Growth and Development

Ask about the child's pattern of growth. As is discussed later, the height, weight, and head circumference of children should be plotted on appropriate growth curves. Has the child's growth been consistent, or has he or she crossed percentile lines on the growth chart? Is the mother concerned about her child's growth?

*The typical ampicillin rash occurs about 7 to 8 days after the drug is started and is not considered a penicillin allergy.

{The normal newborn can take 15 to 20 ounces a day.

Ask, ''How has the child been growing? Are you concerned about his or her weight gain or about his or her linear growth?'' Asking about how quickly the child outgrows shoes and clothes may give you an indication of his or her growth rate.

The child's characteristics or temperament during infancy may be predictive of early developmental progress and of how he or she will respond to new experiences in years to come.

Ask, ''Would you describe your child as active, average, or quiet?'' If this is not the mother's first child, it is appropriate to ask how this infant compares with the family's other children: Is this child slower, faster, or about the same in development?

' 'When did the child first sleep through the night?''

''Do you have any concerns about the child's development? If yes, ' 'What are they?'' ''Has the child ever failed to make progress or ever lost any ability he or she once had?'' ''Does the child have difficulty keeping up with other children?''

After asking general questions about the child's development, you need to get information about specific developmental milestones that reflect the child's ability in four areas: gross motor, language, fine motor, and personal/social development. The following questions should be asked:

' 'At what age did the child roll over for the first time? sit without support? point at objects? wave 'bye-bye'? recognize objects by name? stand holding on? walk without support? say his or her first words? walk up and down stairs without support? learn to dress himself or herself? learn to tie shoes? put two words together? speak in full sentences?''

''At what age was the child toilet-trained?''

How old do you think your child acts now?''

How often does your child have tantrums?''

The Denver Developmental Screening Test, shown in Figure 24-1, was developed to detect developmental delays in the first 6 years of a child's life, with special emphasis on the first 2 years. It is standardized on the basis of findings from a large group of children in the Denver, Colorado, area and tests the four main areas of development indicated previously. A line is drawn from top to bottom of the sheet according to the age of the child. Each of the milestones crossed by this line is tested. Each milestone has a bar that indicates the percentage of the ''standard'' population that should be able to perform this task. Failure to perform an item passed by 90% of children is significant. Two failures in any of the four main areas indicate a developmental delay. This test is a screening device for developmental delays; it is not an intelligence test.

For the school-aged child, the child's social, motor, and language development, as well as emotional maturation, are reflected in current behavior. A nice way to broach this topic is to ask, ''How would you describe your child as a person?'' Follow up with some or all of these questions:

What do you enjoy the most about your child? the least?'' Does your child usually complete what he or she starts?'' How does your child get along with other children his or her age?'' ' 'How many hours of sleep does your child get each night?'' Does the child have any recurrent nightmares?''

Does the child have temper tantrums?'' Whereas tantrums in toddlers and preschoolers are not unusual at those ages, tantrums in a school-aged child are unusual and may indicate potentially serious problems.

''What type of responsibility can he or she be given?''

How old was your child when he or she started school?''

Denver II

Examiner: Date:

9 12 15 18

Name: Birthdate: ID No.:

YEARS 3

Percent of children passing 25 50 75

(See back of form)

PREPARE CEREAL : BRUSH TEETH, NO HELP ; PLAY BOARD/CARD GAMES DRESS, NO HELP

PUT ON T-SHIRT NAME FRIEND WASH & DRY HANDS

BRUSH TEETH WITH HELP

PUT ON CLOTHING-

FEED DOLL

HELP IN HOUSE

DRINK FROM CUP

IMITATE ACTIVITIES PLAY BALL WITH EXAMINER

WAVE BYE-BYE INDICATE WANTS ; PLAY PAT A-CAKE

COPY

DRAW PERSONS PARTS COPYH DEMONSTR.

PICK LONGER LINE COPY

DRAW PERSON 3 PTS

copyO

THUMB WIGGLE TOWER OF 8 CU8ES

IMITATE VERTICAL LINE

TOWER OF 6 CUBES TOWER OF 4 CUBES

TOWER OF 2 CUBES DUMP RAISIN, DEMONSTRATED

REGARD OWN HAND i

; SMILE RESPQN-SIVELY

: FEED SELF WORK FOR TOY

TAKE 2 CUBES : PASS CUBE RAKE RAISIN I LOOK FOR YARN REACHES

SCRIBBLES PUT BLOCK IN CUP

; DEFINE 7 WORDS OPPOSITES-2

COUNT 5 BLOCKS

KNOW 3 ADJECTIVES

DEFINE 5 WORDS ; NAME 4 COLORS UNDERSTAND 4 PREPOSITIONS SPEECH ALL UNDERSTANDABLE KNOW 4 ACTIONS ; USE OF 3 OBJECTS I COUNT 1 BLOCK USE OF 2 OBJECTS NAME 1 COLOR

REGARD RAISIN ' FOLLOW 180'

FOLLOW

TO MIDLINE

3 WORDS 2 WORDS ONE WORD DADA/MAMA SPECIFIC

JABBERS

COMBINE SYLLABLES

KNOW 2 ACTIONS NAME 4 PICTURES SPEECH HALF UNDERSTANDABLE POINT 4 PICTURES : BODY PARTS-6 NAME 1 PICTURE COMBINE WORDS POINT 2 PICTURES

THROW BALL OVERHAND

BALANCE EACH FOOT 6 SECONDS HEEL-TO-TOE WALK BALANCE EACH FOOT 5 SECS. I BALANCE EACH FOOT4 SECS BALANCE EACH FOOT 3 SECONDS HOPS

IMITATE SPEECH SOUNDS

SINGLE SYLLABLES TURN TO VOICE

KICK BALL FORWARD i WALK UP STEPS

RUNS

I WALK BACKWARDS WALK WELL STOOP AND RECOVER STANDALONE STAND-2 SECS.

TEST BEHAVIOR

SQUEALS LAUGHS "OOO/AAH" VOCALIZES ( RESPOND TO BELL

I PULL TO SIT - NO HEAD-LAG

; BEAR WEIGHT ON LEGS SIT-HEAD STEADY HEAD UP 90°

(Check boxes for 1 st, 2nd, or 3rd test)

Typical

Yes No

Compliance (See Note 31)

Always Complies Usually Complies Rarely Complies

Interest in Surroundings

Alert

Somewhat Disinterested Seriously Disinterested

Fearfulness

None Mild

Extreme Attention Span

Appropriate Somewhat Distractable Very Distractable

YEARS

Figure 24-1 Denver Developmental Screening Test. (Reprinted with permission from William K. Frankenburg, MD, Denver Developmental Materials, Inc., Denver, Colo.)

DIRECTIONS FOR ADMINISTRATION

1. Try to get child to smile by smiling, talking, or waving. Do not touch him/her.

2. Child must stare at hand several seconds.

3. Parent may help guide toothbrush and put toothpaste on brush.

4. Child does not have to be able to tie shoes or button/zip in the back.

5. Move yarn slowly in an arc from one side to the other, about 8" above child's face.

6. Pass if child grasps rattle when it is touched to the backs or tips of fingers.

7. Pass if child tries to see where yarn went. Yarn should be dropped quickly from sight from tester's hand without arm movement.

8. Child must transfer cube from hand to hand without help of body, mouth, or table.

9. Pass if child picks up raisin with any part of thumb and finger.

10. Line can vary only 30 degrees or less from tester's line.|/

11. Make a fist with thumb pointing upward and wiggle only the thumb. Pass if child imitates and does not move any fingers other than the thumb.

12. Pass any enclosed form. Fail continuous round motions.

13. Which line is longer? (Not bigger.) Turn paper upside down and repeat, (pass 3 of 3 or 5 of 6)

14. Pass any lines crossing near midpoint.

15. Have child copy first. If failed, demonstrate.

When giving items 12, 14, and 15, do not name the forms. Do not demonstrate 12 and 14.

16. When scoring, each pair (2 arms, 2 legs, etc.) counts as one part.

17. Place one cube in cup and shake gently near child's ear, but out of sight. Repeat for other ear.

18. Point to picture and have child name it. (No credit is given for sounds only.)

If less than 4 pictures are named correctly, have child point to picture as each is named by tester.

19. Using doll, tell child: Show me the nose, eyes, ears, mouth, hands, feet, tummy, hair. Pass 6 of 8.

20. Using pictures, ask child: Which one flies?... says meow?... talks?... barks?... gallops? Pass 2 of 5, 4 of 5.

21. Ask child: What do you do when you are cold?... tired?... hungry? Pass 2 of 3, 3 of 3.

22. Ask child: What do you do with a cup? What is a chair used for? What is a pencil used for? Action words must be included in answers.

23. Pass if child correctly places arid says how many blocks are on paper. (1, 5).

24. Tell child: Put block on table; under table; in front of me, behind me. Pass 4 of 4. (Do not help child by pointing, moving head or eyes.)

25. Ask child: What is a ball?... lake?... desk?... house?... banana?... curtain?... fence?... ceiling? Pass if defined in terms of use, shape, what it is made of, or general category (such as banana is fruit, not just yellow). Pass 5 of 8, 7 of 8.

26. Ask child: If a horse is big, a mouse is_? If fire is hot, ice is_? If the sun shines during the day, the moon shines during the_? Pass 2 of 3.

27. Child may use wall or rail only, not person. May not crawl.

28. Child must throw ball overhand 3 feet to within arm's reach of tester.

29. Child must perform standing broad jump over width of test sheet (8 1/2 inches).

30. Tell child to walk forward, ceOac=Da=oco->- heel within 1 inch of toe. Tester may demonstrate. Child must walk 4 consecutive steps.

31. In the second year, half of normal children are non-compliant.

OBSERVATIONS:

Figure 24-1 cont'd

' 'How is he or she doing in school?'' ''Has he or she ever been left back?''

''Has your child's teacher ever told you that he or she suspects a problem?'' If yes, ' 'What is the problem?''

''What is your child's grade level for reading? math?'' ''What does your child enjoy doing during his or her free time?''

''What kinds of things scare him or her?''

How does the child get along with his or her brothers and sisters?''

How much time does your child spend watching TV? playing video games? on the computer?'' Does he or she have a TV in his or her room?''

It is useful to ask whether the child has any disturbing habits. This question allows the parent or guardian to vent any previously unexpressed concerns. This may be asked as follows:

' 'Is there anything about the child's behavior that worries you or that is different from that of other children?''

In 2007, because of striking increase in the prevalence of autism and autistic spectrum disorders, the American Academy of Pediatrics recommended screening all children for the following behaviors:

• Not turning when the parent says the baby's name

• Not turning to look when the parent points and says ''Look at. . .,'' and not pointing themselves to show parents an interesting object or event

• Lack of back-and-forth babbling Smiling late

Failure to make eye contact with people

Because it is clear that early intervention can significantly improve the outcome for children with autism and autistic spectrum disorders, the Academy recommends that this screening be performed at least twice during the first 2 years of life.

Immunization History

The pediatric history contains detailed information about immunizations. The current recommended immunization schedule, as of October 2008, is shown in Table 24-1. Because the

Table 24-1 Table of Vaccines by Age Group

IPV Hep B HIB PCV

Rotavirus

Annual influenza vaccine

MMR VAR Hep A

Booster doses of DTaP, HIB, PCV Hep A, second dose (IPV, Hep B*)

DTap, fifth dose MMR, second dose VAR

Tdap MCV4 HPV4

Note: The vaccine schedule changes frequently. Also, new combination vaccines become available; please refer to the www.cdc.gov/nip immunization web site (accessed June 26, 2008) for the latest indications, and refer to the package inserts for individual vaccine products.

DTaP, diphtheria and tetanus toxoids and acellular pertussis vaccine; Hep A, hepatitis A vaccine; Hep B, hepatitis B vaccine; HIB, Hemophilus influenzae type B vaccine; HPV4, human papillomavirus vaccine (as of 2008, licensed only for girls and women); IPV, inactivated poliovirus vaccine; MCV4, conjugated meningococcal vaccine; MMR, live attenuated measles, mumps, and rubella; VAR, varicella vaccine; PCV, pneumococcal conjugate vaccine; Rotavirus, oral, live attenuated rotavirus vaccine; Tdap, tetanus, reduced-dose diphtheria toxoids, and acellular pertussis vaccine.

*The third doses of these two vaccines can be given as early as 6 months, but should be given by 18 months if not given earlier.

6 months-5 years 12 months

12-18 months

4-6 years

11 years and up immunization schedule is updated every 6 months, please refer to the Centers for Disease Control and Prevention web site at www.cdc.gov/nip (accessed June 26, 2008).

Vaccines are one of the major successes of 20th century medicine;clinicians are unlikely to ever see many of the vaccine-preventable diseases such as polio or diphtheria, and if an immunized child does have one of these diseases, that child may have an immune deficiency. However, if the child is missing one or more vaccines, you should consider the possibility the child is suffering from a vaccine-preventable illness.

As the schedule of vaccines has become rather complex, many parents are unsure about the exact vaccines given to the child. Ask to see the immunization record, which many parents carry with them. Also, many localities have centralized vaccine registries where health-care providers can access the record of a particular child.

You can partially reconstruct the child's vaccine history, if necessary, with the following questions:

How many sets of vaccines has your child had?'' (The primary series is given at 2, 4, and 6 months of age.)

''How many injections did the child get each time?'' (Most schedules will have 2 or more injections per visit.)

Did the child get shots right after his or her first birthday? How many?'' ''How about at 15 to 18 months?''

What shots did he or she get before kindergarten?''

For the child 11 or older, ask, ''Has she gotten any vaccines recently? How many?'' Recent additions to the vaccine schedule provide adolescents with protection against pertussis, menin-gococcal disease, hepatitis A, and, for girls, human papillomavirus, the leading cause of cervical cancer. Also ask, ''Did your child have a reaction to any of the shots?''

For an older child, ask ''Has he or she ever had chickenpox?'' See the Clinicopathologic Correlations section at the end of this chapter for a detailed description of this disease, whose incidence is decreasing.

Social and Environmental History

The social and environmental history should include the parents' ages and occupations, as well as the current living conditions. Ask these questions:

''How many rooms do you live in?'' ''Who lives in your home?'' ''Are there any pets?''

''Does anyone in the household smoke? Are there carpets? Is dust a problem? Are there problems with cockroaches or other environmental contaminants?''

''Does the child sleep in his or her own room? Does the child sleep in a crib or a bed? Does the child sleep in the parents' bed?''

''Is the child cared for in any other house?''

''Who supervises the child during the day?''

''How does the family have fun together?''

''Do both the child's parents share in family life?''

''What is the condition of the paint and plaster in your home?''

''Has the child had any known exposure to lead?''

Dust and chips from deteriorating lead-based paint are the most common sources of lead exposure in young children. Although the rates and severity of pediatric lead poisoning have declined in the United States, childhood lead poisoning remains a problem throughout the world. The effects of lead poisoning are more pervasive and longer lasting in children than previously believed, and they occur at levels once thought safe. Prenatal exposure and exposure in children 2 to 3 years of age are of particular concern. In 2006, elevated blood lead levels were found in 39,000 children* on screening blood tests. Children who are younger than 6 years, especially 1- and 2-year-olds, are at greatest risk because of normal hand-to-mouth activity. Although pica (a morbid craving to ingest nonfood substances such as chalk or coal) has been implicated in lead poisoning, children more commonly ingest lead-containing dust through normal hand-to-mouth activity. Ask the parent or guardian the following:

''Does the child live in or visit a home that was built before 1960?'' ''Has any renovation been done in your home recently?''

''Does the child have a sibling, house mate, or friend with an elevated blood level of lead?'' ''Has the child visited other countries for substantial periods of time?'' ''Does the child live near a heavily traveled major highway, bridge, or elevated train?'' ''Does the family use ceramic pottery from another country?''

''Does the child come in contact with an adult whose job or hobby involves exposure to lead?''

If the answer to any of these questions is yes, the child should be tested with a direct blood lead test.

Other questions related to safety in and around the home concern the presence of smoke detectors and window guards in the home, use of a crib with the child sleeping on his or her back, supervision and hot water temperature during baths, and use of car seats and bicycle helmets.

Family History

The pediatric family history is basically the same as in the adult history but may play a more significant role in identifying genetic disorders and inborn errors of metabolism. When taking the family history of a pediatric patient, it is worthwhile to construct a pedigree or genogram, a graphic representation of the family history. As illustrated in Figure 24-2, in a pedigree, boys and men are represented by squares;girls and women are represented by circles;the patient, or

*See www.cdc.gov/nchs/lead/surv/stats.htm.

w

87

72

86

80

CHD

CHD

Colon Ca

CHD HT CHD Obesity

Male

Female

Patient

Deceased male Deceased female

77 HT

70 Cataracts

25 70

Killed GI problems

Pulmonary embolus

40 A&W

39 A&W

Figure 24-2 Pedigree (family tree). A&W, alive and well; Ca, cancer; CHD, coronary heart disease; CVA, cerebrovascular accident; GI, gastrointestinal; HT, hypertension.

proband, is illustrated with an arrow;and for individuals who are deceased, the shape is black, or a line is drawn through the circle or square. Information about three generations should be obtained: that is, the child and his or her siblings;the parents and their siblings;and the grandparents. For each individual, the following information should be obtained:

If alive, name and current age • Presence of any illnesses, such as diabetes, asthma, coronary artery disease, hypertension, stroke, and cancer

Presence of birth defects or genetic disorders such as sickle cell disease, hemophilia, cystic fibrosis and Tay-Sachs disease; if known, each individual's carrier status for any of these conditions should be noted as well

Any miscarriages or children who died in infancy or later

If deceased, age at and cause of death

Presence of consanguinity

By analyzing the pedigree, the examiner can gain insight into the child's risk for having specific diseases in the future.

Review of Systems

The review of systems needs to be age-appropriate, and so it is described along with the approach to the physical examination in the following sections.

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