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Overview of the WCC visits from 1 to 2 years of age. Maria I. Diaz, MD St. Barnabas Hospital Department of Pediatrics 7/29/10. Overview. Interval history and anticipatory guidance: Diet Elimination Sleep Dentition Development and behavior Injury prevention Physical Exam.

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Overview of the wcc visits from 1 to 2 years of age

Overview of the WCC visits from 1 to 2 years of age

Maria I. Diaz, MD

St. Barnabas Hospital

Department of Pediatrics

7/29/10


Overview
Overview

  • Interval history and anticipatory guidance:

    Diet

    Elimination

    Sleep

    Dentition

    Development and behavior

    Injury prevention

  • Physical Exam.

  • Immunizations.

  • Screening.

  • Questions



DIET

Amount and frequency of feedings:

Three meals and two nutritious snacks per day. Include infant in family meals.

Table vs Baby foods, including types:

Continue to introduce table foods in amount and variety. Fruits and Vegetables daily. Fe rich food. No peanuts, popcorn, hot dogs, candy, no bones.


DIET

Whole milk intake:

Limit intake to 24 oz/day.

Juice intake:

Limit juice intake (4-6oz/day), encourage water.

Offer drinks in a cup; wean bottle.

Appetite/food refusal:

Advise appetite may vary and weight gain may slow down.

Avoid food battles. Resist offering food to console or reward.


Elimination
Elimination

Stools:

Frequency and consistency of stools may change.

Discuss what constitutes constipation.

Urine:

At least 3-4 wet diapers a day.

May discuss readiness for potty training-

may be too early.


Sleep patterns
Sleep Patterns

Sleep schedule, including naps:

Maintain bedtime routine

Is the child waking up at night? Why?

?Teething, night terrors, hungry.

Delay entry to room; reassurance without picking infant up.


Dentition
Dentition

  • How many teeth so far?


Dentition1
Dentition

Ensure regular dental visits.

Don’t let infant sleep with bottle/pacifier in mouth.

Does the child let you brush teeth?

Use non-fluoride toothpaste or wipe teeth or toothbrush with water


Development and behavior
Development and Behavior

Surveillance

  • 12 m/o

  • 15 m/o

  • 18 m/o  M-CHAT

  • 24 m/o


Development and behavior1
Development and Behavior

  • First steps, a developmental

    milestone most babies reach

    between 11 and 15 months.


Development and behavior2
Development and Behavior

  • Picks up pellet with

    unassisted pincer

    movement of forefinger

    and thumb by 1 y.


Development and behavior by 1 y
Development and Behavior by 1 y

  • A few words besides

    “mama”, “dada”.

  • Plays simple ball game


Development and behavior3
Development and Behavior

  • Waving bye-bye,

    a developmental milestone

    that most babies can reach

    once they are 7 to 14 months


Developmental health watch by 1y age
DEVELOPMENTAL HEALTH WATCH by 1y/age

  • If a child displays any of the following signs

  • he or she should be referred.

  • Does not crawl

  • Cannot stand when supported

  • Does not search for objects that are hidden

  • while he watches.

  • Says no single words ("mama" or "dada")

  • Does not learn to use gestures, such as waving or shaking head

  • Does not point to pictures or objects


Development and behavior4
Development and Behavior

  • Pretend play, or imitating

    activities, developmental

    milestone that most

    infants reach when they

    are about 10 to 16 months

    old


Development and behavior by 15 m
Development and Behavior by 15 m

  • Walks alone;

    crawls up stairs

  • Makes tower

    of 3 cubes


Development and behavior by 15 m1
Development and Behavior by 15 m

  • Indicates some desires

    or needs by pointing;

    hugs parents.


Development and behavior by 18 m
Development and Behavior by 18 m

  • Walks up stair with

    one hand held;

    explores drawers

    and wastebaskets.


Development and behavior by 18 m1
Development and Behavior by 18 m

  • 10 words (average);

    names pictures;

    identifies one or more

    parts of the body.


Development and behavior by 18 m2
Development and Behavior by 18 m

  • By 18 months, you might be thinking of temper tantrums and the terrible twos, but this is also a very fun time with your kids


Development and behavior by 2 y
Development and Behavior by 2 y

  • Runs well, walks up and down the stairs, one step at a time; opens doors.

  • Tower of 7 cubes; circular scribbling; imitates horizontal strokes.


Development and behavior by 2 y1
Development and Behavior by 2 y

  • Listens to stories with

    pictures.


Development and behavior by 2 y2
Development and Behavior by 2 y

  • Vocabulary grows to

    more than 50 words

    and they begin to put

    words together.


Development and behavior by 2 y3
Development and Behavior by 2 y

  • Parallel play, typical of most kids around age two


Developmental health watch
DEVELOPMENTAL HEALTH WATCH

  • If a child displays any of the following signs they should be referred:

  • Cannot walk by 18 months

  • Walks exclusively on toes

  • Does not speak 15 words by 18 months

  • Does not use two-word sentences by age 2

  • Does not follow simple instructions by age 2


Injury prevention
Injury Prevention

  • Do not leave child unattended-EVER.

  • Monitor siblings around child.

  • Monitor child’s behavior around pets.


Injury prevention1
Injury Prevention

Car seat:

Forward-facing

car seat used in back

(if child > 20 pounds).


Injury prevention2

Issues

Baby proof home?

Anticipatory Guidance

Window guards, safety plugs, cabinet clips, gates.

Tie up dangling cords.

Safe play zone in home.

Keep small or sharp objects out of child’s reach, including cigarettes, matches, lighters.

Injury Prevention


Injury prevention3

Issues

Baby proof home?

Anticipatory Guidance

Water safety in bathtubs, pools, check water temperature. Keep buckets, bathtubs empty after use.

Injury Prevention


Injury prevention4
Injury Prevention

Don’t cook/hold hot

liquids while holding

infant. Don’t leave hot

items unattended in

areas accessible to infant.



Injury prevention6

Issues

Baby proof home?

Anticipatory Guidance

Keep poisonous substances, medicines, cleansers, etc. out of child’s reach.

Keep all products in their original containers, safety caps on at all times.

Poison control number should be accessible.

Injury Prevention


Physical exam
Physical Exam

  • Height, weight and head circumference parameters.

  • General: overall; observe for developmental milestones.

  • HEENT: Check dentition.

  • CV: Heart murmurs.

  • Abd: Hernias, masses.

  • Ext: In toeing / tibia torsion, bowed legs, toe-walking.

  • Skin: rashes, neuro stigmata.

  • Neuro: Tone.


Immunizations

12 m/o

15 m/o

18 m/o

24 m/o

See schedule.

Immunizations


Screening

Issues

Anemia screening.

Lead screening.

Tuberculosis screening.

Anticipatory Guidance

Iron rich foods.

Lead safety tips.

Risk factors.

Screening


Follow up next wc visit
Follow up: next WC visit

  • 12 m  3 m

  • 15 m  3 m

  • 18 m  3-6 m

    Earlier f/u visit if medically or socially indicated.



Physical examination results are normal for a 2-year-old girl during a health supervision visit. She follows two-step commands, speaks 10 words, points to pictures that you name, and sorts objects by color. She uses a spoon well, but does not use a fork. She plays alongside other children but does not share toys. Her mother would like to know if she should be concerned about the girl's development. Of the following, your BEST response is that her daughter:

  • Has normal development

  • Is delayed in her expressive language skills

  • Is delayed in her fine motor skills

  • Likely has a hearing impairment

  • Needs more social interaction with other children


Physical examination results are normal for a 2-year-old girl during a

health supervision visit. She follows two-step commands, speaks 10 words,

points to pictures that you name, and sorts objects by color. She uses a

spoon well, but does not use a fork. She plays alongside other children but

does not share toys. Her mother would like to know if she should be

concerned about the girl's development. Of the following, your BEST response is that her daughter:

  • Has normal development

  • Is delayed in her expressive language skills

  • Is delayed in her fine motor skills

  • Likely has a hearing impairment

  • Needs more social interaction with other children


You are seeing a 1 y/o patient in your clinic for a health supervision visit.

You explain the recommended screening tests for this visit to the medical

student who accompanies you.

Of the following, the MOST appropriate recommended screening test at

this visit is:

  • Blood lead concentration by fingerstick

  • Blood lead concentration by venipuncture

  • Complete blood count with differential count

  • Serum ferritin

  • Serum iron


You are seeing a 1 y/o patient in your clinic for a health supervision visit.

You explain the recommended screening tests for this visit to the medical

student who accompanies you.

Of the following, the MOST appropriate recommended screening test at

this visit is:

  • Blood lead concentration by fingerstick

  • Blood lead concentration by venipuncture

  • Complete blood count with differential count

  • Serum ferritin

  • Serum iron


The mother of a 2-year-old girl is very concerned that her supervision visit.

daughter is developmentally delayed. She explains that the

girl speaks in two- to three-word phrases. She can feed

herself with a spoon, but is unable to button her clothing.

She can follow simple two-step commands and can climb

stairs. However, she is not yet toilet trained. Findings on

physical examination are unremarkable.

Of the following, you are MOST likely to:

1. Discuss the normal developmental milestones of a 2-year-old child

2. Refer the child for a neuro-developmental evaluation

3. Refer the child for audiologic evaluation

4. Refer the child for occupational therapy

5. Schedule a 6-month follow-up evaluation to see if the child has reached the milestones


The mother of a 2-year-old girl is very concerned that her supervision visit.

daughter is developmentally delayed. She explains that the

girl speaks in two- to three-word phrases. She can feed

herself with a spoon, but is unable to button her clothing.

She can follow simple two-step commands and can climb

stairs. However, she is not yet toilet trained. Findings on

physical examination are unremarkable.Of the following, you are MOST likely to:

1. Discuss the normal developmental milestones of a 2-year-old child

2. Refer the child for a neuro-developmental evaluation

3. Refer the child for audiologic evaluation

4. Refer the child for occupational therapy

5. Schedule a 6-month follow-up evaluation to see if the child has reached the milestones


  • One of your 2-year-old patients has prolonged crying and supervision visit.

  • screaming episodes every time her parents deny her access to

  • something she desires. The mother reports that the girl often

  • throws herself on the floor, kicking and thrashing about for long

  • periods of time. She asks you how she should handle her

  • daughter's behavior.

  • Of the following, your BEST suggestion is that the parents should:

  • 1. Consider giving in to the girl only when she is outside of the home to avoid a major tantrum

  • 2. Give the daughter 10 minutes of time-out for each temper tantrum

  • 3. Move the girl to a safe place if needed and ignore her when she has a tantrum

  • 4. Offer the child a treat if she calms down

  • 5. Physically restrain the child until the tantrum is over


One of your 2-year-old patients has prolonged crying and screaming

episodes every time her parents deny her access to something she desires.

The mother reports that the girl often throws herself on the floor, kicking

and thrashing about for long periods of time. She asks you how she should

handle her daughter's behavior.

Of the following, your BEST suggestion is that the parents should:

1. Consider giving in to the girl only when she is outside of the home to avoid a major tantrum

2. Give the daughter 10 minutes of time-out for each temper tantrum

3. Move the girl to a safe place if needed and ignore her when she has a tantrum

4. Offer the child a treat if she calms down

5. Physically restrain the child until the tantrum is over


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