Overview of the WCC visits from 1 to 2 years of age

Maria I. Diaz, MDSt. Barnabas Hospital

Department of Pediatrics8/27/09

Overview Interval history and anticipatory guidance:

DietEliminationSleepDentitionDevelopment and behaviorInjury prevention

Physical Exam. Immunizations. Screening. Questions

DIET

DIETAmount and frequency of feedings:Three meals and two nutritious snacks per day. Include infant in family meals.

Table vs Baby foods, including types:Continue to introduce table foods in amount and variety. No peanuts, popcorn, hot dogs, candy, no bones. Encourage parents to give fresh fruits, encourage Fe rich foods.

DIETWhole milk intake:Limit whole milk intake to 24 oz/day.Juice intake:Limit juice intake (4-6oz/day), encourage water. Offer drinks in a cup; wean bottle.Appetite/food refusal: Advise that appetite may vary and that weight

gain may slow down. Avoid food battles. Resist offering food to

console or reward.

Elimination

Stools: Frequency and consistency of stools may

change. Discuss what constitutes constipation.

Urine: At least 3-4 wet diapers a day.May discuss readiness for potty training- may be too early.

Sleep Patterns

Sleep schedule, including naps:Maintain bedtime routine

Is the child waking up at night? Why? ?Teething, night terrors, hungry.

Delay entry to room; reassurance without picking

infant up.

Dentition

How many teeth so far?

Dentition

Ensure regular dental visits.

Don’t let infant sleep with bottle/pacifier in mouth.

Does the child let you brush teeth?Use non-fluoride toothpaste or wipe teeth or

toothbrush with water

Development and Behavior

Surveillance 12 m/o 15 m/o 18 m/o M-CHAT 24 m/o

Development and Behavior

A baby taking her first steps, a developmental milestone most babies reach between 11 and 15 months.

Development and Behavior

Picks up pellet with unassisted pincer movement of forefinger and thumb by 1 y.

Development and Behavior by 1 y

A few words besides “mama”, “dada”.

Plays simple ball game;

Development and Behavior

A baby waving bye-bye, a developmental milestone that most babies can reach once they are 7 to 14 months old

If a child displays any of the following signs he or she should be referred.•Does not crawl •Cannot stand when supported •Does not search for objects that are hidden while he watches.•Says no single words ("mama" or "dada") •Does not learn to use gestures, such as waving or shaking head •Does not point to pictures or objects

DEVELOPMENTAL HEALTH WATCH by 1y/age

Development and Behavior

Pretend play, or imitating activities, developmental milestone that most infants reach when they are about 10 to 16 months old

Development and Behavior by 15 m

Walks alone; crawls up stairs by 15 m

Makes tower of 3 cubes

Development and Behavior by 15 m

Indicates some desires or needs by pointing; hugs parents.

Development and Behavior by 18 m

Walks up stair with one hand held; explores drawers and wastebaskets.

Development and Behavior by 18 m

10 words (average); names pictures; identifies one or more parts of the body.

Development and Behavior by 18 m

By 18 months, you might be thinking of temper tantrums and the terrible twos, but this is also a very fun time with your kids

Development and Behavior by 2 y

Runs well, walks up and down the stairs, one step at a time; opens doors.

Tower of 7 cubes; circular scribbling; imitates horizontal strokes.

Development and Behavior by 2 y

Listens to stories with pictures.

Development and Behavior by 2 y

Two-year-olds are beginningto communicate quite a bit, as their vocabulary grows to more than 50 words and they begin to put words together.

Development and Behavior by 2 y

Parallel play, typical of most kids around age two

If a child displays any of the following signs they should be referred:

•Cannot walk by 18 months •Walks exclusively on toes •Does not speak 15 words by 18 months •Does not use two-word sentences by age 2 •Does not follow simple instruction by age 2

DEVELOPMENTAL HEALTH WATCH

Injury Prevention

• Do not leave child unattended-EVER.

• Monitor siblings around child.• Monitor child’s behavior around

pets.

Injury Prevention

Car seat:Forward-facing car seat used in back (if child > 20 pounds).

Injury Prevention

Issues1. Baby proof

home?

Anticipatory GuidanceWindow guards, safety plugs, cabinet clips, gates.Tie up dangling cords.Safe play zone in home.Keep small or sharp objects out of child’s reach, including cigarettes, matches, lighters.

Injury Prevention

Issues1. Baby proof

home?

Anticipatory Guidance

Water safety in bathtubs, pools, check water temperature. Keep buckets, bathtubs empty after use.

Injury Prevention

Don’t cook/hold hot liquids while holding infant. Don’t leave hot items unattended in areas accessible to infant.

Injury Prevention

Injury Prevention

IssuesBaby proof home?

Anticipatory GuidanceKeep poisonous

substances, medicines, cleansers, etc. out of child’s reach.

Keep all products in their original containers, safety caps on at all times.

Poison control number should be accessible.

Physical Exam Height, weight and head circumference

parameters. General: overall; observe for

developmental milestones. HEENT: Check dentition. CV: Heart murmurs. Abd: Hernias, masses. Ext: In toeing / tibia torsion, bowed legs,

toe-walking. Skin: rashes, neuro stigmata. Neuro: Tone.

Immunizations

1. 12 m/o

2. 15 m/o

3. 18 m/o

4. 24 m/o

See schedule.

Screening

Issues1. Anemia

screening.

2. Lead screening.

3. Tuberculosis screening.

Anticipatory Guidance

1. Iron rich foods.

2. Lead safety tips.

3. Risk factors.

Follow up: next WC visit

12 m 3 m 15 m 3 m 18 m 3-6 mEarlier f/u visit if medically or

socially indicated.

Questions

Physical examination results are normal for a 2-year-old girl during a health supervision visit. She follows two-step commands, speaks 10 words, points to pictures that you name, and sorts objects by color. She uses a spoon well, but does not use a fork. She plays alongside other children but does not share toys. Her mother would like to know if she should be concerned about the girl's development.

Of the following, your BEST response is that her daughter:

1. Has normal development 2. Is delayed in her expressive language

skills 3. Is delayed in her fine motor skills4. Likely has a hearing impairment 5. Needs more social interaction with other

children

You are examining a young boy during a health supervision visit. His mother reports that he says "mama, " "dada," "bye," "up," and "ball." Following the examination, he sits on the floor in front of his mother while playing with a toy car. When he sees a jack-in-the-box on a shelf, he points to it. After being instructed to do so by his mother, he brings the jack-in-the-box to her.

Of the following, these developmental milestones suggest that the child is CLOSEST to

1. 12 months of age 2. 15 months of age3. 18 months of age4. 21 months of age5. 24 months of age

The mother of a 2-year-old girl is very concerned that her daughter is developmentally delayed. She explains that the girl speaks in two- to three-word phrases. She can feed herself with a spoon, but is unable to button her clothing. She can follow simple two-step commands and can climb stairs. However, she is not yet toilet trained. Findings on physical examination are unremarkable.

Of the following, you are MOST likely to:1. Discuss the normal developmental milestones of a 2-year-old child

2. Refer the child for a neuro-developmental evaluation3. Refer the child for audiologic evaluation4. Refer the child for occupational therapy 5. Schedule a 6-month follow-up evaluation to see if the

child has reached the milestones

One of your 2-year-old patients has prolonged crying and screaming episodes every time her parents deny her access to something she desires. The mother reports that the girl often throws herself on the floor, kicking and thrashing about for long periods of time. She asks you how she should handle her daughter's behavior.

Of the following, your BEST suggestion is that the parents should: 1. Consider giving in to the girl only when she is outside of the home to avoid a major tantrum

2. Give the daughter 10 minutes of time-out for each temper tantrum

3. Move the girl to a safe place if needed and ignore her when she has a tantrum

4. Offer the child a treat if she calms down5. Physically restrain the child until the tantrum is over