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Well Care Examinations for pediatrics: growth and development of babies, children and adolescents . Debbie King RN, MSN FNP, PNP, APRN. Communication in primary care pediatrics . Professional interaction, sensitive yet nonjudgmental. Include parent and child.

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well care examinations for pediatrics growth and development of babies children and adolescents

Well Care Examinations for pediatrics: growth and development of babies, children and adolescents

Debbie King RN, MSN

FNP, PNP, APRN

communication in primary care pediatrics
Communication in primary care pediatrics
  • Professional interaction, sensitive yet nonjudgmental. Include parent and child.
  • Common courtesies count. Socialize.
  • Start interview with open ended questions, build rapport. Repeat important phrases.
  • Use close ended questions for clarification.
  • Limit medical jargon, be aware of body language and “guide the interview”.
  • Empathize and acknowledge parental concerns.
  • Recognize personal limitations
  • Summarize the interview
talking to parents
Talking to Parents
  • EFFECTIVE COMMUNICATION IS THE KEY.
  • OBSERVE INTERACTION BETWEEN PARENT AND CHILD.
  • ASSESS FAMILY DYNAMICS.
  • ADDRESS PARENTAL CONCERNS IN A NONJUDGEMENTAL MANNER.
talking to parents4
Talking to Parents
  • ESTABLISHMENT OF LONG TERM RELATIONSHIPS.
  • PRIMARY CARE GIVERS ROLE IS MULTIDEMENSIONAL.
  • IMPORTANT TO ADDRESS THE NONMEDICAL AND PSYCHOSOCIAL CONCERNS OF PARENTS.
  • ADDRESS PARENTAL FEARS.
  • ALLOW OPPORTUNITY FOR QUESTIONS.
normal newborn and infant development
Normal newborn and infant development
  • Influenced by biological and environmental factors.
  • Primitive reflexes are present from birth until 6 months. Suppression related to normal development and/or reappearance could indicate brain damage.

Moro Reflex- allowing infants head to drop back. Disappears by 4 mos.

Rooting Reflex and Sucking Reflex

Palmer or Grasp Reflex-Disappears 3mos.

Stepping Reflex-disappears 2mos.

  • Tonic Neck Reflex-(fencer) Disappears 3mos
new born visits 3 days old
New Born Visits (~3 days old)
  • Introduction
  • Congratulations
  • Other children
  • Pre-natal
  • Due date
newborn visit
Newborn visit
  • Type of delivery
  • Birth weight
  • Discharge weight and age
  • Hearing test
  • GBS status
  • Mother and Baby blood types
newborn visit8
Newborn visit
  • PKU
  • Hepatitis B #1
  • Bilirubin –ordered stat as needed
  • Circumcision-research contends “reduced risk of HIV in circumcised males”
  • Diet
  • Breast/bottle
new parent education
New Parent Education
  • Provide verbal and written information
    • Feeding
    • Schedule
    • BF support
    • Positioning of the newborn
    • Safety
    • Illness
new parent education10
New parent education
  • Exposure-limit visitors and outings
  • BM’s- vary with babies
  • Hick-ups- are frequent
  • Sneezing-normal and frequent
  • Congestion-off and on and is normal
new parent education11
New parent education
  • Dressing/layers- do not overdress
  • Siblings
  • Car seat
  • Finger nails- file only for 6 weeks
new parent education12
New parent education
  • Cord care- there is none
  • Smoking-avoid exposure
  • Sun-not directly, can use sun-block
  • Oral Needs- Gums and Pacifier-new research contends “pacifier use for all sleep periods is necessary to prevent SIDS”
new parent education13
New parent education
  • Illness protocols
  • Office procedures with calls
  • When to call
  • Recheck schedule- varies
general info
General info
  • Average weight 7 lb
  • Average length 20-21 inches
  • Normal average weight loss is 10% in first 3-4 days
  • Normal- is to regain back to birth weight by 14 days
general info15
General info
  • Weight doubles by 4 months
  • Weight triples by one year
  • Weight quadruples by two years
  • Normal weight gain is 6-8 oz per week for 6 months
  • Normal weight gain is 3-4 oz per week from 6-12 months
  • Normal weight gain 1-2 years old is 8-9 oz per month
slide16
FYI
  • Theories are important in practice to help you know “normals”
  • They will be on boards (only a few pediatric theorist questions)
  • Should self study
    • Erikson
    • Mahler
    • Skinner
    • Maslow
    • Kohlberg
    • Piaget
    • Roy
breast feeding
Breast Feeding
  • Breast milk or iron fortified infant formulas provides complete nutrition for infants first 4-6 months of life.
  • First 1-2 months, 2-3 ounces of formula or 10 minutes on each breast q 2-3 hours.
  • Breast milk digests 1 ½ hr, formula digests up to 4 hers. Breast-fed infants feed 8-12 times per 24 period compared to formula fed infants at 6-8 times per 24 hr period.
  • Mother’s milk (colostrum 7-10 days) is high in protein, immunoglobulins and secretory IgA. Allergy and infection protective.
  • Breast feeding is the recommended method of feeding.
exam of newborn importance of clinical experience
Exam Of Newborn - Importance of Clinical Experience
  • General
    • hydration
  • Skin- Color- Birth marks
    • If highly abnormal consider neuro consult
  • Head- Shape- Size
  • Eyes- red reflex- alignment
    • crossing
  • ENT- ear placement
    • If abnormal check kidneys
newborn
Newborn
  • Mouth- palate
  • Chest/heart-
    • ~140- ?murmur
    • tachypnea
    • poor feeding
    • cool lower ext- ?COA
    • pulses
  • Lungs/resp- ~30-60
  • Abdomen- cord
  • GU- Open, rectum
newborn20
Newborn
  • Musculoskeletal- hips
    • Tone
  • Neuro- (reflexes) startle, tone, grasp,

rooting, sucking, gag, crying

symmetry of movement

2 week visit
2 Week Visit
  • Birth weight
  • Weight today-should be back to BW
  • Age of discharge-
    • If this is first visit
      • Do all of the first visit as well
  • Diet
  • Color
  • Advise parents not use any medications
2 week visit22
2 Week Visit
  • Circumcision
  • PKU
  • Address concerns of parents
  • Exam- 2 week is Repeat of New Born exam
1 month visit
1 Month Visit
  • Temperature
  • Height
  • Weight
  • HC
  • Percentiles- Know how to ‘plot’ yourself
1 month visit24
1 Month Visit
  • Diet- Vitamins A,C,D for babies BF only
  • Startles
  • Lifts head holds erect
  • Focus
  • Head support
1 month visit25
1 Month Visit
  • Hands fisted
  • Eyes- sees short distance, may cross off and on, follows to mid line, may seem to look just by or over you
  • Sleep-still pretty irregular
  • Personality- fussy vs. happy
1 month visit26
1 Month Visit
  • Spitting- amounts
  • Sneezing/ congested
  • Grunting
  • Only sleeps, eats, and poos
  • Colic
    • May be noted around this age
1 month visit27
1 Month Visit
  • Medication not to be used this early
  • Safety
  • 1 month exam
    • Same as New Born

-Summarize

Hep B #2 today

-Warn- more immunizations at 2 months

2 month visit
2 Month Visit
  • Temperature
  • Height
  • Weight
  • HC
  • Percentiles-
    • no pattern yet
2 month visit29
2 Month Visit
  • Smiles
  • Coos
  • Focus and follow
  • Tone- increased head control
  • Diet-
    • vitamins if breast fed
    • no solids
2 month visit30
2 Month Visit
  • Cuddle, eye contact, play
  • Increase tummy time
  • Position
    • Torticollis is common problem and may be avoided in many babies
  • Intake amount
  • elimination
  • 2 month exam- Same as New Born
  • Still no medications
4 month visit
4 Month Visit
  • Temperature
  • Height
  • Weight
  • HC
  • Percentiles- 3 is a pattern
4 month visit32
4 Month Visit
  • Diet- BF, formula
  • Laughs, ah-goo
  • Reaches may start to bring to mouth
  • May start to transfer hand to hand
  • Rolls- front to back
  • Sleep- longer at night
  • Intake and elimination
  • Still no medicines are recommended
4 month visit33
4 Month Visit
  • Self Soothes
  • Increase tummy time
  • Review safety- car seats, toys
  • Activities- ex. Johnny Jump Up
  • 4 month exam- same as New Born

extra focus on tone and strength

encourage team work of parents

Follow up on previous visits

past concerns ex; constipation, not sleeping much

past unmet milestones

If first visit gather all info that was needed at all previous visits.

solids
Solids
  • Solid foods introduced at 6 months (weight twice of birth weight or 13lbs, consumption of 32oz of formula q day, frequent feeding > 8-10 times per day.
  • Iron fortified cereal (rice) is introduced.
  • Fruits and veggies within a few weeks and meats introduced at 6-9 months.
  • Order in not important, but only add 1-2 new foods per week.
  • Careful of excessive juice intake = Diarrhea and/or feeling full
    • 2 ounces of juice per day per the AAP.
  • Weaning from breast/bottle to cup 6-18 months. Homogenized milk at 12 months. Skim or 2% not before 2 years.
6 month visit
6 Month Visit
  • Temperature
  • Height
  • Weight
  • HC
  • Percentiles
6 month visit36
6 Month Visit
  • Diet- start solids, so less liquids

- finger foods, new research contends “that meat be included in the food package for breast-fed infants at 6 months”

one new food every 3 days

  • Reaches, grasps, racks
  • Transfers hand to hand well
  • Sits alone or almost
  • Rolls both ways
  • Set schedule- eating, sleep
6 month visit37
6 Month Visit
  • Knows name
  • Babbles
  • Encourage crawling
  • Vocalizes
  • Safety! Child proof
  • Teeth
  • Intake and elimination
  • May use Tylenol for pain or fever. Motrin is now approved down to six months. No other OTC meds approved
6 month visit38
6 Month Visit
  • 6 month Exam

-Same as all past with focus on

-Strength -Standing

-Socializing with provider

-Add Fluoride-if on well water

-Summarize -Encourage

9 month visit
9 Month Visit
  • Temperature
  • Height
  • Weight
  • HC
  • Percentiles
9 month visit40
9 Month Visit
  • Diet- more table food, cup, self feed
  • Schedule- toddler like
  • Safety- add poison control
  • Encourage mobility- crawling
    • Should have started at 7 to 8 months
  • Pulling up
  • Beginning good pincer skills
9 month visit41
9 Month Visit
  • Cruising
  • Stands alone
  • Responds to name
  • Understands no, bye
    • Parents may begin saying no and removing from unacceptable places, ECT
    • May begin to respond to one step commands
9 month visit42
9 Month Visit
  • Babbles more-
    • Starts about 8 months mama, dada- just sounds
  • Same PE
  • Intake and elimination
  • Order/evaluate- HGB
  • Summarize
  • Next exam at 12 months
  • Advise may see increase illness with increase in mobility
12 month visit
12 Month Visit
  • Height
  • Weight
  • HC
  • Temperature
  • Percentiles (Triple BW)
12 month visit44
12 Month Visit
  • Diet- all table food

-except shell fish and honey

-start whole milk, cup, self feed

  • Sleep- schedule
  • Continue to encourage

-verbalizing, mobility, walking

12 month visit45
12 Month Visit
  • Says mama and dada with meaning
  • 3 to 5 words
  • Waves
  • Good pincer grasp
  • Begins pointing
  • Temper tantrums
  • Plays games
  • Follows one step command
  • May be walking now (by 14 mo.)
12 month visit46
12 Month Visit
  • Loves books and outside
  • Safety is more important
  • Car seat-24 months and 20 lbs. to face forward
  • Teeth-just water and tooth brush
12 month visit47
12 Month Visit
  • Follows one step command
  • Stoops and recovers
  • Imitates
  • T.B./ lead questionnaires for exposure
12 month visit48
12 Month Visit
  • 12 month exam

-head to toe

- More difficult

-Be creative, playful

-May notice hand preference soon, yet could be as late as 5 years for set handedness

-testicles- should be down

12 month visit49
12 Month Visit

-hydrocele- gone

-summarize this visit and growth and development since birth, seeing that areas have been covered and documented

-Choose care givers carefully (baby-sitters)

-Next visit 15 month and all basic vaccines will be completed except Hep A

15 month visit
15 Month Visit
  • Height
  • Weight
  • HC
  • Temperature
  • Percentile
15 month visit51
15 Month Visit
  • Diet- same as 15 month

- avoid juice trap, no juice is needed

  • Schedule
  • Walks well, even backward
  • Climbs
  • Knows some body parts
  • Stacks 2 blocks
15 month visit52
15 Month Visit
  • Behavior- big issue
  • Books/ music
  • 1 hr TV only or none or baby videos
  • Follow directions
  • Few words 7-10
15 month visit53
15 Month Visit
  • 15 month exam

- head to toe

- very difficult to do with this age

- heart first

- mouth last

- observe walking forward and backward

15 month visit54
15 Month Visit
  • - FYI intoeing is normal until age 7
  • Summarize
  • Encourage parents
  • Next visit at 18 month with focus on development
18 month visit
18 month visit
  • Same growth evaluation
  • Diet- no battles!
  • Sleep- constant schedule
  • Safety- ex. Lead exposure
  • Development- important issue now

-can see signs of autism

In a prospective study by the high risk siblings research consortium, Dr. Zwaigenbaum suggests that head growth accelerates over the first two years of life in children with autism.

18 month visit56
18 month visit
  • Expected milestones:

- 2 word combos starting

- Builds tower of 3 to 4 blocks

- scribbles

-throws ball

-runs

-climbs (even stairs with help)

-sustains eye contact

18 month visit57
18 month visit

-enjoys being bounced/swung

-interested in other children

-play hide and seek

-pretends

-points with index finger

-plays appropriately with toys

-follows two step command

18 month visit58
18 month visit

-stacks 3-4 blocks

-4 to 20 word vocab

-listens to stories

-names objects

-scribbles

-shows affection- kisses

18 month exam
18 month exam
  • Head to toe
  • May still be difficult
  • Not all bruises are abuse
  • Encourage parents
  • Foster independence
18 month exam60
18 month exam
  • Wash own hands
  • Pick up toys
  • Remind some decrease in eating is nl
  • Advise parents to call as needed
  • Next check up is at 2 years
developmental delay
Developmental Delay
  • Delays in reaching milestones is serious
    • May educate parents to ‘practice’ with baby or toddler and reassess in a month
    • If still delayed refer ASAP
      • Early intervention is the key to reaching as much potential as possible
general info62
General info
  • Growth slows from 2-6 years
  • Normal growth is about 3 inches per year
  • Normal weight gain is about 4.5 lbs. per year
  • An average 6 year old is about 46 lbs. and 46 inches
2 year visit
2 year visit
  • Repeat of 18 month exam
  • If new pt review milestones
    • Make sure all past milestones have been met!
  • Now should be able to
    • Build tower with 6-7 blocks
    • Jumps with two feet of the floor
    • Uses pronouns
    • Kicks a ball
    • Has 2-5 word combos
    • Copies a line

Still measure on infant scale for height and weight and plot on infant growth chart

2 year visit64
2 year visit
  • Usually more cooperative
  • Advice on

-toileting- may be able to verbalize needs

‘Wait’ is my advise

slide65
FYI
  • FYI
    • immunization- know schedule
    • head circumference
      • Macrocephaly- too large
      • Microcephaly- too small
      • Plagiocephaly- abnormal shape
    • Torticollis –head tilted due to tight neck muscles

Know what to do- for each DX

slide66
FYI
  • Day care
    • Assess plans at every visit
    • DWP illness-expectation
    • Biting
teething formation begins 3 rd fetal month ends in adolescence
Teething(formation begins 3rd fetal month, ends in adolescence)
  • Central incisors upper 6-8 months, lower 5-7 months
  • Lateral incisors upper 8-11 mo., lower 7-10 mo.
  • Cuspids upper and lower 16-20 mo.
  • First molars upper and lower 10-16 mo.
  • Second molars upper and lower 20-30 months
slide68
FYI
  • Refer to Harriet Lane for all normals on
    • Respirations - based on age
    • Blood pressures - based on age and size
    • Heart rates - based on age

may be helpful to keep charts in exam rooms

talking to children
Talking to Children
  • SIZING EACH OTHER UP
  • KIDS HAVE DIFFERENT CONCERNS
  • AGE APPROPRIATE
  • CAUTION: NONVERBAL CUES
  • CHILD FRIENDLY ENVIROMENT
  • LET CHILD PARTICIPATE
  • AVOID POWER CONTROL
3 year visit
3 year visit
  • Add vision screen
  • Stands for height and weight
    • Need to switch to a standing growth chart
  • No HC on normal child
    • There is no place to chart on standing chart, but may use the infant chart if needed
  • Add BP
  • Chart on proper growth chart!
3 year visit71
3 year visit
  • Assess BMI
  • TB questionnaire
  • Pre-school?
  • Verbal skills- 90% understood by strangers
  • Knows colors
  • Gives first and last name
3 year visit72
3 year visit
  • Count 1-10
  • Copies a circle
  • Pedals tricycle
  • Walks up stairs
  • Knows gender
  • Friends
  • Dresses with help
3 year visit73
3 year visit
  • 3 year exam
  • Head to toe- may still have round tummy
  • Advise parents
    • Stool holding is common
    • Stuttering is common
    • Time outs should be for 3 minutes
      • But parent may need to adjust to be in control
    • Encourage more playtime and reading
4 and 5 well care
4 and 5 Well-care
  • Height
  • Weight
  • Temperature
  • Percentiles
  • UA- age 5 and then PRN in future
  • Hearing, vision
4 and 5 well care75
4 and 5 Well-care
  • 4 year milestones
    • Stacks 10 blocks
    • Throws overhand
    • Walks down stairs
    • Runs with out losing balance
    • Sings, draws
    • Knows real vs. fiction
    • Talks about day/life
    • Knows gender
    • 100% understandable
4 and 5 well care76
4 and 5 Well-care
  • 5 year milestones
    • Skips
    • Rides bike
    • Counts on fingers
    • Draws shapes
    • Draws a head, two extremities and eyes
      • But no body yet
    • Prints some letters
4 and 5 well care77
4 and 5 Well-care
  • Dresses alone except tying
  • Self care with toileting
    • Except maybe wiping
  • Knows ABC and colors
  • Knows about strangers
  • Knows about secrets
  • Gives appropriate answers
    • What do you do if you are hungry?
4 and 5 well care78
4 and 5 Well-care
  • Exam 4 and 5 year

-head to toe exam

-add cranial nerve exam –know how!

-add walk on toes and heels

-jumps

-check spine

4 and 5 well care79
4 and 5 Well-care
  • Remember! At All check ups review:

-seatbelt -teeth

-school -safety

-sun block -diet

-elimination -strangers

-sleep -sports

-behavior -TV time!!- increase in education of limited time spent here

-friends -chores

personal and social skills summary
Personal and Social skills summary
  • Indiscriminate social smile at 2-3 months.
  • Discriminate social smile at 6 months.
  • Stranger anxiety begins at 7 months and peaks at 12 months.
  • Separation anxiety begins between 8-9 months and peaks around 14 months.
  • Peek-a-boo is a big hit at 7 months.
  • Drinks from a cup at 12 months.
  • Uses a spoon at 15-18 months.
  • Washes/dries hands at 2 years.
  • Uses a spoon well, buttons at 3 years.
  • Washes/dries face at 4 years.
  • Dresses without assistance at 5 years
school age 6 10
School age 6-10
  • Height
  • Weight
  • Temperature
  • Percentile
  • BP
  • BMI
school age 6 1082
School age 6-10
  • Development 6-10
    • Varies
    • Refer to current pediatric diagnosis and treatment and to Uphold and Graham
  • Age 9-10
    • Begin tanner assessment
    • Assess preparation for puberty
summary of skills
Summary of skills

Fine motor Skills

Gross motor Skills

Good head control in 2-3 months.

Rolls front to back in 4-5months.

Rolls back to front in 5-6 months.

Sits alone 5-6 mos.

Crawls 7-8 months

Pulls to stand 9-10 m

Walks forward12-14m

Walks backward 14-16

Walks up stairs 3yr

Walks down stairs 4 yr.

Skips 5 yrs.

Grasp/shake rattle 2-3m

Reach for object 3-4m

Rakes 4-6 months

Hand transfer 4-6 months

Pincer 9-12 months

Stack 2 blocks 14 months

Copies line 2yrs.

Copies circle 3 yrs.

Draws person 3 parts 5 yr.

Draws person 6 parts 6 yrs.

language development
Language Development
  • Normal hearing is essential speech/language development.
  • Important developmental milestone.
  • Children with suspected delays should be referred ASAP.
  • Look for lack for response to sound at any age, failure to achieve language skills, and parental concerns.
  • Vocalizing does not preclude a hearing loss.
  • Language skills are either receptive or expressive.
paiget s stages of development
Paiget’s Stages of Development
  • Sensorimotor – (birth-2 years). Children approach the world through sensations and motor actions. Develop object permanence, spatial relationships, and causality.
  • Preoperational – (2-6 years).Mental processes are liked to their own perception of reality. No separation of internal and external reality.
  • Concrete operational – (6-11years). Can perform mental operations if it relates to real objects. Concept of mass, volume, number.
  • Formal Operations – (>11 years). Develop the capacity for abstract thought.
fyi obesity
FYI: Obesity
  • Screen thyroid
  • Screen lipid
  • Screen metabolic panel
  • With increased lipids-refer to cardiology
  • screen fasting insulin
  • With or without increased insulin-refer to endo
  • Refer all to nutritionist
fyi obesity87
FYI: Obesity

Encourage sport participation

Re-check height, weight in 3 months

research shows the only true way to correct obesity in children is to prevent it.

general info88
General info
  • Average school age child gains about 5 lbs. and 2.5 inches per year
  • Average 10 year old is 70 lbs. and 54 inches
well care 11 13 years
Well Care 11-13 years
  • Height
  • Weight
  • Temperature
  • Percentiles
  • BP
  • BMI
well care 11 13 years90
Well Care 11-13 years
  • Medications
  • Parental concerns
  • Sports concerns
  • *HEEADSSS
  • Teen health history
    • See text
  • *Adolescent questionnaires review together
headss the review of systems for adolescents
HEADSS: The "Review of Systems" for Adolescents
  • 1]. HEADSS is an acronym for the topics that the physician wants to be sure to cover: home, education (ie, school), activities/employment, drugs, suicidality, and sex. Recently the HEADSS assessment was expanded to HEEADSSS [2] to include questions about eating and safety
well care 11 13 years92
Well Care 11-13 years
  • Confidentiality!
  • P.E.
    • Head to toe
    • Be considerate
adolescence
Adolescence
  • The period of life beginning with puberty and extending for an average of 8-10 years.
  • Puberty focuses on physical changes resulting in the ability to reproduce.
  • Mean age for the initiation of puberty is 11.2 years but may range from 9.0 to 13.4.
  • Females typically reach adolescence 2 years earlier than males.
adolescence94
Adolescence
  • During adolescence, a teenager’s weight doubles, and height increases 15-20%.
  • During puberty, major organs double in size, lymphoid tissue decreases in mass.
  • Musculature increases in size and strength.
  • Boys attain greater strength and mass continues into late puberty.
  • Motor coordination lags behind in growth and stature and musculature but improves.
talking to adolescence s
Talking to Adolescence’s
  • Unique challenges IE: physical awkwardness, emotional turmoil, and social isolation, labeled difficult.
  • Provider needs to use a different approach.
  • “Information must come from adolescent.”
  • Be prepared for overbearing parents.
  • 3 stages of adolescents: early 11-13, middle 14-16, late 16-18. Taylor exam.
  • Discuss confidentiality. Exceptions are suicidal or homicidal behavior, sexual or physical abuse. Treatment of STD’S.
growth and development of puberty
Growth and Development of Puberty
  • Physical changes of puberty include:
    • Growth spurts
    • Development of secondary sexual characteristics
    • Maturation of genital organs
    • Onset of menstruation for girls
male growth spurts
Male Growth Spurts
  • Height spurt beings at age 11. Reach peak height velocity 13 ½ to 14yrs.
  • Boys increase the quantity of body fat before beginning their height spurt.
  • They lose fat until the growth spurt has finished and gradually again increase fat.
  • 1st sign of puberty begins around 10 and 12 marked by scrotal and testicular growth.
  • Pubic hair can occur any time between ages 10 and 15.
slide98
Boys
  • Penis grows significantly a year or so after the onset of testicular and pubic hair(10-13).
  • 1st ejaculation is a notable event, occurring 1 year after initiation of testicular growth.
  • 90% of boys have this event between 11-15.
  • Gynecomastia occurs in a majority of boys. Usually disappears within 2 years.
  • Pubertal development may not be completed until age 18.
slide99
Boys
  • Height velocity is higher in males(8-11cm) than in females(6 ½ -9 ½cm) per year.
  • Axillary hair, deepening of the voice, and the development of chest hair occurs in mid puberty, about 2 years after onset of growth of pubic hair.
  • Facial and body hair begin to increase at ages 16-17.
female adolescents
Female Adolescents
  • Onset of growth spurt is between 8-17.
  • Mean age for peak height velocity growth is 12 years.
  • Average duration of growth spurt is 3 years.
  • Females grow 2½-5 inches in height per year and gain 8-20 lbs.
  • Increase in height may lead to poor posture.
  • Pelvis grows and becomes shapely.
  • Increase of adipose tissue from 15-27%.
secondary sex characteristics
Secondary Sex Characteristics
  • Thelarche (breast development)
    • Stimulated by estrogen
    • Breast size varies and asymmetry is common
    • Development of a breast bud from glandular tissue
    • Areola widens and eventually elevates from the chest wall
    • Mature breast is characterized by the protrusion of the nipple
secondary sex characteristics102
Secondary Sex Characteristics
  • Adrenarche (pubic hair growth)
    • Concurrent with breast development, or a little later in most girls
    • Initial growth is slightly pigmented and straight
    • Starts off with fine growth on the labia majora
    • Quantity of hair increases and distribution spreads from the labia to the mons veris
    • Texture becomes coarser, curlier, and darker
    • Final stage established in about 2 yrs. with typical female triangular distribution with a horizontal upper border
tanner staging
Tanner Staging
  • Breast Development or “Thelarche”
  • Pubic Hair Development or “Adrenarche or Pubarche”
  • Male Genital Development
external and internal genitalia
External and Internal Genitalia
  • Labia major, mons veris and symphysis pubis develop as fat is deposited.
  • As a result of increase in fat, the labia majora fall inward and obscure the labia minora.
  • Clitoris becomes larger and more erectile and the entire introitus appears larger.
  • Estrogen causes vaginal lining to transform into think stratified squamous epithelial cells containing glycogen.
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External and Internal Genitalia
  • Thickness of vaginal lining varies with cyclic circulating levels of hormones.
  • Vaginal secretions result from decrease hormone stimulation.
  • Leukorrhea(white mucoid discharge) often precedes menarche by approx. 1 year.
  • Uterus changes from tubular formation into a hollow muscular organ.
  • Endometrial lining proliferates in preparation for menarche.
external and internal genitalia106
External and Internal Genitalia
  • Fallopian tubes grow.
  • Ovaries increase in size and develop an adequate vascular system to trigger the release of luteinizing hormone and to initiate ovulation.
  • Anovulatory menstrual cycle is due to slower development of ovarian function compared to endometrial function.
menarche
Menarche
  • Grand finale of puberty in women, average 12.5 years.
  • Occurs approximately 1-3 years after thelarche and during Tanner Stage 3 or 4.
  • Initial menstrual cycle may be irregular in quantity and duration.
  • Frequently anovulatory, secondary to immature ovarian function.
  • Rhythmic menstrual pattern set in about 3-4 years after menarche begins.
early adolescence 11 13 years
Early Adolescence 11-13 years
  • Interests focus on same gender peer group identification. Peer acceptance importance.
  • Define normalcy in relation to their peers.
  • Thinking is concrete. Lacks the ability for abstract thinking. Easily overwhelmed and overruled.
  • Expresses sexuality through dress, body language, and curiosity about sexual acts.
  • Research contends “the last area of the brain to mature is the part capable of deciding, I’ll finish my homework, take out the garage, and then I’ll IM my friends”
middle adolescence 14 16 yrs
Middle Adolescence 14-16 yrs.
  • Most turbulent stage. Psychologically egocentric and preoccupied with self.
  • Self esteem is established through recognition of the peer group.
  • Behavior is characterized by profound mood swing and rebellion.
  • Struggles for independence. Uses abstract reasoning and introspection for a better understanding of self and other.
  • Sexual behavior is explorative and exploitative.
risk factors for suicide attempt in adolescent
Risk factors for suicide attempt in adolescent
  • Lack of social connections
  • Alcohol and substance use
  • Non-intact family of origin
  • Firearms in the household
  • Poor communication with parents
  • Prior suicide attempt
  • History of abuse/violence victimization
  • Sexual identity issues
suicide risks
Suicide risks
  • Family history of
    • Depression
    • Suicide attempts
    • Mood disorders in mothers
    • Alcoholism or legal troubles in father
  • Stressful life events, to include
    • Break-up with a partner (in males)
    • Separation of parents
    • Disciplinary crisis
    • Problems at school or work, or not being affiliated with either.
14 16 well care
14-16 Well-care
  • Height
  • Weight
  • Temperature
  • Percentiles
  • BP
  • BMI
14 16 well care113
14-16 Well-care
  • Vision, hearing
  • Medication
  • Sports form
  • HEEADSSS
  • Adolescent questionnaire review together
14 16 well care114
14-16 Well-care
  • Discuss driving and risky behavior
  • P.E.- head to toe

-girls are usually tanner IV at this age

fyi eye exams
FYI- Eye exams
  • Begin attempting well care visits at gge 5 or 6, or with any neuro complaints at sick visits
    • Optic nerve
    • Optic disk/cup
  • Darken room
  • Practice makes perfect
17 21 well care
17-21 Well-Care
  • Treat as adult
  • P.E.
    • STD screen
    • Paps- start age 21 or 3 yrs. after 1st intercourse
    • FYI-get up to date on street drugs, or at least have a cheat sheet to refer to.
      • For example do you know that the effects of inhalants include: hearing loss, neuropathies, limb spasms, CNS damage, bone marrow damage, liver and kidney damage, O2 depletion…..
late adolescence 17 21 yrs
Late Adolescence 17-21 yrs.
  • Develops a sense of self and purpose to life.
  • Sexual behavior is more expressive and less exploitative.
  • Intimate and monogamous relationships are developed.
  • Abstract reasoning skills are fully developed.
  • Individual is able to interact with the adult world and consider long term implications.
review immunization
Review immunization

-Hep B -Pneumococcal

-DTAP -Influenza/ FluMist

-HIB -Varicella

-IPV -MMR RotaTeq

Hep A -Menactra

Boostrix and ADACEL

Two new ones- for HPV- Gardasil and Cervarix

You should bring the CDC immunization guide with you for the quiz!