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Health Supervision III Visit Guidelines-Sl Revised
Health Supervision III Visit Guidelines-Sl Revised
Health Supervision III Visit Guidelines-Sl Revised
VISIT GUIDELINES
SCHOOL-AGED CHILD
SUZANNE LEFEVRE MD
Anticipatory Guidance:
Kids age 4-8 need 800mg of Calcium per day; one 8 oz glass of milk contains 300mg
Recommend limiting juice to no more than 6 oz of 100% fruit juice.
Food jags (favoring 1 or 2 foods) and picky eating are normal behaviors.
Anticipatory Guidance
No specific interventions are warranted for night time wetting
because its so common at this age.
Stress importance of balanced diet in preventing constipation
Height
Weight
Blood Pressure
General physical exam to include
Visual acuity- objective
Hearing screen- objective
Check for obvious dental caries
Check gait, spine and extremities
Be alert for signs of abuse
Screening: Hemoglobin if at risk for anemia (i.e., special health
needs, low iron diet or environmental factors
Immunizations: See current recommended schedule (DTaP, IPV,
MMRV)
Anticipatory Guidance
No specific interventions are warranted for night time wetting
at this age.
Sleep Patterns
Same as 4 year old visit
Screening
Urinalysis
Other screening as indicated by risk: lead,
hemoglobin, PPD
Regular exercise/family
activities
Brush teeth at least 2
times per day. See
dentist 2 times per year.
TV viewing should be
limited and monitored
Encourage interaction
with other kids,
grandparents and adults
Spend time playing with
child every day
Elimination
Child: Do you have a
bowel movement every
day? Is it hard or soft?
Does it hurt?
Parent: Does your child
have problems with day
time wetting, night time
wetting or soiling?
Anticipatory Guidance
By age 6 only 10% of
children will wet the bed
If problems are
identified, enuresis,
constipation and
encopresis.
Screening:
Same as 5 year old
School Readiness
Years from 3 to 6 are historically called preschool because of
their importance for preparing the child for the tasks of school
Determine any parental concerns about school readiness by
asking trigger questions
School Readiness
Parental concerns regarding developmental milestones
Communication/Language
Knowledge of letters,
words and symbols
Ability to recognize letters
and numbers
Articulate speech
Behavioral/Emotional Skills
Ability to take another
persons point of view and
follow rules
Separation anxiety
Social shyness
Temper tantrums and
tendency to be aggressive
when fearful are indicators
of emotional immaturity
Selective Attention
Ability to attend to important stimuli and ignore distractions
Deficit: Difficulty following multi-step instructions, completing assignments
and behaving well
Sequencing
Ability to remember things in order
Deficit: Difficulty organizing assignments, planning, spelling and telling
time
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004
Expressive
Ability to recall required words effortlessly (word finding), to control
meanings by varying position and word endings, to construct meaningful
paragraphs and stories
Deficit: Difficulty expressing feelings and using words for self-defense,
with resulting frustration and physical acting out; struggling during circle
time and language based subjects
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004
References
Bright Futures, Health Supervision III
Guidelines 2008 AAP Publication
Caring for your Baby and Young Child
AAP Publication
Nelsons Textbook of Pediatrics 2004
Pediatrics: A Primary Care Approach,
Carol Berkowitz, MD, FAAP, 2008
Nutrition
School
Child: What subjects do you like? What do you think about your
grades?
Parent: How are your childs reading and writing skills? What did you
learn at the parent-teacher conference?
If school failure is suspected discuss need for comprehensive approach
involving parents, school and pediatrician.
Height
Weight
Blood Pressure
Look for signs of puberty
Screening
Hemoglobin, PPD if high risk
Nutrition
Sleep Patterns
Development/ Behavior
Child: Where do you spend your time after school?
Parent: What are the most enjoyable activities you do together? What
activities are most likely to cause friction or problems?
Age 10 is a prime year for sports competition. Year round participation in
multiple sports my reduce over-use injuries of same muscle groups.
Strength training is appropriate with proper supervision.
Parents should discuss tobacco, alcohol and illicit drug use.
Encourage parents to prepare girls for menarche.
Height
Weight
Blood Pressure
Make sure to include assessment for scoliosis, Tanner staging and
exam of genitalia
Screening
Hemoglobin for menstruating females
Urine dipstick should be done between 11 and 21
Cholesterol and PPD for high risk kids
Injury Prevention
Seat belts
No power tools unless supervised
Water activities should be supervised
Children this age should not operate personal watercraft
Sunburn protection
School Failure
Failure in school can have lifelong consequences. The causes of
school failure are often multiple including: chronic illness,
behavioral, emotional and social issues
Background
10 15% of school age children repeat or fail a grade
More likely among males, minorities, low socio-economic status and
single parent households
Children with disabilities are nearly 3 times as likely to repeat a grade as
those with no disability
Disability
Learning
Speech or language impairment
Mental retardation
Emotionally disturbed
Children who are small for gestational age are nearly twice as likely to
experience school failure
School Failure
Background
Grade failure is linked strongly to subsequent dropping out of high
school
10% of drop-outs had no failures
22% of drop-outs failed one grade
39% of drop-outs failed 2 grades
School Failure
Conditions and Associated Factors
Endogenous Factors
Chronic disease
Anemia
Asthma
Sleep Apnea
Cystic Fibrosis
SLE
Crohns Disease
Acute conditions causing school absence
Sensory impairment
Vision
Hearing
Perinatal conditions
Prematurity
FAS
In utero drug exposure
Maternal conditions affecting pregnancy
Neurologic disorders
Brain injury
Tic disorders
Seizure disorders
Toxic exposures
Endogenous Factors
Learning disability
Language and Speech Disorder
Phonologic language
Expressive language
Receptive language
Stuttering
Learning disorder
Reading
Writing
Mathematics
Mental Retardation
Communication disorders
ADHD
Autistic spectrum disorders
Genetic disorders: Fragile x
Endocrine disorders: Hypothyroidism
Psychiatric disorders
Oppositional defiant disorder
Conduct disorder
OCD
Anxiety disorders: phobias, panic
Substance abuse
School Failure
Conditions and Associated Factors
Exogenous Factors
Family
Divorce/Separation/conflict
Poverty
Frequent moves
Substance abuse
Depression
Attitudes towards education
Low level of family support
Inadequate accommodations
for studies at home
Neglect/Abuse
Environment
Neighborhood/housing
TV/computers
Peers
Peer pressure for low performance
Substance abuse
Exogenous Factors
School Failure
Medical Assessment and Subsequent Interventions
History
School history
Details of current difficulties
School setting
Educational support
School absences
Achievement
Onset of problems
Results of educational testing
Preschool performance
Communication with the school
Attention profile
Attention
Hyperactivity
Impulsivity
Family history
Educational achievement and difficulties
Mental retardation
ADHD
General conditions
Tic disorders
PKU
Thyroid disease
Psychiatric disorders
Pregnancy complications
Birth complications
Prematurity
Hypoxia
Low Birth weight
History
Developmental history
Motor milestones
Language milestones
Regression
Social skills
Temperament
Current Medical Conditions
Acute
Chronic
Medications
Past medical history
Head trauma
CNS conditions
Sleep history
Social history
Peer group
Family stress: poverty, conflict, single
parent
Family orientation toward education
Mobility
Extracurricular activities
Substance abuse
Sexual behavior
Nutrition: diet
Strengths
Developmental Assessment
Vision and Hearing Screen
Physical Exam
Laboratory screening
School Failure
Medical Assessment and Subsequent Interventions
School Failure Interventions
As indicated by assessment
(e.g., treatment of
hypothyroidism)
Advocate for more complete
assessment
Attend school meetings
Advocate for IEP that consists
of more than simply having a
child repeat the grade that
was failed
Advocate for alternatives to
grade retention
Mixed-age classes
Individualized instruction
Tutoring
Home assistance program
Smaller class size
Alternative education settings
Guidance counseling
School Failure
Medical Assessment and Subsequent Interventions
Prevention
Promote school readiness during health supervision visits
Assess childrens strengths and weaknesses
Assess educational progress at all health supervision visits
Implement some interventions listed previously before failure occurs
Assess peers, activities, and health-impairing behaviors