monitoring of children’s health
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Monitoring of children’s health. Prof.Dr. Emel Gür İ.Ü Cerrahpaşa Tıp Fakültesi Çocuk Sağlığı ve Hastalıkları ABD Sosyal Pediatri Bilim Dalı. Examination Maintance Improvement of health. To prevent diseases and disabilities Early diagnosis and treatment - PowerPoint PPT PresentationTRANSCRIPT
Monitoring of children’s healthMonitoring of children’s health
Prof.Dr. Emel Gür
İ.Ü Cerrahpaşa Tıp Fakültesi
Çocuk Sağlığı ve Hastalıkları ABD
Sosyal Pediatri Bilim Dalı
ExaminationExaminationMaintanceMaintance
ImprovementImprovementof healthof health
To prevent diseases and disabilities Early diagnosis and treatment To prevent deaths of babies and children Support to families for healthy raising of
children
AimAim
Prevention of diseases
Follow up of growth and development
Appropriate feeding according to age
Immunisation
Support to families
Health education
Consultancy
Family planning
Early diagnosis and treatment
History
Physical examination
Lab. tests
Activities
Steps in monitoring of childrens Steps in monitoring of childrens healthhealth
Follow up Meeting and history
Examination of growth and development
Detailed physical examination
Screening
Immunisation
Health trainning and counseling
Mother’s questions
Determination of the next appointment
Monitoring of the growthMonitoring of the growth
Aim; to follow up the health, to detect health problems in its early stage , to prevent malnutrition
At each examination weight, height and head circumference sholud be correctly measured, standart growth curve should be evaluated and it sholud be interpreted in the right way
Parents should participate actively in the examination of growth
Periods in the monitoring of babies and Periods in the monitoring of babies and childrenchildren
AGE GROUPS PERIODS OF MONITORING
FİRST 48 H ONCE
15. DAY ONCE
41. DAY ONCE
2 - 12 MONTHS 2, 3, 4, 6, 9, 12. MONTH
1 – 3 YEARSWITH THE PERIOD OF 6 MONTHS
≥4 YEARSWITH THE PERIOD OF 1 YEAR
Bebek ve Çocuk İzlem Protokolü. T.C Sağlık Bakanlığı AÇSAP Genel Müdürlüğü. Genelge 2008/45.
Growth curves for Turkish childrenGrowth curves for Turkish children
Weight curves for Turkish childrenWeight curves for Turkish children
Marked curves of children’s weightMarked curves of children’s weight
good dangerous
attention catch up of growth
Monitoring and support of developmentMonitoring and support of development(Guide for monitoring of chidren’s development)(Guide for monitoring of chidren’s development)
Is there any worry about child’s development, hearing, talking, understanding, use of hands and body movements?
Can your child explain what he wants? What is your child understanding? What is he doing with his hands and fingers, what is the way
he is making his body movements? What is the way he communicates with the family members
and foreigners? Can you give us information about the way he is playing
games?
Screening of developmentScreening of development
Screening of developmental problems is useful for monitoring of risk infants
Denver II is a reliable screening test for the children at their first 6 years of life
Development, personal and social inteligence,fine and rough motor skills and language are examined by Denver II test
Screening of Early ChildhoodScreening of Early Childhood
Strabismus
Vision problems
Hearing problems
Interruption of growth
Child abuse
Teeth problems
Cornea reflex
Allen, Snellen tables
OAET Measurement of growth
and weight
History , inspection, physical examination
Physical examination
Screening of newbornScreening of newborn Hypothyroidism Phenylketonuria Hydrocephalus Cleft palate Congenital heart
deseases Hernies Undescended testis Hypospadias
Serum T4/TSH Guthrie Measurement of head
circumference Physical examination Physical examination Physical examination Physical examination Physical examination
ScreeningScreeningRoutine screening History Inspection Physical examination Laboratory tests Sensorial tests Additional screening (family history, ethnicity etc..)
Screening of school-age Screening of school-age childrenchildren
Scoliosis
Parasitosis
Behaviorial disorders
Physical examination
Stool smear
History , examination
Screening of NewbornScreening of Newborn
Newborn Screening ProgramsNewborn Screening Programs
Phenylketonuria screening program, which has been implemented in 22 cities by support of the Turkish Republic ministery of health since 1987, was carried out by Istanbul University Faculty of Medicine, Hacettepe University Faculty of Medicine, Cumhuriyet University Faculty of Medicine, Dokuzeylül University Faculty of Medicine in 74 cities.
General newborn screening programs in Turkey; 1993 Phenylketonuria 2007 Congenital hypothyroidism 2008 Biotinidase deficiency Since 2006 Newborn metabolic screening tests are being
analysed at Ankara central laboratory and İstanbul Hıfzıssıhha Institute.
Time of taking blood sample Time of taking blood sample for newborn screening testsfor newborn screening tests
Blood should be taken in the first 48-72 h, after first enteral feeding (appsolutely before child is being discharged)
For the PKY ve biotinidase screening at least 48 h enteral feeding (75 kcal/kg/day)
Blood sample taken in the first 24 h can give a false negative result for PKY and biotinidase; for hypotiroidism it can give a false positive result
Total parenteral nutrition can lead to falce negative results
If the blood sample was taken too early or before feeding, it should be repeated in 1-2 weeks
Taking blood sample Taking blood sample for newborn screeningfor newborn screening
•Heel should keep warm (max. 42 C, heated by wet towel for 3 min) and under the level of hearth
•It should be cleaned by 70% isopropyl alcohol and left to dry
•Plantar face of the heel is punctured at its media or lateral side by steril lancet (at depth of 2.0-2.4 mm)
Use of Guthrie cards Use of Guthrie cards at newborn screeningat newborn screening
The first drop of blood is cleaned by gauze, later drops make contacts with Guthrie cards an by this way 5 marked areas are fullfilled (heel should not be squeezed, carton should not be suppressed )
•Front and rear side of the card’s marked section should be filled out completely. However, blood should be absorbed at only one side.
•Blood sample should be dried at horizontal position at room temperature at least 3 hours.
•There should not be any contact at card’s marked section before and after taking blood sample.
Right blood sample
Unequal spread of blood
Blood clots at sample
Wrong filled circles
Poor saturation
Recording and delivery Recording and delivery of Guthrie cardof Guthrie card
• ID, address, name of hospital , number of sample , date of birth date of blood sampling, prematurity, transfusion, time and way of feeding should be written on Guthrie card.
• Card should be covered in an envelope and immediately delivered to City Health Council , Center of Public Health (Fatih Grup Başkanlığı ) and Refik Saydam Hıfzısıha center.
• Screening status should absolutely be recorded at file of the baby.
Screening of Screening of Phenylketonuria Phenylketonuria
Frequency 1/10 000 (Turkey: 1/4 500)
Each year 250-300 patient, from 20-25 persons one is carrier
Caracterized by sever motor-mental retardation
Detected by fluorescent immunoassay (FIA)
In the case of positive result test should be repeated (FIA, enzyme, paper chromatography, HPLC, Tandem mass spectrometry)
Ozalp I, Coşkun T, Tokatli A, Kalkanoğlu HS, Dursun A, Tokol S, Köksal G, Ozgüc M, Köse R. Newborn PKU screening in Turkey: at present and organization for future. Turk J Pediatr. 2001;43 (2):97-101.
FLOW CHART FOR PHENYLKETONURİA
BLOOD SAMPLE
İNAPPROPRİATE BLOOD SAMPLE
APPROPRİATEBLOOD SAMPLE
REPEATED BLOOD SAMPLE
SCREENING LAB.FA LEVEL
( FIA METHOD)
≤2 mg/dl 2.1 – 3.9 mg/dl ≥4 mg/dl
REPETEAD BLOOD SAMPLE
≤ 2 mg/dl ≥ 2.1 mg/dl
DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISMHPLC method FA>120µmol/L and FA/tirozin>2 follow; FA>360 µmol/L treatment.i
3 day
72 h
3.-5.day
NORMALAccess to lab3-5 day
72 h
Access to lab. 2-3 day
Biotinidase deficiency General frequency 1:60 000
Turkey 1:11 763 (117 case/year)
Convulsion, hypotonia, ataxia, vision, and hearing loss, skin rash, mental retardation, acidosis, coma, death
Screening is performed by colorimeric test
If biotinidase deficiency is +, the spectrophotometric test is performed
Baykal T, Huner G, Sarbat G, et al. Incidence of biotinidase deficiency in Turkish newborns. Acta Paediatr, 1998;87(10):110-3.Tanzer F, Sancaklar M, Büyükkayhan D. Neonatal screening for biotidinase deficiency: results of a 1-year pilot study in four cities in central Anatolia. J Pediatr Endocrinol Metab. 2009;22(12):1113-6.
FLOW CHART FOR BİOTİNİDASE DEFFİCİENCY
BLOOD SAMPLE3.-5. DAY
UNAPPROPRİAE BLOOD SAMPLE APPROPRİATE
BLOOD SAMPLEREPETEADBLOOD SAMPLE
SCREENİNG LAB.(colorimetric method)
ENZYMEACTİVİTY (+)
REPETEAED BLOOD SAMPLE
ENZYME ACTİVİTY ↓ or (-)
DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISMSpectrophotometric method <3.5U/L (enzyme activity as %)
Enzyme activity <%30 partial, <%10 total enzyme defficiency
ENZYME ACTİVİTY (+)
ENZYME ACTİVİTY ↓ or (-)
Access to lab. 2-3 day
72 h
Access to lab. 3-5 day
72 h
HypothyroidismHypothyroidism Frequency of 1/3500-4000 (World), Turkey : 1/2700
Severe growth retardation and mental retardation
Heel blod sample for screening: TSH and T4 level
TSH; primary and compensated hypothyroidism is recognized, central hypothyroidism is skipped (low false positivity)
T4; primary, secondary, tertiary hypothyroidism, TBG deficiency, hipertiroksinemi, slow rise in level is diagnostic for con. hypothyroidism (compensated hypothyroidism could be skipped)
Yordam N, Calikoğlu AS, Hatun S, Kandemir N, Oğuz H, Tezic T, Ozalp I. Screening for congenital hypothyroidism in Turkey. Eur J Pediatr.1995;154(8):614-6.Update of newborn screening and therapy and congenital hypothyroidism. Pediatrics 2006;117(6):2290-303.
Lafranchi SH. Newborn screening strategies for congenital hypothyroidism: an update. J Inherit Metab Dis. 2010 Mar 2. [Epub ahead of print]
FLOW CHART FOR CONGENİTAL HYPOTİROİDİSM
BLOOD SAMPLE
INAPPROPRİATEBLOOD SAMPLE
APPROPRİATEBLOOD SAMPLE
REPEATEDBLOOD SAMPLE
SCREENING LAB. TSH level
<15 mlU/L 15-50 mlU/L >50 mlU/L
REPEATED BLOOD SAMPLE
<15 mlU/L
NORMAL
≥15 mlU/L
APPROPRIATE LAB. Serum T4 <10µg/dl;TSH>10mlU/L
CONSULTATION OF SPECIALISTDEPARTMENT FOR
PEDIATRICENDOCRINOLOGY
Accessto lab.2-3 day
72 h
3.-5.day
Accessto lab.3-5 day
72 h
Developmental dysplasia of the hip
DDH frequency 1.49% Should be screened at all newborns by physical examination It should be repeated at each examination till child start to
walk Ortoloni and Barlow test are reliable at first 3 months Restricted abduction at hip is the most reliable after 3
months of age Ultrasound is helpfull before 4 months of age, X ray is
helpfull for diagnosis after 6 months of age Children with positive signs should be refered to ortopedist For risk infats ultrasound is suggested at the period of 4-6
weeks (breech birth, musculo-skeletal deformities, positive family history etc.)
Examination of the hip jointExamination of the hip joint
Barlow maneuver Subluxation, unstable hip
Ortoloni maneuverDislocated hip
Examination of the hip jointExamination of the hip joint
Restricted hip abduction (<60º)
Prevention of developmental hip displasiaPrevention of developmental hip displasia
Keeping hip at abduction and slightly flexion , keeping knee at flexion is the most appropriate position for the normal development of the hip joint
Swaddle and supine positions are not recommended (side position is also risky)
Keeping legs with upside down position increase the risk
Baby diapers bond should be wide ; clothes should not be narrow
Appropriate carriage (baby sling)
Iron defficiency anemia Iron defficiency anemia Frequency of 40% among toddlers in our country For term babies at 4-6 months, for preterm babies at 2-3 months
of age iron storage is becoming sufficient . İf iron defficiency lasts more then 3 months, it can lead to serious
problems of development In countries with frequency of more than 10%, for term healthy
babies it is recommended to check up Hb/Hct at the age of 6-12 months
In our country iron is given profilactic (1mg/kg) to all term born children (breastfeeding and feeding with cow milk), starting at the age of 4 months and continuing for 1 year. Among preterm born children profilaxy starts at the age of 2 months.
Control Hb should be taken at the age of 9 months Hb< 11 g/dl : treatment with iron and after 1 month control.
Treatment should be continued at least for 3 months. Hb controlu should be made at adolescence
Urinary tract infectionsUrinary tract infections Frequency: females 3%, males 1.1% The main reason for the chronic renal insufficiency at
underdeveloped and developing countries Diagnosis and treatment on time is very important Screening should be performed in the age of 5 year and
in adolescency Screening should be performed at fresh sample of urine
by stick test In the case of positive result, mycroscopic examination
should be made Detail examination of urine and urine culture should be
taken at those with symptoms of infection
Screening for congenital heart diseasesScreening for congenital heart diseases
The half of the congenital heart diseases could be detected at the first newborn physical examination
The early diagnosis makes prevention of heart failure, hypoxemia, infective endocarditis
It should be examined at all newborns by history and physical examination
Cardiovascular system should be carefully examined at each examination
Femoral artery pulse palpation, auscultation of heart are very important screening methodes
EKO screening is recommended for all babies at risk at 16. GH
HypertensionHypertension
Frequency at children: 1-3% Important for the heart, brain, kidney, eye complications For healthy children tansion should started to be measured
at the age of 3 years, and later on it should be measured at each examination
Measurement should be made at sitting position Cuff height should be 80-100% of the mid-upper arm
circumference or two thirds of the length of the upper arm Hypertension; blood pressure above 95 percentile according
to patients age and sex
Measurement of the arteria pressureMeasurement of the arteria pressure Resting for 3-5 min. before measurement
Measurement should be made at sitting position (for infants supine position)
Cuff should be put at supported right upper arm
Cuff should be placed at two thirds of the length of the upper arm, it should surround complitely circumference of the arm
Cuff should be placed 2 cm above the fossa cubitalis
A stethoscope should be placed on palpable brachial artery pulsations
Measurement of the arteria pressureMeasurement of the arteria pressure
Cuff should be inflated 20-20 mm above sistolic blood pressure and should be deflated with the speed of 2-3 mmHg/sec.
Sistolic blood pressure: point of the 1. korotkoff sound
Diastolic blood pressure: point of 5. korotkoff sound disappears
If the BP is high: it should be measured on the other arm and the other leg and measurement should be repeated 1 week later
Examination of the blood pressure Examination of the blood pressure measurementmeasurement
At least three measurements of blood pressure According to sex and age;
BP<90p= Normal: no need for folow up TA=90-95p.=borderline. No symptoms: follow up. TA=90-95p with symptoms: evaluation (urine, hemogram, urine culture, elektrolyts,
urea,creatinine, uric acid , renal ultrasound, EKG ) TA>95 p =HT: advanced evaluation at hospital
Hyperlipidemia
Atherosclerotic changes begins at childhood age . Annual risk evaluations should be done at all children after age of two Histories such as coronary artery and cerebrovascular deseases or any
sudden death caused by cardiological reasons before age of 55 at family should be interpreted.
T. cholesterol level>240 status of mother or father. Histories such as obesity, hypertension, diabetes or smoking at child. Cholesterol and lipid levels should be checked at children with risk
factors. Lipoprotein analysis should be done at children with t. cholesterol
level>200 mg/dl. Diet programs should be carried out once in each 5 years if LDL<110
mg/dl , once in each year if LDL=110-129 mg/dl , continuously if LDL>130 mg/dl.
Hearing ScreeningsHearing Screenings The frequency of hearing loss is %1-3 at normal babies, %2-4 at
babies remained in intensive care. Age of application to a health care institution is 3.8 years in our
country. A serious two-sided hearing loss influences speech and cognitive
development negatively Aim is to determine the hearing loss before third month. Initiation of treatment before sixth month has a significant effect at
language development. Newborn and infants should be screened with histories and physical
examinations in a subjective way ; subjektif, childrens at pre-school period (3-4-5 years) should be screened with hearing tests in an objective way.
It is recommended that hearing tests should be done intermittently till the end of the period of adolescence.
Hearing screenings at healthy infantsHearing screenings at healthy infants
*Newborn : Auropalpebral reflex, recoil,moro reflex
* First Month : recoil ,interruptions at feeding
* 3-4 months : Begins to turn head toward the sound source
* 4-7 months : Turns head completely toward the sound source
* 9-13 months: Finds directly source and direction of the sound
*21-24 months :Replies with short sentences against to the people who warns orally.
Children with risk factors for hearing loss
Sensorineural hearing loss history at family Birth weight <1500 g Low apgar score (1.min<5, 5.min<7) Intrauterine infection, bacterial meningitis Ventilation more than 5 days . Hyperbilirubinemia requiring blood exchange Use of ototoxic drugs AOM with effusion lasting along 3 months Syndromes accompanying with hearing loss. If otoacoustic emission test (OAE ) and brainstem evoked potentials
(ABR)should be carried out at risky children, hearing loss can be reduced at %20 percentage , this should be carried out for all children at first 48 hours .
OAE should be carried out at all babies in first 48 hours after birth.
OAE test reflects the sound energy originated at cells in the inner ear ; and measured by microphones at outer ear.
If OAE test fails , repeating after two months, If repeating fails too, then auditory brainstem responses ( ABR ) test should be carried out.
Audiometric hearing test should be done to all children in pre-school age (4 years old)
Objective Hearing Screening
Screening of visionScreening of vision
Strabismus 2-6%, refraction disorders 20%,
amblyopia 2-4% Amblyopia; loss of visual acuity ≥ 2/10 or difference
between eyes ≥2/10 In the first 3 months permanent strabismus, after 3. month
of age permanent and temporary strabismus is patological and it is the most common reason for amblyopia
If strabismus was not treated in the first 6 years it leads to amblyopia, after 12 years of age amblyopia could not be treated.
Screening of visionScreening of vision
*0-3 months red reflex
cornea reflex
inspection
* 6-12months red reflex
cornea reflex
inspection
*3 and 5 years
visual acuity
red reflex
cornea reflex
inspection
*Abnormal
assymetric
constutional disorder
*Abnormal
assymetric
constutional disorder
* Reduced
abnormal
assymetric
constutional disorder
Screening of visionScreening of vision
Newborn; response of the baby to mother’s face 2-3 months; focus on objects 4-5 months:attention to toys and enviroment 6. month: following moving objects VEP, optokinetic nystagmus 3-4-5 years; test for visual acuity Visual acuity should be periodically examined
until the end of adolescence
Red ReflexRed Reflex
• Ophthalmoscopic examination for red reflex among newborns
*red reflex examination should be repeated in a few months
*white reflection; retinoblastoma, retrolental fibroplasia, lens opacities, congenital cataract,(TORCH)
Corneal reflex(Hirschberg testi )
Health educationHealth education Good communication (non-verbal and verbal
communication) To focus attention, to show empathy Avoidance of authoritarian attitudes Talking with precise and clear language First praising right behaviors, then correcting mistakes Suggestions should be appropriate to families level Suggestions should be appropriate to child’s age İt should be checked out if suggestions are understandible Practical applications Written educational materials(brochure etc.)
First evaluationFirst evaluation(7-15. day)(7-15. day)
Benefits of breatfeedingBreastfeeding counselingUmbilical cord care, bath, clothesCleanning the skin, prevention of diaper rashCauses of crying, frequency of urine and defecationImportance of hand-washing, the hazards of smokingBed for baby, sleeping position, rhythm of sleeping (15-18 h)Disandvantages of swaddling and teatAt 15 day of life D vit. (400 ıU/day) for 1 yearBaby should not be left alone with children under 10 years oldwith
2-4. months evaluation2-4. months evaluationRelations between baby and parents or siblingsImportance of play and talk with babyGrowth and development, breastfeeding and
problemsVaccines, the importance and reactionssleeping ( at least 16 h per day, 2-3 times a day)Baby care, crying causesDefecation (consistency is more important than
number)Risk for aspirationFamily planning (1.5- 2 months control)
6-9. month evaluation6-9. month evaluationHarmony in the familyExamination of growth and developmentcontinuation of breastfeedingVaccines, the importance and reactionsCare and hygienesleeping (12-14 h, at least 2 times a day) Importance of playing with babyAdditional feeding, eating using a spoon and glassFall from a height, hot water, sockets, water-filled
containersCare of milk teeth
1 year evaluation1 year evaluation Introduction to family table (3 main meals, 2 snacks)Encourage self-feedingsleeping (at least once at daylights)Brushing teeth with a soft brush without toothpasteMeasures to be taken to prevent accidentsSetting rules and discipline, praise and reward
constraintWish for independence should not be supressed but
should be supervisedThere could be a lack of appetite, no need for force
2-3 year evaluation2-3 year evaluation
Importance of introducing a child to a family table Balanced nutrition Loss of appetite Adequate consumption of milk Accidents discipline (prize, penalty) Time for sleeping (once a day) Teeth care, visiting dentist Playing games under control Toilet habits
4-5. year evaluation4-5. year evaluation Balanced feeding, importance of conversations at family
table Friends, playing games (under control) Answering questions about sexuality Dental care(brushing teeth with fluoride toothpaste for
children), visiting dentist sleeping (sleeping at daylight not necessary) Support for pre-school education Name, surname, address and telephone number should be
taught Child should be worned regarding foreigners Household and responsibility Traffic rules
6-11 year6-11 yearSleeping patterns (going to bed at 20.00-21.00
o’clock, totally 9-10 hours of sleeping)Balanced feeding, prevention of snack between
meals, importance of breakfasttooth brushing (twice a day), visiting dentistAnswers to questions about sexualitySchool adjustment, learning problemsTV, computer games (1 hour per day)Education regarding child abuse preventing accidentsHabits of reading books
12- 21 year evaluation12- 21 year evaluation
Healthy communication Respect for private life TV, computer games, internet usage should be supervised Smoking, substance use, sleeping (8-10 h), regular exercişse(at least 3 times a week)) Balanced feedşng (3 meals) Brushing teeth, visiting dentist (twice a year) No weapons at home, preventions of accidents Questions and issues related to sexuality, encourage the education and development of new skills
In our country;
0-1 years old 60%
1-5 years old 70% children benefit from “monitoring of children’s health “
RecommendationsRecommendations
“Monitoring of children’s health “ outpatient departments should be increased;Those departments should be integrated to general child outpatient departments;“Monitoring of children’s health “ service including health education and education of parents;It should be understood as ‘ missed opportunities’