Health Maintenance

Introduction

The main goal of health maintenance is to insure that the parents have an opportunity to meet with the pediatrician, have their child examined and discuss issues that arise at different stages of development. Primarily we are interested in 

  1. Immunizations - click here for link to immunization schedule
  2. Anticipatory guidance
  3. Promotion of safety concerns
  4. Feeding practices
  5. Assessment of growth and development - click here for link to developmental milestones
  6. Early detection of treatable disorders
  7. Observation of parent-child interaction

It is very important for the pediatrician to offer encouragement to the parents and compliment on how well they are doing in caring for their child. Mentioning how well they are doing can not be over emphasized. Parents often do not hear these words and they are often necessary to keep them enthused about performing the difficult task of raising children. This encouragement should continue at all visits. It is also important for the pediatrician to talk directly to the child and include them in discussions.

 

2 Weeks

  1. Assess the growth and development. It is very important to discuss feeding practices and encourage the mother who is nursing. No introduction of solids or juices. Discuss common issues like going out, wardrobe, traveling, sleep, colic, feeding, elimination, etc
  2. Important to express how well the baby and the parents are doing. 
  3. On physical exam carefully assess growth, presence of murmurs, pulses, hip exam, head size and shape, and general activity and alertness of the baby.  By two weeks of age, babies should have regained their birthweight
  4. Safety issues: sleep position and crib contents in preventing SIDS (sleep supine, "Back to Sleep", eliminate bed clothes and stuffed animals in the crib, hard mattress, and eliminate smoking from the environment), sun (no exposure until 6 months), hot and cold temperature avoidance, and car seat, smoke detectors, fire extinguishers, bathing water temperature, no strings or necklaces
  5. Immunizations: if haven't had the first Hepatitis B, give at this time. Give out booklets for immunizations that will be begin at the 2 month visit.
  6. Discussion of the need for Vitamins and Fluoride. Nursing babies should be supplemented with 400 IU of Vit. D
  7. Office procedures, hours, and how to get in touch with the physicians when the office is closed. Always encourage the parents to call if they have questions but calling during office hours is appreciated.
  8. Check state screening results
  9. Screen for maternal depression with Edinburgh Postnatal Depression Scale
  10. Return visit

 

2 Months

  1. Assess the growth and development including head circumference, achievemnet of milestones. 
  2. Feeding pratices are unchanged, no introduction of solids necessary.  Emphasize that no cereal or other solids should be placed in the bottle.
  3. Physical examination
  4. Answer questions
  5. Immunizations: Discuss the importance and indications for immunizations and reassure and answer questions. Hepatitis B #2, IPV(Polio) #1, DPT#1,Hib #1,Prevnar #1,Rotavirus #1
  6. Safety issues:  infant, do not leave baby alone on top of high surfaces such as changing tables, do not drink hot liquids while holding baby
  7. Vision and hearing assessment. 
  8. Tylenol dosing 10-15 mg/kg/dose q4-6 hours. 
  9. Screen for maternal depression with Edinburgh Postnatal Depression Scale

 

4 Months

  1. Assess growth and developmentBy 4 months, the infant’s weight should have doubled and many infants are sleeping through the night. 
  2. Discussion of the introduction of solid (baby) foods. Generally start with cereals and introduce fruits and vegetable during the next 2 months. Important to discuss amount of foods to be fed and how often. Children will usually let the parents know when they are full and there is no set amount that they need to feed. "Babies have the right of refusal." It is a good idea to not place juice in bottles to prevent the development of caries and a desire for sweets.
  3. Safety issues-electrical outlets, hiding cords from appliances and curtains and blinds, cabinets need to be locked, stairways protected, adjusted hot water temperature to below 120 F to prevent accidental scalding. 
  4. Immunizations: IPV#2, DPT/Hib#2, Prevnar#2,Rotavirus#2
  5. Increased drooling and placing of things in mouth starts at this age although most infants do not have teeth until they are about 6 months old.
  6. Rolling over, good head control, follows 180 degrees, laughs
  7. Inquire about sleep, hearing, elimination issues.

 

6 Months

  1. Assess growth and development. Starting to sit, transfers objects, babbles, rolls over
  2. May introduce chicken and beef. Infant should continue on breast milk or formula with iron but may need to supplement with solids at this age.  May introduce a cup with milk or juices. 
  3. Discussion of teething, sleeping, elimination, weaning if nursing
  4. Safety concerns: should have the phone number of POISON CONTROL (1800 222-1222), infant can be exposed to sun but should have a hat a at least 15 SPF sun protection, bike helmets if on back of bicycle, watch small objects that child will put in mouth and choke (toileet paper roll is a good comparison of diameters that are acceptable for toys.), water safety, safely storing medicines and cleaning supplies. 
  5. Immunizations:, IPV#3,DPT#3,Hib#3, Hepatitis B#3, Prevnar#3,Rotavirus #3

 

9 Months

  1. Assess growth and development - infant should be able to wave bye-bye and sit without support
  2. More finger foods will be introduced and emphasize that the pieces of food given be small to avoid choking. All foods are acceptable as long as they are in the proper consistency.
  3. Begin dental care by gently wiping off teeth and may introduce toothbrush
  4. Shoes: shoes are only decorations and protectors and children do not need shoes to learn to walk. Shoes should be soft, wide, cheap, and fit. 
  5. Safety becomes very important as the child becomes more mobile. Putting things in the mouth very common at this age and know what to do if child chokes. Discuss use of toddler car seat for children greater than 20 pounds. 
  6. Hematocrit to screen for anemia and a PPD if indicated
  7. Development- mama/dada, sits well, pulls to standing, pincer grasp, understands few words
  8. Sleep and bedtime issues, elimination, hearing, crossed eyes?

 

12 Months

  1. Assess growth and development
  2. Child may switch to whole milk and should be on whole milk until 2 years old
  3. Begin to discuss bottle caries and the importance of not taking bottle with sugar containing liquids to bed.
  4. Discussions about discipline and what the parents should expect from their child
  5. Immunizations: MMR#1 and Varicella Vaccine, DaP#4,HiB #4, Prevnar#4
  6. Screening for lead if indicated
  7. Diet, elimination, sleeping habits
  8. Accident prevention, change car seat, handgun safety, outdoor supervision, swimming pools, poisonings, Ipecac, stairs, cords and anything hanging
  9. Testing for lead - Chicago requires a blood test for children age 3 and younger, either at ages 6. 12, 18, 24 or 36 months  OR at 9, 15, 24 and 36 months.  Click here for Chicago's recommendations for lead screening

 

15 Months

  1. Assess growth and development
  2.  Catch up on any vaccinations that may have been missed
  3. Reiterate previous safety issues focusing on the fact that as the child becomes more mobile there is potential for more accidents 
  4. Diet, elimination, sleep habits

 

18 Months

  1. Growth and development.  The APP recommends that all children be screened for autism spectrum disorders at their 18 and 24 month WCC.  Click here for information about screening tool, MCHAT
  2. Safety
  3. Immunization catch-up, Hep A # 1
  4. Hematocrit and lead
  5. Bottle caries, dental care
  6. Discussion of healthy diet
  7. Discipline

 

2 Years

  1. Growth and development
  2. May begin discussion about toilet training. The NIH website has a number of links to resources for parents who would like to read about toilet training
  3. Guns
  4. Screen Time - AAP recommendations
  5. May switch to low fat milk
  6. Speech may often consist of some stuttering and this is usually normal. Expressive language may lag behind receptive 
  7. HepA #2

 

3 Years

  1. Growth and development
  2. Discussion about stranger danger and awareness of no touching
  3. Carseat/seatbelt issues
  4. Amount of television viewing, stressing increased physical activity, discussions about weight and diet
  5. Suggest visit to dentist
  6. Preschool 
  7. Assessment of vision and possibly hearing. Parents may be given home vision test to use.
  8. Blood pressure

 

4-6 Years

  1. Immunizations- IPV#4, DaPT#5, MMR#2, Varicella# 2
  2. PPD if indicated
  3. Hematocrit and Urine
  4. Hearing and vision
  5. School anticipatory guidance
  6. Bike helmets and rollerblade protective equipment
  7. Healthy diet and stress importance of physical activity, lowfat diet, is weight gain excessive? 
  8. How to deal with strangers and touching. Important to express this to children at the time that you are examining them. 
  9. Discuss sleeping, elimination, snoring
  10. How is the child getting along with other children?
  11. Amount of television viewing? 
  12. Proper seat belt use

 

8 Years

  1. Review how the child is doing in school and how they are getting along with peers
  2. Emphasize safety issues- seat belts, helmets, sun protection, water safety, guns, separate ammunition from the gun, bike helmets, mouth guards 
  3. Growth and weight gain. Is the child active
  4. Television viewing and exposure to violence
  5. Sleep, snoring, enuresis, elimination

 

10 - 12 Years

  1. Review school performance
  2. Introduce topic of sexual development and body changes
  3. Discuss the avoidance of nicotine, alcohol, and drugs
  4. On physical exam check spine for scoliosis, Tanner Stagingimg019_0.jpg
    http://www.addison.ac.uk/endocrine_modules/module1/lecturers_material/ht...
  5. Safety
  6. Personal hygiene- deodorants and antiperspirants, bathing, skin, menarche and use of tampons
  7. You should discuss the ability of the patient to see the pediatrician alone and stress that the doctor-patient relationship is strictly confidential. 
  8. Meningococcus Vaccine after 11 years old
  9. Females- begin Human Papilloma Virus Vaccine (HPV) Second shot 2 months later and then 4 months later. 

 

14 Years

  1. Physical exam- close attention to growth and sexual development. Answer questions concerning differences between teenagers of the same age. Scoliosis check , Tanner Staging
  2. Skin care and discussion of acne
  3. Contraception and sexually transmitted diseases
  4. Alcohol, smoking, drugs, and sex. Important to tell the adolescents that they have the ability to do what they want and if they are firm in their decision to not use drugs or alcohol, nobody will hold them down and force them. 
  5. Discussions about teen- parent relationship and how important is for the parents to talk to their kids. Also, parents must carefully monitor the teens behavior especially looking at their school performance, friends and acquaintances, and general behavior.
  6. At times it is important to "side" with the teenager
  7. Immunizations- Td booster (q 10 years), if didn't get initial Hepatitis B vaccine this is the time to start, Varicella vaccine if the adolescent is unimmunized and hasn't had chickenpox.
  8. Routine gynecologic examination is not performed by many pediatricians. If there is a problem a gyne exam may be done but if you are uncomfortable or inexperienced, a referral may be appropriate.

 

References

  1. Colson ER and Dworkin PH. Toddler Development. Pediatrics in Review. 1997; 18:255-259.
  2. Johnson CP and Blasco PA. Infant Growth and Development. Pediatrics in Review. 1997; 18:224-242.
  3. Sturner RA and Howard BJ. Preschool Development 1: Communicative and Motor Aspects. Pediatrics in Review. 1997; 18:291-301.
  4. Sturner RA and Howard BJ. Preschool Development 2: Psychosocial /Behavioral Development. Pediatrics in Review. 1997; 18:327-336.

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