Well Child Care Module
Health Supervision/Prevention
Health supervision, which includes assessment of growth and development, prevention of disease by
immunization, prevention of injury by education, screening for treatable conditions, and promotion of a
healthy environment and a healthy lifestyle, is essential to pediatric practice and primary care. Physicians
routinely incorporate strategies for prevention of illness and injury into routine health supervision.
Immunizations have resulted in a drastic reduction in the rates of certain infectious diseases. Injuries cause
the majority of deaths in childhood and adolescence. Illness and injury prevention must be a prominent and
recurrent theme during health maintenance and other health care visits. The American Academy of
Pediatrics and most medical groups no longer use the term “accident” as most childhood injuries are
believed to be predictable and preventable.
***Specific poisoning management and domestic violence are covered elsewhere in the curriculum***
Competencies
1.
List the most common preventable morbidities in childhood and adolescence and describe
strategies for prevention.
2.
Describe the components of a health supervision visit including health promotion and disease and
injury prevention, the appropriate use of screening tools, and immunizations for the following
ages:
Newborn
Infant
Toddler
School-age
Adolescent
3.
Discuss the rationale and indications for and proper timing/use of the following screening tests:
Neonatal screening
Urinalysis
Developmental screening
CBC
Hearing/Vision screening
Lead screening (blood lead level, environmental lead questionnaire)
Tuberculosis testing
4.
Define anticipatory guidance and describe how it changes based on the age of the child. Be able
to provide age-appropriate examples of anticipatory guidance about growth, nutrition, behavior
and development, immunizations, injury prevention, pubertal development, sexuality, and
substance abuse.
5.
Discuss injury prevention strategies for different ages and provide examples of anticipatory
guidance aimed at the following:
Motor vehicle safety/Car seats
Infant Sleeping Position
Falls
Burns
Poisonings
Bicycle safety
Choking
Water safety
Firearm safety
Fire safety
STDs
6.
List the immunizations currently recommended from birth through adolescence and identify
patients whose immunizations are delayed. Know contraindications to and adverse side effects of
each immunization.
Clinical Practice: You should try to see an infant, toddler, school-aged child, and adolescent for a
health care supervision at some point in the clerkship.
Development
The physical maturation and intellectual, social, and motor development of the child follow predictable
patterns and provide the physician with a good indicator of the child’s health and neurological
function. The clinician must be familiar with normal patterns of development in order to detect
deviations that might be the first sign of a medical or psychosocial problem.
Competencies
1.
Describe the four developmental domains of childhood (gross motor, fine motor, social, language)
2.
Describe the use of assessment tools available for evaluation of age-related developmental
changes (e.g. Denver Developmental Standard Test 2, Bright Futures, HEADSS) and know
milestones of the following groups:
Infants (including primitive reflexes and their disappearance)
Toddlers
Preschoolers
School-aged children
Adolescents (including pubertal changes)
3.
Describe how abnormal findings on the developmental screening tools may suggest underlying
medical diseases, developmental disorders, or autism. Know how to evaluate developmental
delays. Know how to incorporate gestational age into your assessment.
Clinical Practice: You should try to see a patient with real or possible (e.g. parental concerns)
developmental or speech delay at some point in the clerkship. You should also perform a
developmental assessment on at least one child in the clerkship (either in clinic or in the hospital
setting).
Behavior
Providing anticipatory guidance especially in the areas of normative or expected behaviors and
identification of abnormal behavior is critical to pediatric practice. Knowledge of age-appropriate
behavior allows the physician to recognize deviant behaviors and facilitates earlier intervention.
Competencies
1.
Describe the emotional disturbances or medical conditions that may manifest as alterations in
school performance and peer or family relationships.
2.
Describe how somatic complaints may represent psychosocial problems.
3.
Identify normal patterns of behavior in the following age groups: (examples given)
Newborn/Infants: development of social skills
Toddlers:
autonomy
School age:
independence
Adolescence:
abstract thinking
4.
Describe the typical presentation and know the appropriate management of common behavioral
problems and issues in the following age groups: (examples given). Be able to identify these
abnormalities based on history and physical examination findings.
Newborn/infants: sleep problems, colic
Toddlers:
temper tantrums, toilet training, feeding problems
School age:
enuresis, attention deficit, encopresis
Adolescence:
eating disorders, risk-taking behavior, conduct disorders
Clinical Practice: You should try to see at least one patient with a behavioral concern e.g. colic,
temper tantrums, enuresis, encopresis, poor school performance etc. while on the clerkship.
Growth
Growth is a defining feature of childhood. Genetic and environmental factors influence the rate of
growth and the final stature and body habitus the child attains. Regular monitoring of growth provides
the clinician with one of the best indicators of the underlying health of the child.
Competencies:
1.
Understand the importance of monitoring the growth of children and include measurement and
assessment of growth in all patient evaluations. Know how to measure weight, height, body mass
index, and head circumference and plot the measurements on an age-and gender-appropriate
growth chart.
2.
Describe variants of normal growth in health children, including familial short stature and
constitutional delay.
3.
Identify and describe abnormal growth patterns based on the family growth history and the child’s
previous growth (e.g. microcephaly, macrocephaly, short stature)
4.
Identify failure to thrive and overweight/obesity in a child or adolescent and outline the
differential diagnosis and initial evaluation of each.
Clinical Practice: You should try to see at least one patient with an issue related to growth while on
the clerkship.
Nutrition
Proper nutrition promotes growth and helps maintain health. Some degree of assessment of nutrition
is a component of almost every pediatric medical visit. In patients presenting with abnormal growth,
nutritional assessment is central to diagnosis and treatment.
Competencies:
1.
Know the components of and be able to obtain a routine diet history for the following ages:
(examples given)
Infants: type, amount, frequency of breast or formula feedings, solid foods, dietary supplements
(vitamins, iron, fluoride)
Toddler: milk, juices, fast foods, meal patterns
Adolescent: meal patterns, nutritional supplements, alcohol, soda, snacking, fad diets
2.
Know the caloric requirements needed to support growth in infants and determine the caloric
adequacy of an infant’s diet. Know the expectations for how much weight infants should gain
over the first year of life.
3.
Describe the advantages of breastfeeding and describe common difficulties experienced by
breastfeeding mothers. Know the difference between breast milk and commercially available
formulas and be able to state the differences between breast and formula-fed babies e.g. weight
gain, stool patterns.
4.
Know the maternal and infant contraindications to breastfeeding. Know what drugs are unsafe for
use by breastfeeding mothers.
5.
Describe the signs and symptoms of common nutritional deficiencies in infants and child (e.g.
iron, vitamin D, fluoride, inappropriate caloric volume) and how to prevent them. Know which
vitamins and minerals may require supplementation in infants, children, and adolescents.
6.
Identify children with specific or special nutritional needs (e.g. patients with chronic illness,
prematurity, abnormal growth patterns, failure to thrive, obesity).
7.
Describe nutritional factors that contribute to the development of childhood obesity and failure to
thrive.
Clinical Practice: You should try to see several patients with concerns about appropriate nutrition.
This can be in the outpatient or inpatient setting.
DIAGNOSES TO KNOW:
Attention deficit disorder
Anorexia nervosa
Macrocephaly
PKU deficiency
School failure
Head banging
Colic
Bulimia
Microcephaly
Encopresis
Temper tantrums
Hearing loss
Constitutional growth delay
Familial short stature
Obesity
Enuresis
Autism