Case 3

3-Year-old well child check - Benjamin

Author: Ardis Olson, M.D., Dartmouth Medical School, and David Kwee, M.D.,
Morehouse School of Medicine
Learning Objectives
Describe the key components of a toddler well-child visit, including:
The importance of identifying parent concerns in order to set priorities
for the visit effectively.
The role of the physician in guiding parenting skills through affirming
and validating parent's efforts and recommending and facilitating
modifications in parenting and behavior.
Nutritional assessment and recommendations for diet and feeding
behaviors.
Assessment of dental health and common factors leading to childhood
caries.
Methods for performing developmental assessment screening tests
and developmental surveillance.
Methods for performing a physical examination tailored to the age and
mood of the child.
Topics for anticipatory guidance, such as safety.
1.
List key developmental milestones for children between the ages of 3 and 5
years old.
2.
Identify eczema and discuss first-line therapy. 3.
Discuss the common causes and work-up of anemia in an otherwise healthy
child, as well as first-line therapy of iron-deficiency anemia.
4.
Summary of clinical scenario: This case focuses on the health maintenance
visit of a preschooler. Benjamin is a picky eater with a poor diet, dental caries,
and iron- deficiency anemia. He is also discovered to have atopic dermatitis.
Key Findings from
History
Inadequate vitamin and iron intake
Excess milk and juice intake
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Control battles about food
Bottle at bedtime
Gun in the home
Key Findings from
Physical Exam
Atopic dermatitis on trunk and antecubital
fossae
Caries
Differential
Diagnosis
Anemia due to:
Iron deficiency
Chronic blood loss
Lead poisoning
Chronic illness (such as collagen
vascular disease, malignancy, or HIV)
Hemoglobinopathy
Decreased marrow production
ncreased destruction of red cells or
precursors
Atopic dermatitis vs. psoriasis
Key Findings from
Testing
Fingerstick hemoglobin: 10 grams/deciliter
(g/dL), indicating anemia
Final Diagnosis
Iron-deficiency anemia
Atopic dermatitis
Case highlights: The case teaches how to conduct a preschool-aged
maintenance visit, including counseling on nutrition, dental health, and behavior
issues. Skills for assessing strabismus are discussed and treatment of atopic
dermatitis is covered.
Key Teaching Points
Knowledge
Atopic diathesis: Each of the following may occur in isolation, but given a
history of one, you should ask questions to determine the presence of the other
conditions:
Eczema
Allergic triggers
Asthma symptoms
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Atopic dermatitis/eczema (the itch that rashes):
Thickening and inflammation of skin
Tends to be familial, but with multifactorial inheritance
Often environmental (allergic) triggers
Anything leading to itching can exacerbate eczema.
Health maintenance visit:
Ensure childs comfort and cooperation.
Gather interval and family history (including maternal depression).
Review immunizations.
Screening:
Tuberculosis (TB):
Assess risk
If there is a risk factor, a purified protein derivative (PPD) should be placed
and read by a medical professional in 48 to 72 hours.
Lead:
Assess risk (mouthing objects, pre-1950s housing, housing near busy
interstate, or recent immigrant)
Anemia:
Typically screened for at 12 months and again at preschool or kindergarten
entry (if there are risk factors, then testing may be done at any visit). The
initial 12-month window coincides with a period in development when diet,
particularly iron sources, is often in flux.
Anticipatory guidance:
Nutrition:
Inadequate vitamin and iron intake due to poor diet: One study found that
preschool-aged children consumed 80% of the recommended fruit
servings/day and 30% of the recommended vegetable servings/day. Many
of the vitamins preschoolers consume come from fortified foods.
Vitamin D: Children should receive vitamin D supplementation, as it is
very difficult to attain the recommended daily allowance through
nutritional sources or from sun exposure.
Iron: A central nervous system co-catalyst, essential for normal
development. Predominant sources in toddlers are meat, legumes,
and iron-fortified cereals.
Excess milk and juice intake:
Diminishes appetite for other foods and results in a diet that lacks
iron.
Can add substantial calories to a diet and contribute to the
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development of early obesity.
AAP recommends only one or two servings of fruit juice a day.
Can result in early dental caries: Recommended discontinuation of the
bottle by age 12 to 15 months.
Exercise:
Numerous studies have demonstrated a positive effect of physical activity
on prevention of obesity.
Dental:
Controversy about when first dental visit should occur:
American Association of Pediatric Dentists (AAPD) and the American
Academy of Pediatricians (AAP) both state that all children should be
seen within six months of the first tooth eruption or by one year of
age.
However, many communities lack pediatric dentists, and many
general dentists feel that the first visit should be at age 3 years.
AAP states additionally that all children should be screened by six
months for risk of caries.
Safety: In the toddler years, overall safety issues become increasingly important
because of the increased independence, inquisitiveness, and motor skills of
preschoolers. Injuries are a major morbidity in the preschool years.The Injury
Prevention Program (TIPP) is a systematic method for pediatricians to counsel
parents and children about adopting behaviors to prevent injuries.
Car seats:
Older than 24 months, or have outgrown height/weight limits on their
car seat, use forward-facing car seat in car's back seat.
Older children stay in a booster seat until they reach a height of 4 feet
9 inches (142 centimeters).
Firearms in the home:
Preferably remove. If cannot, use safety lock, store in locked cabinet,
keep ammunition in separate locked cabinet.
Study showed that 52% of parents who owned guns think their
children are "too smart" or "know better"; also showed that, when
given the opportunity, boys 812 years will handle a gun (76%) and
pull the trigger (48%).
Consider potential suicide risk for teenagers.
Fire safety
Poison control
Car accidents
Risk of lead poisoning
Behavior/temperament:
Temper tantrums
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Toilet training:
Requiring assistance toileting at age 3 years is not a clear sign of
developmental delay, but may preclude attendance at child care or
preschool.
Eating habits:
Food rewards and punishment may promote obesity by interfering
with children's ability to regulate their own food intake.
Developmental surveillance and screening:
Especially important in preschoolers so physician can intervene early if
necessary.
Involves physician observation and parental history.
Parents' Evaluation of Developmental Status (PEDS) is an evidence-based
surveillance and screening tool for children birth to 8 years that elicits and
addresses parents concerns about their childs development, behavior, and
mental health.
Modified Checklist for Autism in Toddlers (M-CHAT) is a validated tool for
screening toddlers between 16 and 30 months of age to assess risk for
autism spectrum disorders (ASD).
General pediatricians do not conduct official developmental assessments but
do practice developmental surveillance and screen for areas of concern
during each visit. However, evidence suggests that developmental
surveillance by itself is not enough to pick up developmental problems.
States are mandated to provide developmental assessments and services
for children < 3 years at risk for developmental delays by experts such as
early interventionists, developmental-behavioral pediatricians, child
psychiatrists, child psychologists, and/or early childhood learning specialists.
For children 3 to 5 years, the school systems provide services to help them
catch up to their peers.
Expected developmental milestones (from AAPs Bright Futures):
3-year-old 4-year-old 5-year-old
Social/
behavioral
Dresses self
Feeds self
Knows gender
and age
Is friendly to
other children
Plays with toys
Engages in
fantasy play
Listens and
attends
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Communication
Speaks in 23
word sentences
75%
understandable
States first and
last names
Sings a song
Most speech
clearly
understandable
Articulates well
Tells a simple
story using full
sentences
Appropriate use
of tenses and
pronouns
Counts to 10
Follows simple
directions
Cognitive
Knows name and
use of cup, ball,
spoon, crayon
Names colors
Aware of gender
Plays board
games
Draws a person
with 3 parts
As children get
ready for
school,
the
developmental
milestones shift
to more
cognitive
processes.
Asking parents
about pre-k
performance is
important.
Physical
development
Builds tower of
68 cubes
Throws a ball
overhand
Rides a tricycle
Copies a circle
Hops on one foot
Balances on one
leg for 2 seconds
Copies a cross
Pours, cuts, and
mashes own
food
Brushes teeth
Balances on
one foot, hops,
and skips
Ties a knot
Mature pencil
grasp
Draws a person
with ! 6 body
parts
Prints some
letters and
numbers
Copies squares
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and triangles
Undresses and
dresses with
minimal
assistance
Skills
History:
Approach child in a way that will ensure his/her comfort and cooperation.
Establish a connection with the family and understand their social dynamics
in order to successfully gather key information and provide anticipatory
guidance at well child checks.
Ask about stresses and family change in a non-threatening way.
Physical exam:
If exam needs to be truncated due to child's behavior, focus on:
Neurodevelopment
Monitoring previously recognized findings
New findings identified by parents
Physical problems common in preschoolers for which intervention can
help
Start with the least invasive parts of the exam (e.g., listen to heart and
lungs), and move on to increasingly invasive ones (ears).
Vital signs
Temperature, heart rate, respiratory rate, blood pressure
Plot height and weight and body mass index (BMI) on growth chart.
HEENT
Mouth:
Caries
Ears:
Middle ear effusions may persist after earlier upper respiratory infection and
affect hearing
Eyes:
Strabismus: Eyes not properly aligned with each other
Hirschberg light reflex: Screening test for strabismus.
Cover tests: Determines presence and amount of ocular deviation.
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Neck
Enlarged thyroid is rare in children.
Shotty (pea or marble-sized, nontender, and easily mobile) nodes in
cervical and inguinal chains are normal in children and may persist for many
years.
Cardiac
Murmurs
Most murmurs will be functional
New murmurs of congenital heart disease are unlikely
Murmurs of atrial septal defect (ASD) sometimes are appreciated only
in older children
Lungs
Yield likely to be low in a healthy child, but may hear subtle wheezing in a
child with history of allergies
Abdomen
Palpate for organomegaly and masses:
Most common: Stool
Occasional: Enlarged kidney
Very rare: Abdominal tumor (Wilms' or neuroblastoma)
Musculoskeletal
Observe for gait variants. In-toeing is most common variant seen at this
age:
Usually due to tibial torsion, with or without femoral anteversion.
Tibial torsion usually spontaneously resolves by age 8 years (often
well before).
Careful history required to rule out potentially treatable causes.
Often walking will strengthen anterior leg muscles and allow
correction.
Persistence has been associated with joint problems later in life.
If in-toeing does not resolve by age 4 years, referral to orthopedic
surgeon may be warranted.
Genitals
Check for hernias.
Use opportunity to teach about who can appropriately examine the child.
Girls at this age may have nonspecific vulval erythema due to
underdeveloped self-hygiene skills.
Neurological
Assess muscle tone, strength, coordination, reflexes.
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Look at overall neurodevelopmental statusachievement of gross and fine
motor skills, language, social skills.
Differential diagnosis
Likely diagnoses
Anemia:
Iron deficiency
Most likely acquired cause of anemia in a 3-year-old child with poor
nutritional intake.
10% of low-income preschoolers have iron-deficiency anemia, versus
7% of other preschoolers.
Unclear whether cognitive problems result from iron deficiency,
anemia itself, or concurrent environmental factors in children at risk
for iron deficiency.
1.
Chronic blood loss
May be caused by food allergies or gluten enteropathy
2.
Lead poisoning 3.
Chronic illness, such as collagen vascular disease, malignancy or other
illness
4.
Hemoglobinopathy
Thalassemia, G6PD deficiency, or sickle cell disease
More commonly found in those of Mediterranean, Asian or African
descent
5.
Less likely diagnoses:
Decreased marrow production (e.g., aplastic anemia), hemolytic anemias, and
vitamin deficiencies (e.g., folate and B6) are rare in children and present with a
more severe anemia (hemoglobin < 9 g/dL).
Rash:
Psoriasis
Can occasionally look like eczema
Rare in children this young
When present, occurs as a generalized rash known as guttate
(droplet-shaped) psoriasis, and usually precipitated by a strep
infection
1.
Seborrheic dermatitis
Unusual to have new case of seborrheic dermatitis at age 3 years, but
should be part of the differential diagnosis, especially in early infancy
(e.g., cradle cap).
2.
Atopic dermatitis (eczema) 3.
Studies
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Anemia screening:
Fingerstick hemoglobin
May be done in the office
Rapid result
Spun hematocrit relies on blood volume and hydration status can
affect result
Normal hemoglobin between 6 months and 6 years is 10.514 g/dL.
Allergy testing:
Radioallergosorbent test (RAST)
Blood test used to determine to which substances a person is allergic
Management
Advice for addressing eating problems:
Jointly discard the bottle in the trash. 1.
Limit eating to three meals and two snacks per day. 2.
If child is thirsty, give her/him water. 3.
No bargaining or cajoling. 4.
Hunger should drive food choices, and only healthy options should be
provided.
5.
Dessert should never be used as an incentive for good eating. 6.
Change diet content by gradually introducing new foods child is likely to try
and slowly decreasing the quantity of old favorites.
7.
Anemia:
Oral iron supplementation: If the anemia is mild, many providers will
provide a trial of iron rather than do further workup. If hemoglobin recovers
to within normal range, that is sufficient evidence of iron-deficiency anemia:
Elemental iron 24 mg/kg divided once or twice daily
Atopic dermatitis:
Lubricate extensively
Anti-inflammatories in short bursts:
Topical hydrocortisone: Alternate a higher concentration for severe
flares with a lower concentration for minor bouts.
Newer topical anti-inflammatories such as calcineurin inhibitors are
effective, but safety concerns with these are not fully resolved.
Anti-histamines to reduce itching:
Newer, non-sedating:
Loratidine (Claritin)
Cetirizine (Zyrtec)
Traditional, with sedative side effects:
Diphenhydramine (Benadryl)
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Hydroxyzine (Atarax, Vistaril)
Treat associated skin infections aggressively.
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