Child and Adolescent Care

00:00 Okay, more fun stuff.

00:02 I’m going to talk about the health maintenance for children and adolescents and I’ll be using guidelines to talk about how to keep them healthy along with some personal experience with best practices for children and adolescent care.

00:17 So you always want to establish a good history for kids particularly during early childhood so you’re going to want to ask about a birth history but that doesn’t mean every single aspect of the birth history or how the child felt as they were being delivered, they’re probably not going to be able to answer that question too well.

00:35 But you do want to know how old was mom when you were born, any problems during pregnancy, at what gestational age was the child born, and any problems after delivery.

00:49 I think those are really the key points that you want to elucidate.

00:52 Getting a birth weight is important during infant year, not so much after they pass two years of age, it’s not as critical.

01:00 You’re going to want to ask about child development, and so asking the parent or caregiver about development and developmental stages.

01:08 That should be part of your records so that’s just easy to go through a list.

01:13 I find it, because I have a varied practice, difficult to remember all of the different milestones at different stages.

01:21 But the other thing I would recommend doing is certain things the child can actually do for you right there.

01:28 Can the child tell time? Well, that’s one of the reasons I have a watch with hands on it instead of a digital watch.

01:34 That’s why I wear a watch at all.

01:35 You can't just show them the phone, they’ll read the numbers.

01:39 Can they tell their left from their right side, can they put on their shoes, can they hop, skip, and jump? These are kind of fun things you can do in the office just to cross-check the development.

01:48 It doesn’t mean you don’t believe the parents, but it allows for more time, and speaking of that, watch that home environment, that’s at many times reflected in the clinical encounter.

02:01 So while I’m sitting back and taking all this history, I’m actually doing an exam as well.

02:06 Even though I’m sitting there and the child’s with the caregiver on the other side of the room maybe, I’m watching how they interact.

02:13 I’m watching how the child interacts with me, the environment, its siblings, and therefore, I think it’s giving me some conclusions as to maybe this child is withdrawn.

02:26 Maybe there’s some negative interaction that I see between the parent, maybe there’s a tension there.

02:33 And that can clue in as to maybe the kid’s not doing as well in school or having more accidents.

02:39 So watching that interaction, it’s a nice chance just to observe a child.

02:43 ADHD is another good example, is the child hyperactive in the room I have stories about, you know, “Oh, he can’t be controlled” and “Billy’s going wild.” And then you look at poor Billy, you know, the five-year-old, who’s just sitting there with hands on his lap kind of looking like this down at the floor and you realize it may not be the problem with the kid so much as the parent.

03:03 And that’s critical as well for thinking about school readiness.

03:08 To me, I work in a setting with low-income patients.

03:14 I think the biggest risk I see to this child’s health and wellbeing overall isn’t tuberculosis or anemia or even obesity, as important as that is for kids.

03:27 It’s failure to progress well in school.

03:30 And so I always -- starting certainly in those developmental stages, and then focusing a lot once they get to pre-K, prekindergarten education, I’m talking about what they’re doing in school and how much they’re reading, because getting -- you know, not just passing through school.

03:47 So many kids that I see are very happy with Cs and Ds because they’re just passing on to the next grade.

03:53 But that’s not going to keep them competitive and get them where they want to be by the time they reach in junior high and high school.

04:00 So talking about school readiness is important really at every stage.

04:04 Diet, spend a lot of time on diet with kids.

04:08 The things that I really focus on for healthy diet and prevention of obesity are two.

04:14 One, if there’s some intake of fruits and vegetables, at least some on a regular basis, and if they’re avoiding sugar-sweetened beverages; between those two things you can avoid a lot of pitfalls when it comes to obese kids.

04:30 Of course, you want to asses a full diet, but that’s one thing -- a pearl I like to share.

04:36 The other, physical activity, it’s usually not a problem for younger children because they want to go out and play, you just need to give them the environment to go out and play.

04:45 If that is a problem because of the physical environment, parents try to get that kid out there, and what’s good for the kid is good for the family.

04:52 So oftentimes when I see an obese four-year-old, they have an obese nine-year-old sibling, and mom and dad are obese too.

04:59 So it’s good for that kid walking, you know, around the block six times a day at a good rate is a good for the family too.

05:06 The other pitfall with physical activity that I find is particularly among girls and particularly when they turn around 11 years old, that desire to play and the social acceptability of that goes down.

05:20 And, you know, what’s important, well, it’s socializing, and that is important.

05:27 But sitting, texting, talking, that doesn’t necessarily help with in terms of reducing the risk of obesity.

05:37 Boys, it is a little different and I’m sorry it’s a cultural bias, but it is there, that still many are in sports and they play sports as their form of socialization, if girls don’t have that outlet.

05:50 And it can be sports, it can also be things like dance or other forms of activity, but really I try to watch girls in particular because I think that’s a critical period where they can start gaining weight.

06:03 Sleep, important for kids, most kids I find, the younger kids are getting enough sleep and doing it right; adolescents, more of a challenge.

06:13 They want to stay up till midnight, they want to sleep in till 10 AM, therefore, they might be skipping breakfast, which goes back to nutritional issues that are concerning.

06:22 So really, I try to stay on to ensure that they have a good environment for sleep as well.

06:29 All right.

06:30 So a head-to-toe exam, I’m just going to highlight a few things.

06:33 Every child gets a body mass index at each visit.

06:37 Cardiac exam is one of the more important exams you can do particularly for a pre-participation physical for a child that’s going in to a sport You’re going to want to do both the full cardiac exam including palpation, auscultation while sitting and standing, assessment for a heave, assessment of the PMI, all that, So a complete exam for those kids.

06:58 Hips get checked for laxity through age two years, so that’s a critical one.

07:06 And genitalia, kids may feel embarrassed but it’s important to continue to check and this is just a quick inspection for boys, you know, making sure the testicles are descended bilaterally.

07:19 But it is important, it’s part of the physical nature of the exam so we should make sure that gets done.

07:26 All right, what about recommended screening exams among children? This is good fodder for your exam as well.

07:31 The maximum time or the highest point prevalence for anemia in childhood is at one year old, so absolutely they should have a hemoglobin check at that time.

07:41 Many of us continue to check annually during a high-risk period between one and five years old, these are for average-risk kids, all of these recommendations.

07:52 But after five years old, if they’ve had normal hemoglobin levels, it’s not really a strong imperative to continue to check it.

07:59 Hearing and vision, try to check it at age four years.

08:02 The kids may or may not be cooperative, but usually, if you’re a little bit patient, they will give you a good hearing and vision check.

08:13 Fluoride varnish I think is miraculous, I think of it like vaccines for the teeth.

08:19 And again, this is from personal experience.

08:21 I know that dental care among the toddler set is a real challenge, getting them to brush twice daily, getting them to floss even worse.

08:32 Fluoride varnish kind of has my back in that it’s going to be protective against dental carries.

08:37 So it’s a great idea.

08:39 And so make sure they’re visiting the dentist every six months.

08:43 So the American Academy of Pediatrics recommends lipid screening between 9 and 11 years of age and again in late adolescence.

08:51 I do believe in that because getting the result and getting the number could show who’s at risk and therefore be motivational for kids to change their diet.

09:02 And then for all kids, considering lead and tuberculosis screening in those at-risk, particularly those who have immigrated here from low-income countries.

09:14 Vaccinations. Just to cover a few pearls on vaccinations, not meant to be comprehensive in the review of vaccinations today.

09:22 That would take a long time.

09:24 But we give the acellular pertussis vaccine because it’s associated with less side effects, particularly seizures versus the whole cell vaccine.

09:30 However, what’s becoming more and more evident is that the immunity induced by the acellular pertussis vaccine is not as strong and that’s why there’s now a booster recommended for kids routinely at age 11 to 12 years after the usual booster between four and six years of age.

09:47 And the overall protective effect of these vaccines may only be a few years.

09:53 In several outbreaks of pertussis in California, children who are up-to-date in their vaccination still acquired pertussis, although the severity of infection tends not to be as bad when you’ve been vaccinated.

10:06 Human papilloma virus vaccine, this is a tremendous advance in the use of vaccines.

10:13 It’s a vaccine that can actually prevent cancer, yet it remains underused.

10:18 I think it’s something along the lines of 60% of females are receiving the vaccine, and much lower rates of coverage among males.

10:26 But it is recommended between ages 9 and 26 years for both boys and girls and I try to give it earlier rather than later.

10:36 The vaccine is a lot less effective after an individual has initiated sexual activity, so give it beforehand.

10:42 I’m an advocate in healthy kids of trying to get it on board at age nine.

10:48 All right.

10:49 And then some vaccines are frequently forgotten.

10:52 The meningococcal vaccination can prevent a terrible outcome of invasive meningococcal disease.

10:59 So, that one is at age 11 to 12 and 16 to 18.

11:02 And don’t forget the influenza vaccine, important in kids, and that’s every fall.

11:08 So another area that’s somewhat controversial is screening for autism because the United States Preventive Services Task Force found insufficient evidence that screening for autism is effective, but the American Academy of Pediatrics recommends using a validated tool at age 18 and 24 months.

11:27 The most commonly used is the Modified Checklist for Autism in Toddlers.

11:31 This was associated with a high false-positive rates.

11:33 They went back to the drawing board and came out the M-CHAT Revised with Follow-up, and that two-stage screening process improved on the specificity.

11:43 And one of the reasons to screen is that we now know with autism spectrum disorders that early intensive therapy has significant improvements in language, cognition, and adaptability, critical outcomes in patients with autism.

12:00 All right, among adolescents now specifically, again, the body mass index really should be conducted at every exam, every well child exam.

12:08 For sexually active females, they should be screened for chlamydia and gonorrhea that does not involve pelvic examination.

12:14 Urine test with DNA analysis is sufficient.

12:18 And a screening for depression among adolescents between 12 and 18 years old is recommended as long as there’s follow up available.

12:26 Things we don’t screen for, and this might come up on your exam.

12:28 We don’t screen routinely for scoliosis anymore, nor do we screen for cervical cancer until age 21 years.

12:35 So it’s really not part of adolescent medicine right now.

12:38 Instead, what I’d recommend is this mnemonic for assessing adolescents.

12:44 Looking at their home and environment, looking at education and employment and they start to become employed, what kind of activities are they doing outside of school, and then some risk factors: drugs, sexuality, and the risk of suicide and depression.

13:01 All those are critical issues during adolescence that you want to be aware of.

13:07 Let’s talk about risky behaviors among adolescents.

13:10 Let’s start with sexual activity.

13:13 And there’s a picture for you.

13:15 It’s romance down by the dirty creek, in the mud, with a bunch of sticks lying around.

13:21 So in the next two minutes this couple will be attacked by ants, and yet oh young love, it’s awesome.

13:27 And about half of adolescents report being sexually active, overall, the rate of sexual activity among adolescents is actually falling.

13:34 And even better, the adolescent pregnancy rate has declined precipitously in the last 10 to 15 years, and that’s great.

13:43 So the keys to maintaining a healthy sexual being during adolescence is good, open communication with the adolescent about what they’re doing and having an open discussion about different family planning options and those should absolutely include long-acting reversible contraceptive methods because that’s what really makes, I think, pregnancy rates fall when it comes to adolescent sexual activity.

14:15 So let’s focus no on alcohol use.

14:18 Keys to curbing alcohol use and particularly risky alcohol use which is higher among adolescents is just be open and direct about the subject.

14:28 Really try to emphasize that alcohol is going to impair judgment and I think a lot of adolescents are cognizant of the fact how it affects driving and the risk for drinking and driving, at least intellectually they understand this.

14:41 But it also is a risk regarding sexual choices and that might resonate with adolescents a little more that I found.

14:48 And then you want to try to get a commitment and maybe that’s absence from alcohol and that’s great, but certainly you want to avoid those risky behaviors, drinking and driving.

14:59 Make a commitment that the adolescent has to call their parents if they ever are impaired due to alcohol, and make sure the parent understands that when that call comes they can’t be overly punitive on their adolescent.

15:11 At least the adolescent did the right thing and called them instead of getting behind the wheel or getting in another risky situation.

15:19 All right.

15:20 With that, I hope this was helpful in thinking about the care of children and adolescents.

15:25 There are a lot of pearls for clinical practice there, but if you look at those guidelines, there are also a lot of questions you’re going to see on your exam.

15:32 Thanks.