Common Topics



Common Topics


Tara Conway Copper

Carrie Nalisnick





  • Care of children is best provided through an understanding of their developmental needs, abilities, and common concerns.


  • This chapter addresses anticipatory guidance, normal development, and common issues that arise in outpatient, emergency room, and inpatient settings.


HEALTH SUPERVISION VISITS

Health surveillance through screening, counselling, and provision of anticipatory guidance is among the most important functions of a pediatrician. Routine wellchild visits allow assessment of nutrition, physical and cognitive development, general health, and vaccination status. At each visit, discussion of these topics as well as a complete examination of the patient should occur. Through regular health supervision visits, pediatricians can provide advice and instruction based on the child’s current developmental abilities and anticipation of upcoming developmental milestones. The AAP provides a summary of recommended frequency and content of health supervision visits in the 2014 Periodicity Schedule. Pediatricians identify patients who deviate from normal development and refer to appropriate therapy services as needed. Routine visits also give a forum to counsel parents on common concerns of childhood.


DEVELOPMENT



  • Acquisition of developmental milestones occurs at specific times during childhood and in a particular sequence. Children are monitored for acquisition of milestones, and those who do not develop these skills as predicted require further evaluation.


  • Table 1-1 lists gross motor, fine motor, cognitive, language, and social milestones and the typical age at which these skills are acquired for children 1 month through 8 years.


SLEEPING


General Principles



  • Sleep duration in a 24-hour period decreases as children develop, with infants sleeping 16-20 hours per day and adolescents requiring 9 hours of sleep.


  • The ability to sleep through the night usually develops between 3 and 6 months of age, and beyond that time, infants may continue to wake up because of routine.



    • Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant that is unexplained after thorough evaluation. Risk can be decreased by placing infants in a supine position for sleep, using a firm sleep surface, removing loose blankets from the infant’s crib, parental cessation of smoking, and allowing the infant to sleep in a separate sleep environment from caregivers.





  • There is a dramatic decrease in daytime sleep between 18 months and 5 years of age.


  • Adolescents require 9 hours of sleep per night but get 7 hours of sleep on average, resulting in sleep deficit.








TABLE 1-1 Developmental Milestones by Age



















































































Age

Gross motor skills

Fine motor skills

Cognitive, language, and social skills


1 month

Head up while prone

Hands fisted

Fixes and follows to midline, startles to voice


2 months

Chest up while prone

Hands fisted 50% of the time, grasps a rattle placed in hand

Follows past midline, regards speaker, social smile, coos


4 months

Up on hands in prone, rolls front to back, no head lag

Keeps hands open, reaches for and retains objects in hand, brings hands to midline

Orients to voice, laughs, vocalizes when speaker stops talking


6 months

Sits unsupported, rolls back to front

Raking grasp, transfers hand to hand

Discriminates strangers, consonant babbling


9 months

Crawls, pulls to stand, cruises

Brings 2 toys together, finger feeds

Plays peek-a-boo, uncovers hidden objects, follows a pointed finger, says “dada” and “mama” indiscriminately, orients to name, understands “no”


12 months

Cruises, walks alone

Mature pincer grasp

Says “dada” and “mama” appropriately, 1-2 additional words, immature jargoning, follows command with gesture


15 months

Walks alone, stoops to pick up a toy, creeps up stairs

Builds tower of 2 cubes, imitates scribbling, uses a spoon and cup

3-5-word vocabulary, follows simple commands, names one object, says “no” meaningfully, points to one or two body parts


18 months

Throws ball while standing, walks up stairs with support, sits in a chair

Builds tower of 3-4 cubes, initiates scribbling

10-25-word vocabulary, mature jargoning, points to three body parts and to self


24 months

Jumps in place, kicks ball, throws overhand, walks up and down stairs with support

Builds tower of 6 cubes, imitates vertical stroke

50+-word vocabulary, 2-word phrases, uses pronouns, 50% intelligible, follows twostep commands, refers to self by name, points to 6 body parts, parallel play


3 years

Pedals a tricycle, alternates feet ascending stairs

Builds tower of 9 cubes, independent eating, copies a circle, draws 3-part person, unbuttons clothing

200+-word vocabulary, uses plurals, 75% intelligible, gives full name, knows age and gender, counts to 3, recognizes colors, toilet trained


4 years

Alternates feet descending stairs, hops on one foot

Builds tower of 10 cubes, able to cut and paste, copies a square, buttons clothing, catches a ball

100% intelligible, uses “I” correctly, dresses and undresses with supervision, knows colors, tells tales, group play


5 years

Skips, walks on tiptoes

Copies a triangle

2,000+-word vocabulary, identifies coins, names four to five colors, can tell age and birthday


6 years

Tandem walk

Ties shoes, combs hair, copies a diamond

10,000+-word vocabulary, reads 250 words, knows left vs. right, days of the week, and own telephone number


7 years

Rides a bicycle

Bathes independently

Tells time to the half hour


8 years

Reverse tandem walk


Tells time within 5 min, knows months of the year



Common Concerns


Behavioral Insomnia of Childhood



  • Clinical Presentation



    • There are two types of behavioral insomnia of childhood.


    • Sleep onset association disorder is seen in infants and toddlers who learn to fall asleep only under certain conditions and do not develop the ability to self-soothe.


    • Limit-setting disorder involves delayed sleep onset due to the child stalling or refusing to fall asleep followed by frequent demands for attention once in bed.


  • Treatment



    • Parents must establish a regular sleep schedule and bedtime routine.


    • Methods to allow the child to learn to self-soothe at bedtime generalize to night wakings as well.


    • Children should be put to bed drowsy but awake, and parents must ignore the child or gradually increase the period of time before soothing until the child learns to self-soothe.


    • Parents should be prepared for worsening of the behavior before improvement.


Night Terrors



  • Clinical Presentation



    • Peak occurs between 4 and 12 years of age.


    • Arousal occurs from deep, slow-wave sleep usually in the first third of the night.


    • Presentation is consistent with intense fear including screaming or crying, tachycardia, tachypnea, skin flushing, diaphoresis, and increased tone.


    • The child has partial or complete amnesia of the event.


    • After the event, the physical examination is normal.


  • Diagnostic Evaluation



    • Diagnosis is made based on the typical history.


    • History should also focus on an etiology for disrupted sleep including restless legs syndrome, obstructive sleep apnea, or seizures.


    • Polysomnography is not routinely indicated.


  • Treatment



    • Parental reassurance, education, and good sleep hygiene are most important—these episodes are self-limited and cease with puberty as slow-wave sleep decreases.


    • Scheduled awakenings may be used for frequent episodes. The parent should awaken the child 15-30 minutes prior to the typical time of the episode for several weeks until the episodes stop.


    • Short-acting benzodiazepines can be used in rare, severe circumstances when the child is at risk of injury.


Nightmares



  • Clinical Presentation



    • Nightmares occur during REM sleep and therefore later in the night than night terrors.


    • Nightmares result in arousal, significant anxiety after awakening, and potentially refusal to return to sleep.



    • Children can recall the event.


    • The physical examination is normal.


  • Diagnostic Evaluation



    • The diagnosis is made by the classic history.


  • Treatment



    • Good sleep hygiene is important. Nightlights and security blankets may be effective.


    • The child should avoid frightening television shows before bedtime.


    • In severe cases, assessment by a developmental pediatrician may be warranted.


Sleepwalking



  • Clinical Presentation



    • Peak age of presentation is 4-8 years old.


    • The child arouses during slow-wave sleep in the first third of the night and ambulates in a state of altered consciousness. Bizarre behaviors may occur during the episode.


  • Diagnostic Evaluation



    • The diagnosis is made by the classic history.


    • Polysomnography is rarely indicated unless there is suspicion of obstructive sleep apnea or restless legs syndrome as precipitating factors.


  • Treatment



    • Protect the child from harm. Make sure the bedroom is in a safe place, away from stairs.


    • Parents may place a bell or alarm on the child’s door so that they know when the arousal occurs.


    • Rarely, in severe cases, benzodiazepines may be used.

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Jun 5, 2016 | Posted by in PEDIATRICS | Comments Off on Common Topics

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