Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics. ! I am:
Dr. Rachel Moon -- I’m a Professor of Pediatrics
Dr. Jeremy Middleton - I’m the pediatrics clerkship director and Associate Professor of Pediatrics
Dr. Shakun Gupta - I’m the pediatrics associate clerkship director and Associate Prof of Pediatrics
at the University of Virginia.
Before Your First Well Child Check
You are likely to spend some time in a practice or clinic where you will see babies and children for well child checks - or check ups.
We start seeing infants very frequently and then space out the visits. After the newborn period, we start out every 2 months, then go to every 3 months, then every 6 months, then once a year. Visits are often timed with vaccines or when we need to check their growth, development, or certain lab tests, such as hemoglobin and lead at 1 year of age, vision/hearing at 4-5 years of age, or lipid screening at 9-11 years of age. We will have separate podcast episodes to discuss the newborn checkup and the adolescent visit.
We usually do our first check a few days after the baby is discharged from the hospital.
We see the baby very frequently at that point until the baby is demonstrating good weight gain. We will then see babies at 2 weeks and/or 1 month of age. Then, we see babies at 2 month intervals until 6 months: 2, 4, 6,
Then we go to 3 month intervals: 9, 12, 15, and 18 mos.
After that, we see them at 6 month intervals: 24 months, 2-½ years and 3 yrs.
After that, unless there are ongoing issues, we usually see children once a year.
Before you go into the patient’s room, you should review
-The patient’s chart. If the patient has any medical conditions, developmental concerns, is on any medications, or if there are concerns that have been discussed at previous visits.
-what vaccines, lab tests, and developmental surveys should be done at this visit. If the child is not up to date on vaccines, you may need to catch up on the vaccines.
-You should also review what developmental milestones the child should have met at this age. Different practices use different developmental screening tests - CDC developmental milestones, Ages and Stages questionnaire (ASQ). Use whatever your practice is using. Many practices use the Modified Checklist for Autism in Toddlers (M-CHAT) for autism screening at 15 months and/or 30 months. Many practices have the parents complete these questionnaires while they’re waiting to be seen; in others, you’ll need to go through these with the parent.
-Review the growth chart. You will look at the height and weight for every child. For those younger than 2 years, you will look at the head circumference. If the head circumference is normal, this is an indication that the brain is growing well. For children older than 2 years, you will also look at the body mass index, or BMI. For all of these growth parameters, look at both the absolute percentile and the trend. If the child is not following a growth curve, that could indicate a medical problem.
-Examples: head circumference growing too fast - hydrocephalus
- height is too fast or too slowWe - endocrine problem
- not gaining appropriate weight - calories, gi problem, endocrine problem.
At every visit, you will go through the following:
Introduce yourself to both the parent and the child. If the child is old enough, you can start with asking the child the questions. I usually ask the child, “Do you want to tell me how you’re doing, of do you want your mom or dad to?”
You will start with asking about how the child is doing - and if there are any concerns or questions.
For each one, determine if it is something you are already going to ask about in the course of a regular well child care history (which I will talk about next).
For any concern that wouldn’t be part of your regular history, get focused information (example: a rash – how long has it been there, what have they tried to treat it, has the child had it before). Some people choose to deal fully with that concern in the moment, others will deal with it later in the visit. If you deal with it later, you just can’t forget!
Follow up on any outstanding issues from the past – examples would be asthma control, visits to sub-specialists that were recommended in the past, interval emergency room visits or labs,
behavioral changes that were discussed, etc.
Diet: You will want to know what the baby is taking in, how much, and how often.
In the first year, babies will get most of their nutrition from either human/breast milk or formula. They start with 1-2 ounces every 2-3 hours, then gradually increase to about 32 oz/day.
At 6 months, we start babies on solid, pureed foods. They usually start an iron-fortified cereal, then move to fruits, veg, and meats. Start with one food every few days to look for reactions.
At 6 months, we also usually start them on some peanut product, such as smooth peanut butter, to decrease the chance of developing a peanut allergy.
If they are formula fed, Whole cow’s milk intake starting at 1 yr - need fat in whole milk for brain growth. If they are breast fed, they can continue on with breast milk or switch. Recommend 2-3 cups/day for adequate calcium and vit D intake. Don’t want too much - can cause problems with iron deficiency anemia, both because milk has low iron content, and calcium in milk can inhibit iron absorption.
Switch to 2% or skim milk at 2 years.
You do want to ask the parent what type of milk - some may be on plant-based milk, which has fewer nutrients (Ca, vit D) than cow’s milk.
No juice and sugar-sweetened beverages. We recommend water and milk, because SSB can increase calories and cause tooth decay.
Sleep: how much, any problems. Usually by the time the baby is about 6 months, they are starting to sleep for longer periods and some will sleep for 6-8 hours. In the first yr, when babies are at risk for sudden and unexpected death, you want to ask about safe sleep, so ask about the baby’s sleep position and location.
Elimination: any problems. Beginning at age 2, you can ask about how toilet training is going. Most will become toilet trained between 2 and 3.
Development: ask about appropriate dev milestones (that you reviewed before you went into the room)
Social: who lives in the household. Who takes care of child during day and night? School? Daycare?
If the child is in school, ask the child about their school. What is the name of their school? What grade are they in? What kind of grades do they get? You can ask them about their teacher and their friends.
Activities: what does the child do when they’re not in daycare/school? Are they getting exercise? We recommend that they get some exercise for at least 30 minutes daily.
How much screen time? We recommend no more than 2 hours/day.
Does anyone in the home smoke?
Safety: depending on age, may include discussion about car seats, childproofing the home, safe gun storage, bike helmets, safe internet use, bullying. There may be other topics, depending on where you live or the season. For instance, water and swim safety may be an important topic. You can take the opportunity to do a lot of anticipatory guidance here, which means providing parents with information about what to anticipate in the next few months - and how they can keep their child healthy and safe.
Has the child been to a dentist yet? (If not, may want to consider putting fluoride varnish on teeth and provide them with list of dentists.) How often do they brush their teeth? (we recommend 2x/daily)
Review meds and allergies
Review the growth chart with the family.
You will then do a physical exam.
-A few hints:
-If there is an area of concern that is brought up by family, pay special attention to that in the exam.
-Pay attention to what the child is doing while you are talking with the parents. You can often get a good sense of the child’s developmental capabilities and even much of the neuro exam just by observation.
-In children, depending on age, you may not be able to do the exam head to toe. For school-aged children, you can usually start with the head and make your way down.
-Can’t do that with younger children. So here are my recommendations. First of all, don’t make the child move if they are comfortable. You can do much of the exam while the child is sitting on the parent’s lap. Take advantage of when the child is quiet to listen to the heart/lungs. I usually start with heart and lungs, then move to the abdominal exam. I then go to the head and neck exam. I usually save the ear exam for the end, because that can be the most traumatic for the child. If the child starts crying, you can then have an opportunity to look at the mouth and throat.
-Also, depending on the age, you should not do a genital exam unless you are chaperoned.
-Will talk about adolescent privacy and additional questions in that episode.
If you haven’t already discussed it, after the physical exam is a good time to let the parents know what else needs to be done at this visit. This includes vaccines, blood tests, and other tests, such as vision and hearing tests, that will be done at this visit.
You will also do some anticipatory guidance. If there are any things that came up during the visit that need to be addressed, you can do that now. You can also remind them of guidance that you provided earlier in the visit.
Answer any last questions. Remind them of when their next visit is.
When you come out of the room, you can prepare for your oral presentation.
In your oral presentation, you will start with the child’s age, sex, any brief pertinent medical history (if there is any), and what they are here for. You will then go through your list of elements that you discussed. When you get to the physical exam, you will start with a general statement of the child’s appearance. Present the vital signs and growth parameters. Then present the exam, head to toe - even if you did not do the exam head to toe. End with an assessment and your plan.
Here’s an example:
Jackie is a 5 year old girl with a history of moderate persistent asthma, well controlled on inhaled steroids and albuterol, who is here for her 5 year old check up. The mother has no concerns but is asking how long she needs to take the steroids. She has not had an episode of wheezing in more than 1 year. She has no coughing, and the mother states that she has not required any albuterol in more than 6 months. Jackie’s diet is well-balanced. She is a little picky but eats from all food groups. She drinks 2-3 glasses of skim milk daily. She also drinks 1-2 cups of juice or soda daily. She has no problems with elimination and is fully toilet trained. She sleeps from 8 pm to 6 am daily and doesn’t have any problems with sleep. She speaks in full sentences and is fully understandable. She can draw a square for me and can hop on 1 foot. She just started kindergarten and has a best friend. She lives with her mother and 2 younger siblings in an apartment. Her grandmother takes care of her after school while her mother is at work. She likes to play outside, but her mother and grandmother worry about her asthma and so don’t let her run around too much. She watches TV or plays on the computer for 2 hours every day. With regards to safety, she doesn’t have a bike. There are no guns in the home. She has a booster seat for the car.
On physical exam, Jackie is a talkative, happy 5 year old. Her vital signs are normal for age, and her height, weight and BMI have all been trending at the 75 %ile. Her HEENT exam is normal. She has no adenopathy. Her lung exam is normal, and I heard no wheezing. She has no murmurs on her heart exam. Her abdomen is soft and nondistended. I deferred the genital exam until we can do it together. She has no skin rashes.
My assessment is that Jackie is a healthy 5 year old child who is growing and developing normally. We discussed eliminating the sugar-sweetened beverages from her diet. We talked about how her asthma should not limit her play. Her vaccines are up to date. I talked to mom about the flu vaccine, and she will get that today. She will get vision and hearing screening today. We will see her back in 1 year.
You’ve made it through your first well child check!
I hope that you take the opportunity to see infants and children of different ages during your outpatient time. You will get a good idea of how different children are at these different ages.
Outro:
Thanks for listening to Clerkship Ready - Pediatrics. Hope you found today’s podcast helpful. Don’t forget to subscribe below and rate the podcast!
