnish Program for oral screening or fluoride application is required to complete the training for the Kids Smile Fluoride Varnish Program. Patients with conditions suspected of falling outside the normal screening parameters described in the following section should be re-screened when appropriate or referred to local physicians for further diagnosis and treatment of their acute or chronic conditions. LHDs staff physicians, family practice or pediatric nurse practitioners may diagnose and treat children as appropriate. When no other care is available, children with chronic medical conditions should be coordinated with local physicians or the Kentucky University Clinics. Children with suspected genetics problems should be referred to one of the Genetics Clinics (refer to the Genetics Section). Children with suspected Developmental Delay should be referred for developmental evaluation and screening (refer to the KEIS Section). References: American Academy of Pediatrics Standards of Care, Pediatrics, August 2, 1995, volume 96, number 2. American Academy of Pediatrics, Committee on Infectious Diseases, Pediatrics, 1996, volume 97, number 2. American Academy of Pediatrics, Cholesterol in Childhood, Pediatrics, volume 101, number 1, 1998. American College of Obstetrics and Gynecology, Committee on Gynecologic Practice, March 1995, number 152. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents Third Edition, National Center for Education Maternal and Child Health, 2008, Arlington, VA. WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE (Birth through 15 months) AGE01 M 1 M2 M4 M6 M9 M12 M15 MHISTORY (comprehensive initial and interval history including medical, dietary, developmental, lead, TB, fluoride and oral health risk assessments).Initial/Interval HistoryXXXXXXXXPHYSICAL EXAM (comprehensive)XXXXXXXMEASUREMENTSHEIGHT/WEIGHTXXXXXXXXHEAD CIRCUMFERENCEXXXXXXXXTEMPERATUREXXXXXXXXRESPIRATIONSXXXXXXXX HEART RATEXXXXXXXXBLOOD PRESSUREPELVIC EXAMTESTICULAR EXAMSENSORY SCREENINGVISIONSSSSSSSSHEARINGSSSSSSSSIMMUNIZATIONS6XX6XXXXXXLABORATORY (routine)METABOLIC SCREENING7 XSICKLE CELL DISEASE7XLEAD5RRXRHCT/HGBXURINALYSISLABORATORY (patient at risk)FLUORIDE8RRRRRRRRCHOLESTEROLSTDTUBERCULIN9RRRRRRRRHEALTH EDUCATION (age approp.)2, 10XXXXXXXXRECOMMENDED DENTAL REFERRAL12XRECOMMENDED Fluoride Varnish at eruption of first tooth and at 6 month intervals to age 6 years. 13 SSSSS X=TO BE PERFORMED S=SUBJECTIVE BY HX O=OBJECTIVE BY A STANDARD TESTING METHOD R=TO BE PERFORMED FOR AT RISK PATIENTS 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 comprehensive history should be completed on the initial visit that identifies medical, dietary, developmental, lead, TB, fluoride, and oral health risks. An interval history should be completed each visit after the initial visit. 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 other than those noted on periodicity, follow Pediatric Health Care Guidelines in this section. During the comprehensive history, question parents on the Well Child Pediatric Developmental Age Specific/Appropriate Benchmarks. Refer to the Preventive Guidelines for Pediatrics in this section. Complete a risk assessment if further evaluation is indicated. Parents and caregivers should be advised to place healthy infants on their backs when putting them to sleep. Side positioning is a reasonable alternative but carries a slightly higher risk of SIDS. Consult the AAP statement The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk (2005). 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 Suspected Developmental Delays in Preventive Guidelines, this section.) The HRA is to be completed including the dietary questions for periodic pediatric visits. 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 HYPERLINK "Lead.doc" \o "Lead Section"Lead Section). Only some infants should have immunization at 1 month of age; it is medically necessary at that age for Hepatitis B #2 (provided 1 month has elapsed since Hepatitis B #1) when the mother is surface-antigen-positive; for negative mothers it is optional whether to give hepatitis B #2 at 1 versus 2 months of age. For guidance regarding Metabolic/Sickle Cell Screening, refer to Metabolic/Sickle Cell Disease 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. (See HYPERLINK "Oral%20Health.doc" \o "Oral Health Section"Oral Health Section) Tuberculin test (PPD) should be administered with suspected signs, symptoms of Tuberculosis or history of exposure to Tuberculosis. Frequency of testing varies according to the nature of the risk. (See HYPERLINK "Tuberculosis.doc" \o "Tuberculosis Section"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. 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. If a child comes under care for the first time at any point of the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date. 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. Fluoride Varnish should be applied at eruption of the first tooth and at 6-month intervals to age 6 years. (See HYPERLINK "Oral%20Health.doc" \o "Oral Health Section"Oral Health Section) WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE (16 months through 10 years) AGE1118 M24 M3 Y4 Y5 Y6 Y8 Y10 YHISTORY (comprehensive initial and interval history including medical, dietary, developmental, lead, TB, fluoride and oral health risk assessments).Initial/Interval HistoryXXXXXXXXPHYSICAL EXAM (comprehensive)XXXXXXXXMEASUREMENTSHEIGHT/WEIGHTXXXXXXXXHEAD CIRCUMFERENCEXXTEMPERATUREXXXXXXXXRESPIRATIONSXXXXXXXXHEART RATEXXXXXXXXBLOOD PRESSUREXXXXXXPELVIC EXAMTESTICULAR EXAMSENSORY SCREENINGVISIONSSOOOSSOHEARINGSSOOOSSOIMMUNIZATIONS5XXXXXXXXLABORATORY (routine)SICKLE CELL DISEASE6LEAD4RXRRRRHCT/HGBRRRRRURINALYSISXLABORATORY (patient at risk)FLUORIDE7RRRRRRRRGLUCOSE8RRRRRRRRCHOLESTEROL8RRRRRRRRSTDTUBERCULIN9RRRRRRRRHEALTH EDUCATION10 (age appropriate)XXXXXXXXDENTAL REFERRAL12SSXSSSSSRECOMMENDED Fluoride Varnish at eruption of first tooth and at 6 month intervals to age 6 years. 13SSSSS X=TO BE PERFORMED S=SUBJECTIVE BY HX O=OBJECTIVE BY A STANDARD TESTING METHOD R=TO BE PERFORMED FOR AT RISK PATIENTS 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 a toddler or pre-school child is developing normally or otherwise. If on completion of history and physical exam parameters are noted outside of normal ranges for any conditions other than those noted on periodicity, follow Pediatric Health Care Guidelines in this section. 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, written referral is made to the appropriate source for further evaluation. The HRA is to be completed including the dietary questions for periodic pediatric visits. 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. 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 10ug/dL retest at next periodicity schedule only if risk factor changes. Refer to Lead Poisoning Prevention and Management Section. 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). For guidance regarding metabolic/sickle cell screening, refer to Metabolic/Sickle Cell 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. (See HYPERLINK "Oral%20Health.doc" \l "FluorideProgGuidelines" \o "fluoride guidelines"fluoride guidelines in HYPERLINK "Oral%20Health.doc" \o "Oral Health Section"Oral Health Section) Cholesterol and Glucose screens should only be completed for at risk patients. Refer to Pediatrics Preventive Guidelines in this section. PPD should be administered with any of the High-Risk indicators on the Tuberculin Skin Test Recommendations. Frequency of testing varies according to the nature of the risk. (See HYPERLINK "Tuberculosis.doc" \o "Tuberculosis"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. 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. If a child comes under care for the first time at any point of the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date. Risk factors for dental caries are: bottle weaning after 12 months of age, excessive/long-term use of sippy cup with sugary beverage, white spots lesions on teeth. Fluoride Varnish should be applied at the eruption of the first tooth and at 6 month intervals to 6 years. WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE (11 YRS THROUGH BIRTH MONTH OF 21ST YEAR) AGE1511 Y12 Y13 Y14 Y15 Y16 Y17 Y18 Y19 Y20 YHISTORY (comprehensive initial and interval history including medical, dietary, developmental, lead, TB, fluoride and oral health risk assessments).Initial/Interval HistoryXXXXXXXXXXPHYSICAL EXAM (comprehensive)XXXXXXXXXXMEASUREMENTSHEIGHT/WEIGHTXXXXXXXXXXHEAD CIRCUMFERENCETEMPERATUREXXXXXXXXXXRESPIRATIONSXXXXXXXXXXHEART RATEXXXXXXXXXXBLOOD PRESSUREXXXXXXXXXXPELVIC EXAM/PAP4RRRRRRRRRRBREAST EXAM7SSSSSSSSSXTESTICULAR EXAM9XXXSENSORY SCREENINGVISIONSOSSOSSOSSHEARINGSOSSOSSOSSIMMUNIZATIONSXXXXXXXXXXLABORATORY (Routine)SICKLE CELL DISEASE10LEADHCT/HGB5X6URINALYSISXLABORATORY (Patient at risk)FLUORIDE11RRRRRRGLUCOSE13RRRRRRRRRRCHOLESTEROL13RRRRRRRRRRSTD14RRRRRRRRRRTUBERCULIN12RRRRRRRRRRHEALTH EDUCATION 16 (Age Approp.)XXXXXXXXXXDENTAL REFERRAL16SSSSSSSSSS X=TO BE PERFORMED S=SUBJECTIVE BY HX O=OBJECTIVE BY A STANDARD TESTING METHOD R=TO BE PERFORMED FOR AT RISK PATIENTS 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 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 for any conditions other than those noted on periodicity, follow Pediatric Health Care Guidelines in this section. If developmental delay is suspected based on an assessment of a parents development/behavior concern or if delays are suspected after a screening of developmental benchmarks, a formal developmental screening test is required. (See Development Benchmarks in this section.) The HRA is to be completed including the dietary questions for periodic pediatric visits. 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. 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, dysmennorhea, 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 using the principles of positioning, three levels of palpation, and recommended search patterns. 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 for risk factors, screening, and follow-up information). Testicular exams to identify undescended testicles are an important part of a physical exam for males 1120 years of age, and should be completed three times within this age span. If service is declined, documentation is required. For guidance regarding metabolic/sickle cell screening, refer to Metabolic/Sickle Cell Section. If pre-teens and adolescents are not drinking fluoridated water or are not taking vitamins with fluoride, they should be given a fluoride supplement. (See HYPERLINK "Oral%20Health.doc" \o "Oral Health Section"Oral Health Section) PPD should be administered with any of the High-Risk indicators on the Tuberculin Skin Test Recommendations. Frequency of testing varies according to the nature of the risk. (See HYPERLINK "Tuberculosis.doc" \o "Tuberculosis"TB Section) Cholesterol and Glucose screens should only be completed for at risk patients. Refer to Pediatrics Preventive Guidelines in this section. All sexually active patients should be screened for STD and offered HIV counseling and testing. If a pre-teen 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. 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. 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. 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. PEDIATRIC PREVENTIVE HEALTH GUIDELINES (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 visits provides the health care provider with valuable information in determining the patients health status and potential health risk issues. Two approaches are recommended: A populations approach and an individualized approach. The population approach is designed to promote health among all Kentucky children and adolescents by reducing risks for acute and chronic conditions through adoption of health behaviors. The individualized approach is designed to selectively screen children to identify and reduce risk factors, as well as to identify and appropriately manage acute and chronic conditions. When reviewing the HRA (in each of the age groups) and the complete or interval Health History, and Physical Exam examples of concerns to be alert for, include, but are not limited to the following: CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGCHILD ABUSE/ NEGLECT (Emotional, Physical, Sexual, or Neglect)Family History of Domestic Violence Family History of Substance Abuse Inappropriate Parent/Child Interactions: Consistent Hunger Failure to Thrive (FTT) Abandonment Inappropriate Discipline Unusual/Inappropriate Child Behaviors: Conduct Disorders Habit Disorders Neurotic Disorders Withdrawn Poor Peer Relationship Psychosomatic Complaints Sexual Acting Out Physical Indicators: Unkempt and/or Unclean Malnourishment Unexplained Bruises, Burns, Fractures, Abrasions/Lacerations, Bite Marks, or Scars on Body (anywhere) Vaginal Lacerations (External/Internal) Rectal Excoriations Evidence of having had sex under age 16Provide/refer for parenting classes Basic nutritional counseling Medical nutrition therapy for FTT Referrals for mental health/social services Refer for medical evaluation as indicated Report suspected abuse/neglect to Department for Community-Based Services KRS 620.030INFECTIONSUnsanitary Living Environment Inadequate Parenting Skills Tobacco Smoke Physical Indicators: Prematurity (birth12 months) Malnourishment Poor Physical Hygiene Skin Lesions Respiratory Distress Otitis Media Immune Compromised Acute Emotional Distress Oral infectionsdecay, periodontal, otherAnticipatory guidance hand washing, personal hygiene, s/s infection, dangers tobacco Provide/refer for parenting classes Basic nutrition counseling Screen for WIC services <5 yrs. Refer medical evaluation acute and chronic conditions Refer for dental evaluation if oral problems exist CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGABNORMAL PATTERNS OF GROWTHLow Birth Weight (birth 2 years) FTT (birth 2 years) Inadequate Nutrition Status Underlying Illness Inadequate Parenting Skills History of Upper Body Irradiation Physical Indicators: Head Circumference (Birth to 3 Years) <5% or >95% Height: (Birth to 10 Years) <5% Delayed Growth Asymmetry of Extremities Involuntary Movement of Head or Extremities Poor Hand Control Unsteady Gait Scoliosis (11 to 16 Years) Kyphosis (11 to 16 Years) Absence of Thyroid Thyroid Nodules Enlarged Thyroid Congenitally missing teethProvide/recommend for parenting classes Basic nutritional counseling Medical Nutrition Therapy for FTT Scoliosis/kyphosis screening with 6th grade physical (see guideline) Recommend medical evaluation acute or chronic conditions Refer to Social Services, Regional Pediatrics, and Genetic Services as indicated Refer LBW or FTT for Medical Nutritional Therapy Screen for WIC services <5 years Recommend medical and dental care when appropriate SUSPECTED DEVELOPMENTAL DELAYPrematurity (birth 3 years) Failure to Thrive (birth 3 years) Inadequate Parent/Child Relationship Inadequate Social Environment Speech Impairment (birth 10 years) Organic Disease Seizures/Convulsions/Epilepsy Deafness Blindness Congenital Anomaly(ies) Low Birth WeightRefer to a physician or First Steps for required formal developmental screening test Evaluate parent/child interaction/relationship Assess for birth trauma/ prenatal history Substance abuse during pregnancy (alcohol, drugs, tobacco) Possible home observations visit For medical/dental evaluation of acute chronic organic disease or congenital anomalies consider referral to Commission for Children with Special Health Care Needs (CCSHCN)PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGCARDIOVASCULAR DISEASE/ CHOLESTEROL (2 through 20 Years)The family history is considered positive if these risk factors occur in parents: A family history of cardiovascular heart disease (CHD). This includes an early history of heart attack, angina, stroke, hypertension, or by-pass surgery. A family history of one or both parents having a total cholesterol >240mg/dL. 2. If severe obesity is present in the patient or there is a family history of diabetes, the patient is considered to have risk factors. 3. Numerous white spots on teeth enamel and significant frank decay of teeth.Children/adolescents identified with risk factors should be referred for evaluation. LHD staff should provide nutrition counseling and education regarding food purchasing, food preparation habits and eating patterns. Return visits should be scheduled to evaluate their progress. Recommend for medical and dental evaluation when appropriate.GENETIC DISORDERSFamily history Confirmed diagnosis of genetic disorder Physical 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 Webbing Short digits Severe allergies/asthma Diabetes (type/age onset) Absence of sense of smell BlindnessRefer to physician/regional pediatrics for acute/chronic conditions Refer to Genetic Services for evaluation, diagnosis, counseling First Steps (birth3 years) with confirmed diagnosis as condition indicates Refer diabetes, metabolic disorders for medical nutrition therapy Refer for dental evaluation for palate, lip deformities  PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGDENTAL/ORALProlonged Bottle Use (>6 months) and sippy cup with sugary liquids Poor Dental Hygiene Unfluoridated Water Tobacco/Smokeless Tobacco History of Oral Cancer Physical Indicators: Cavities, use of sugary liquids greater than 3 times a day Red Swollen Gums Leukoplakia Gingivitis Oral Cyst/Lesions Pain, halitosis, loose teeth Loose Teeth MalignmentAnticipatory guidance on weaning from bottle, no juice in bottles, oral care/dental hygiene, and tobacco product use Basic Nutrition Counseling Test of home water for Fluoride as indicated, and providing Fluoride supplementation as indicated see guidelines for annual referral for dental visit >2 years Apply fluoride varnish at the eruption of the first tooth and repeat every 6 months. HEARING LOSSFamily History Recurring Otitis Media Structural Defects or Injuries: Abnormality External Ear Structure Abnormality Internal Ear Structure Physical Indicators: Discharge from Ears Enlarged Tender Lymph Nodes No Intelligible Speech by 2 years Failure to Localize Sound Imbedded Foreign Bodies Impacted Cerumen Furunculosis Mycotic (fungus) InfectionAnticipatory guidance on S/S of infections, antibiotic therapy, feeding position for infants, follow-up ear exam Refer for medical evaluation acute or chronic conditions Refer for parents for genetic services as indicated First Steps (birth 3 years) with confirmed hearing loss diagnosis Refer to CCSHCNOCULAR PROBLEMSConfirmed Blindness Physical Indicators: (birth through 20 years) Eyes rubbed excessively, inflamed, water, red-rimmed, and/or encrusted Eyelids Swollen Injury Eyes Itch, Burn, or Scratch Dizziness, Headaches, or Nausea Squints Eyelids or Frowns Tilts Head or Thrust Head Forward Holds Objects Close Covers or shuts one eye Recurring Styes Inflammation of lacrimal sac Prolonged setting sun sign Asymmetry in Corneal Reflex Absent Pupillary Light Reflex Marked StrabismusAnticipatory guidance S/S eye problems/infections Age appropriate eye screening Refer for medical evaluation acute or chronic conditions Refer for Ophthalmology evaluation Refer for genetic services as indicated Refer CCSHCN Refer to First Steps (birth to 3 years) PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORS AND SYMPTOMSMANAGEMENT/COUNSELINGDIABETESType 1 (formerly called Insulin Dependent Diabetes Mellitus or IDDM) RISK FACTORS Family History SYMPTOMS The Three POLYS (Cardinal Symptom of Diabetes) Polyphagia Polyuria Polydipsia Weight Loss Nausea, vomiting, abdominal pain Child may start bed-wetting Irritability Short attention span Appears overly tired Dry skin Blurred vision Sores that are slow to heal Flushed skin Headache Candida Vaginitis May Exhibit: Hyperglycemia Elevated blood glucose Glycosuria Diabetic Ketosis Ketones as well as glucose in the urine No noticeable dehydration Diabetic Ketoacidosis Dehydration Electrolyte imbalance Loose teeth, bleeding gums, abscess Type 2 (formerly called Non-Insulin Dependent Diabetes Mellitus or NIDDM) RISK FACTORS According to CDC, BMI >85th percentile to <95th percentile is considered at risk for overweight and > 95th percentile is considered overweight. See MCH 14 (Growth Charts for BMI). Family history Race/ethnicity Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS) Periodontal Disease SYMPTOMS Weight gain Fatigue Frequent infections There may be no symptoms Clinical judgment should be used to test for diabetes in high risk patients who do not meet the criteria.Anticipatory guidance regarding food purchasing, food preparation, and nutrition Education and counseling regarding blood glucose testing only if indicated Refer for medical evaluation for acute and chronic abnormal blood glucose results Refer to dentist for oral problems CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGCANCER Leukemia Lymphoma Bone Tumor Brain Tumor Reproductive Organs (11 20 years)Family History Smoking Sexual Intercourse <18 years of age Multiple Sex Partners (1120 years) Non-Condom Use (1120 years) Physical Indicators: Elevated Temperature Skin Lesions Changes in Moles Discoloration or Irregular Shaped Moles Breast Mass (female) Weight Loss Lethargy STDs (1120 years)Anticipatory guidance on warning signs, exposure to ultraviolet rays Yearly breast and testicular exams and monthly self exam instruction Refer for medical evaluation of any suspected acute or chronic conditionsEATING DISORDERS AND UNDERWEIGHTUnderweight: (birth20 years) Physical Indicators: < 10% weight for height Lower percentile than earlier Measurement or major change in percentile Anorexia Nervosa/Bulimia: (1120 years) Distorted body image Excessive athletic involvement Dieting when not overweight Use of self-induced Emesis, Laxatives, and Diuretics to lose weight Organic Disease Physical Indicators: Loss > 10% of previous weight Absence of Menarche after puberty Throat ulcers Teeth erosion and sensitivityRefer for medical evaluation acute or chronic conditions Medical nutrition therapy Refer for mental health services Refer for dental evaluation for oral problemsOBESITYFamily History Diabetes African-Americans, Hispanics, Native Americans, Pacific Islanders Low Socio-economic Status Poor Dietary Habits High fat, sugar, salt content Sedentary Lifestyle Physical Indicators: (birth 10 years) >90% weight for height Higher percentile than earlier Measurements or major change in percentiles High non-fasting cholesterol >200 (1120 years) < Tanner Stage 2 > 90% weight for height > Tanner Stage 2 > 20% over desired weight for heightAnticipatory guidance on health risk associated with obesity, diet and exercise program Refer for medical nutrition therapy Refer for medical/dental evaluation for acute or chronic conditionsPEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGPUBERTAL DEVELOPMENTAssess Tanner Stage Female Sexual Development: (As early as 8 years of age in some females) Physical Indicators: Breast bud formation Pubic hair growth Height spurt, increase body fat, and hips widen Physical Indicators: (Females 1120 years) Breast Mass Delayed Puberty Amenorrhea (Primary or Secondary) Excessive Bleeding gums Male Sexual Development: (As early as 10 years of age in some males) Physical Indicators: Increase in size hands/feet, height, fat and muscle added Testes larger, scrotal skin darkens Pubic hair sparse base of penis Physical Indicators: (Males 1120 years) Inguinal Hernia Undescended Testicle Delayed PubertyAge appropriate anticipatory guidance Tanner Growth and development stage, risk behavior Instruction in self breast exam and self testicular exam Refer for medical/dental evaluation if development grossly accelerated or delayedSUBSTANCE ABUSEFamily History or Personal Use Tobacco/Smokeless Tobacco Alcohol Drugs (prescription or street) Inhalants Anabolic Steroids Physical Indicators, including, but not limited to: Restlessness Disoriented, slurred speech Agitated/aggressive behaviors Nodding off Persistent nasal drip Dilated pupils Needle tracks/scars Abdominal Distention, firm liver Oral pre-cancerous lesions on lips, tongue, or mucosa. Periodontal disease and/or numerous cariesAnticipatory guidance tobacco, alcohol, drug health risk and facts Basic nutrition counseling Refer for medical/dental evaluation, as indicated Refer for mental health services PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORSMANAGEMENT/COUSELINGSEXUAL ACTIVITY(Female and Male) High-Risk Sexual Activity Behavior Non-condom use Non-contraceptive use Multiple Sexual Partners Injecting drug user Desire for Pregnancy Physical Indicators: STD Positive pregnancy screening Evidence of sexual activity under age 16 Oral Human Papilloma Virus, oral lesionsAnticipatory guidance in abstinence, pregnancy prevention, STDs, and HIV Laboratory testing for STDs Refer to family planning, preconceptional, prenatal, WIC, and mental health services Refer for medical/dental evaluation if condition indicates Report sexual abuse to Department for Social Services or Kentucky State Police KRS 620.030SUDDEN INFANT DEATH SYNDROME (SIDS)(Birth to 12 months only) Increased Risk: Prematurity Multiples Male Infants African-Americans Younger Moms Positioning (stomach/prone) Bedding (soft) Overheating Tobacco SmokeAnticipatory guidance on positioning and bedding, effects of tobacco smoke, and clothing Offer Grief Counseling if SIDS occurs Refer to local support group if requested PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGPSYCHOSOCIALFamily history of mental illness Inadequate parent/child interaction Overly sensitive, irritable Inexperience, ignorance Immaturity Denial of problems Low motivation Peer culture, alternative lifestyle Rebellion, risk-taking Abnormal bereavement Sleep disturbance Depression Suicidal ideation, threats, attempts Organic disease Physical indicators: Unkempt appearance Poor hygiene Non-congruent verbalization, mannerism, and expressions Aggressive behavior, acting out Hyperactivity Withdrawn Failure to interact Flat affect Low self-esteem Self mutilation Slash scars wrist/armsAssess adult support systems Anticipatory guidance stress management Offer grief counseling in bereavement circumstances Encourage for medical/dental evaluation acute or chronic conditions Refer mental health services and local support groupsSEDENTARY LIFEInactivity Obesity Physical HandicapAssist with development of safe/regular exercise routine, counseling specific to physical activity for at least 30 minutes 5 or more times a week Basic nutrition counseling Encourage for medical/dental evaluation acute and chronic conditionsINJURIESSafety Seat/Seat Belt Use (all ages) Fire (All ages, especially <4 years) Cribs (Birth3 years) Bedding (Birth12 months) Co-Sleeping (Birth12 months) Choking (All ages, especially <3 years) Food Foreign Objects Water Temperature (Birth 3 years) Drowning (all ages) Sunburns (all ages) Electrical Shock (6 months 3 years) Poisoning (All ages, especially <10 years)Assess working smoke detector in all homes Anticipatory guidance safety seat/seatbelt use Anticipatory guidance age appropriate for each risk factor Plan home fire exit route Carelessness with smoking and matches Crib bar safe spacing 2 3/8 Pillows, soft bedding, cover safety issues Safety precautions when sleeping with baby PEDIATRIC PREVENTIVE HEALTH GUIDELINES (continued) CONDITIONRISK FACTORSMANAGEMENT/COUNSELINGINJURIES (continued)Medicine Poisons Toys (all ages) Sports, individual and team (all ages) Skateboards (520 years) Bikes (320 years, especially 1011 males) Rollerblade (520 years) Basketball (520 years) Football (520 years) Soccer (520 years) Baseball (520 years) Swimming (820 years) Cross Country (1120 years) Occupational (1120 years) Agriculture Trade Sector Service Industry Unskilled labor Vehicular (all ages) Automobile Minibike, Moped, Motorcycle All-Terrain Violence (all ages) Family Weapons Suicide Gangs Homicide Avoid hot dogs, popcorn, peanuts, hard candy, and keep small toys out of reach Provide/refer for Heimlich maneuver instruction Water temp at <120 and always check before bathing Supervision in all water activity, swim lessons, pool fencing, sunscreens, hats, and ear plugs Electrical outlet covers Storage of drugs and toxic chemicals 911 use and Poison Control Phone number S/S drug overdose Age appropriate toys with supervision and instruction on use Playground equipment safety and supervision Sports participation desire and interest Preseason fitness conditioning Appropriate athletic protection gear including mouth guards S/S dehydration and heat exhaustion Parental awareness of child labor laws and hazards with adolescent work On job safety training Job injury prevention Safety seat/seat belt use Drivers education Substance abuse/driving Cycle helmet use Violence issues Coping skills and conflict resolution Resource help list Weapon availability and safety Substance abuse impact Refer for mental health services 4. Report suspected abuse/neglect WELL CHILD DEVELOPMENTAL SCREENING LHDs are no longer required to do a formal developmental screening (such as the Denver Screening) as part of the well child exam. However, the complete comprehensive physical exam shall include: Assessment of the parents developmental/behavioral concern about the individual child. Screening for age specific developmental benchmarks, as outlined on the following page. Documentation of the developmental benchmarks screening and/or Health Risk Assessment Form. If developmental delay is suspected based on this assessment or if there is parental concern, developmental testing is then required and there are two options. The LHD nurse or other health provider may administer a Developmental Screening test using a formal developmental screening tool, (such as the Denver II Developmental Screening tool, Ages and Stages*, etc); or The child may be referred to a local physician for a developmental screening test. If the developmental screening test is positive and the child is under age three, the LHD or private physician is required by federal regulation to refer to First Steps (within two working days. Children up to three years of age should be referred to First Steps, Kentuckys Early Intervention System). Children three years and older should be referred to Developmental Evaluation Services, (refer to the referral process of Developmental Evaluation Services/KEIS Section). * Example: (Ages and Stages Questionnaire [formerly Infant Monitoring System] Source: Paul H. Brookes, Publishers, P.O. Box 10624, Baltimore, Maryland 21285; 1-800-638-3775, ext. 190) Age range: 048 months WELL CHILD/PEDIATRIC DEVELOPMENTAL AGE SPECIFIC/APPROPRIATE 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 LATE CHILDHOOD 810 YEARS Benchmark: Awareness of Others and Outside World 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 Benchmark: Dramatic Physical Changes STAGESWho 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 Benchmark: Who Am I? STAGESSearch for Clearer sense of Self and to Find Place in Larger CommunityPHYSICALHeight 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 Benchmark: Emergence of Realistic Self Image and Adult Behavior STAGESWhere 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 ADOLESCENT STAGES, PHYSICAL, AND PSYCHOSOCIAL BENCHMARKS TANNER STAGES Tanner Staging is also called the Sexual Maturity Rating (SMR) or pubertal development stage and is an essential component of the adolescent exam, as well as height and weight. Tanner Stages can give a continuing appraisal of growth and physical maturation; cues for appropriate anticipatory guidance; and indications of nutritional problems, chronic illness, or other diseases. Physical changes during the late childhood and adolescence are important events, and start at different ages, as early as 8 for some females and not until 13 for other females. Physical changes during adolescence are important events and start at different ages, as early as 10 years for some males, but not until 14 for other males. TYPICAL PROGRESSION FEMALETYPICAL PROGRESSION MALE1. No Secondary Sex Characteristics a) External genitalia looks like a childsPrepubertal: flat breast Pubic hair: none1. Reproductive organs: beginning to mature Height/weight: accelerates, increasing body fatPrepubertal: testes and penis size similar to early childhood Pubic hair: none2. Breast bud formation: breasts enlarge a) Directly under areola, before early pubic hair growth Height Spurt: Increase in body fat deposition, hips widenBreast bud: small and raised Pubic hair: downy sparse growth on sides of labia2. Growth spurt: increase in hands/feet and height, fat and muscle are added Breast Areola: increases in size and slightly darken with or without association of Gynecomastia Testes: larger as scrotal skin reddens and coarsens Pubic hair: downy with sparse growth at base of penis3. Breast enlargement: extends, contour smooths Pubic hair: coarsens, darkens, and spreads Ovaries: maturing, Leukorrhea is normal Height spurt: peaks late in this stage when menarche occursBreast: general enlargement, raising of both breast and areola Pubic hair: increases in amount, coarsening, and curling3. Gynecomastia appears Height spurt: shoulders broaden and muscle mass increases Facial hair: fine at corners of upper lip Facial expression: more adult Voice: Larynx cartilage enlarges, voice may crackTestes and Scrotal skin: Stage 2 continues Penis: lengthens Pubic hair: increase in amount and curling, coarsens, appears in perineum4. Menarche: if has not occurred late in stage 3, should occur Axillary hair: appears just before or after menarche Ovaries: continue to enlarge, ovulation rarely occursBreast: areola and papilla (nipple) form contour and separate from breast Pubic hair: adult appearance and limited in area4. Axillary hair: appears Facial hair: limited to upper lip and chin, darkens, coarsens Sebaceous glands: approach adult size and function Height: increases decelerate Voice: deepens Breast: distinct enlargement, slight projection of areola, and gynecomastia regressesScrotal skin: becomes pigmented Penis: broadens Pubic hair: adult appearance and limited in area5. Height: increase slows since menarche a) Average increase 11 inches, but may increase 24 inches Breast: have adult appearance, areola and breast in same contour Pubic hair: adult appearance, horizontal upper broader5. 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