What nutrition deficiencies are common in 3 year olds?
Pre-schoolers can suffer from poor nutrition. Inadequate fruit, vegetable, and iron intake is quite common.
Calcium and vitaA deficiencies are also common.
What type of vitamin supplementation should children receive?
Vitamin D because it is very difficult to attain he rec. daily allowance through nutritional sources or from sun exposure.
Toilet training for a three year old:
Toddlers at age 3 may not have achieved full toilet “independence” especially toddlers with intense, willful temperaments. Requiring assistance toileting is not a clear sign of developmental delay at this age, but may preclude attendance at child care or preschool.
When do the AAPD and AAP say that all children should be seen by a dentist?
Within 6 mo of the first tooth eruption or by one year of age.
What does the AAP state all children should be screened for by 6 months?
They should be screened by 6 mo to see if they are at a higher risk of developing caries.
When do many dentists feel the first visit should be?
At age 3
What does the National Transportation Safety Board advise for children older than 24 mo?
(or those who have outgrown the weight and height limits on their car seats) should be in a forward-facing car seat
How long should kids over 24 mo stay in a booster seat?
Until they reach a height of 4’9” (142 cm).
What is a major morbidity in the preschool years?
Injuries
Who should evaluate children less than 3 yrs with suspected developmental problems?
Early intervention (state mandated support for children with developmental delays), A developmental-behavioral pediatrician, a child psychiatrist or child psychologist, early childhood learning specialists
Who should evaluate children 3-5 yrs with suspected developmental problems?
If problems detected early, services provided by the school system for 3-5 yr olds can often help these children catch up with their peers.
Socio-emotional developmental milestones for a 3 yr old:
Dresses self and feeds self
Communication developmental milestones for a 3 yr old:
Speaks in 2 to 3 word sentences. 75% understandable.
Cognitive developmental milestones for a 3 yr old:
Knows name and use of “cup, ball, spoon, crayon”
Physical developmental milestones for a 3yr old:
Builds tower of 6-8 cubes, Throws a ball overhand, Rides a tricycle and Copies a circle.
Socio-emotional developmental milestones for a 4 yr old:
Knows gender and age, Friendly with other children, Plays with toys/engages in fantasy play.
Communication developmental milestones for a 4 yr old:
States first and last name, sings a song, most speech clearly understandable.
Cognitive developmental milestones for a 4 yr old:
Names colors, aware of gender, plays board games, draws person with 3 parts, copies a cross.
Physical developmental milestones for a 4 yr old:
Hops on one foot, Balances for 2 seconds, Pours, cuts and mashes own food, Brushes teeth.
Socio-emotional developmental milestones for a 5 yr old:
Listens and attends, Can tell difference between real and make-believe, Shows sympathy/concern for others.
Communication developmental milestones for a 5 yr old:
Articulates well, Tells a simple story using full sentences, Uses appropriate tenses and pronouns, Counts to 10, Follows simple directions.
Cognitive developmental milestones for a 5 yr old:
As children get ready for school, devel. milestones shift to more cognitive processes. Asking parents about school performance is as important as the following: Draws a person with greater than 6 body parts, Prints some letters and numbers, Copies squares and triangles.
Physical developmental milestones for a 5 yr old:
Balances on one foot, Hops and skips, Ties a knot, Has mature pencil grasp, Undresses/dresses with minimal assistance.
What does a typical eczema eruption look like?
Thickened skin and inflammation.
What has eczema been called?
“the itch that rashes” because there is a cycle of irritation leading to scratching, leading to the rash.
What should you educate parents about eczema?
Anything leading to itching (even a child’s rubbing his face on Mom’s sweater) can exacerbate eczema.
How eczema relates to allergies:
Eczema often occurs without a history of allergies. Eczema that occurs with allergies supports an atopic diathesis and should prompt you to ask additional questions about allergic triggers and asthma symptoms.
Family history of eczema?
Eczema tends to be familial, but there are typically multifactorial inheritance patterns and often clear environmental (allergic) triggers.
What are the basic tenets of eczema treatment?
Protecting the skin by lubricating extensively, using anti-inflammatories in short bursts and treating associated skin infections aggressively
What is the best pharmacological treatment for eczema?
Topical hydrocortisone, alternating a higher concentration for severe flares with a lower concentration for minor bouts. Often OTC hydrocortisone is inadequate.
What are the newer anti-inflammatory topicals?
Calcineurin inhibitors. Have proven effective for eczema, although safety concerns have not been fully resolved in this class of medications.
What can help with the itch of eczema?
Simply prescribing antihistamines.
What non-sedating antihistamines are approved for children?
Loratadine (Claritin) and Cetirizine (Zyrtec) may be effective.
What are the traditional antihistamines and what are they used for?
They have sedative side effects. Diphenhydramine (benadryl) and hydroxyzine (Atarax or Vistaril) are often used at bedtime to decrease itch.
What’s important to keep in mind when developing an effective treatment plan?
What treatment has been used already.
Sometime eczema may be confused with what other common inflammatory rashes?
Psoriasis and Seborrhea
What is Psoriasis?
Although psoriasis can occasionally first look like eczema, it is rare in children this young (3 yrs). When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection.
What is Seborrhea?
While it is unusual to have a new case of seborrheic dermatitis at age 3, this should also be part of the differential diagnosis, esp in early infancy (eg cradle cap)
What did a nutritional study of preschool-aged children 2 to 3 years old find?
The study found that these children consumed, on average, about 80% of the recommended fruit servings/day, but only 30% of the recommended vegetable servings/day.
Why is iron intake so important in toddlers and where do they get most of their iron intake?
Predominantly from meat, legumes, and iron fortified cereals. Iron is important for normal development in this age group due to its role as a CNS co-catalyst.
What do recent studies suggest about preschoolers intake of fruit and milk?
100% fruit juice intake and milk may be deficient in many preschoolers diets, with substitution of fruit drinks or other high-fructose corn syrup-sweetened beverages.
How much juice per day does the AAP recommend?
No more than 4-6 oz juice per day.
What does early childhood caries typically have?
A lag time before visible decay. The patterns established when a child is 1 to 3 years old may result in caries when the child is 3 to 5 years old.
Why should bottle use be discontinued by 12 to 15 months?
Although constant use is most damaging, even routine bedtime use of the bottle can lead to cavities. In older toddlers, it becomes more difficult if the bottle has become their transition object or “lovey”
What can promote obesity in children?
Food rewards and punishment in preschoolers can promote obesity by interfering with children’s ability to regulate their own food intake.
What should you do first in a physical exam of a toddler?
Listen with your stethoscope first in case they start crying.
What aspects of the physical exam should you focus on if the exam needs to be truncated due to child’s behavior?
Neurodevelopment, Monitoring previously recognized findings, New findings identified by parents and physical problems common in preschoolers for which intervention may be helpful.
What should you focus on in the HEENT exam?
Mouth - caries
Ears - middle ear effusions that may persist after earlier URI and affect hearing
What should you focus on in the Eye exam?
Strabismus
What should you focus on in the neck exam?
An enlarged thyroid is rare in children. Many children have “shotty” nodes (pea or marble sized contender easily mobile lymph nodes that are not fixed to surrounding structures) in the anterior and occasionally posterior cervical chain. These are normal in cervical and inguinal chains in children and may persist for years.
What should you focus on in the cardiac exam?
Most murmurs will be functional. New murmurs of congenital heart disease are unlikely, but signs of atrial septal defect sometimes are appreciated better in older children.
What should you focus on in the lung exam?
Yield likely to be low in a healthy child. May hear subtle wheezing in a child with a history of allergies.
What should you focus on in the abdominal exam?
Palpation for organomegaly and masses is appropriate. While the most common mass will be stool, children this age occasionally have an enlarged kidney or, very rarely, an abdominal tumor such as Wilms’ or neuroblastoma.
What should you focus on in the musculoskeletal exam?
Several gait variants occur at the toddler age. Most common is in-toeing due to tibial torsion without femoral anteversion:
-Most spontaneously resolve by age 8 years
-Often walking will strengthen anterior leg muscles and allow correction
-Persistence has been associated with joint problems later in life
Careful history and exam for potentially treatable causes of intoning is appropriate. (For most cases, reassurance and follow-up is all that is necessary, but if intoeing does not spontaneously resolve by 4 yrs of age, referral to an orthopedic surgeon is warranted.)
What should you focus on in the genital exam?
Hernias are sometimes seen. This segment of the exam also provides the opportunity to teach about who can appropriately examine the child. Some girls show nonspecific vulval erythema due to poor hygiene once they are toilet trained and caring for themselves in the bathroom.
What should you focus on in the neurologic exam?
Assessment of overall muscle tone, strength and coordination is appropriate. In general, the neuro exam at this age is more focused on assessing a child’s achievement of overall neurodevelopmental status, including gross and fine motor, along with language and social-skills milestones.
What are two methods for examining strabismus?
Hirschberg light reflex and cover/uncover test.
What safety issues are important to discuss with the parents of a three year old?
Car accidents, swimming pools, falls, firearms, poisonings and fires. They are important causes of injury in a toddler and should be reviewed with parents.
At what age should a child be put in a front-facing car seat?
Age 3
What age does SIDS affect?
Children under one year of age (infants)
What advice should you give parents about guns in the home?
Preferably, remove the gun from the home. Put a safety lock on the gun. Keep the gun in a locked cabinet. Keep ammunition separate and locked.
How many boys 8-12 would handle a gun and trigger it?
According to a study from 2001, when given the chance, 76% of boys 8-12 would handle a gun and 48% would pull the trigger. Parents opinions about if their child would handle a gun were not predictive.
If a three year old has a history of poor diet, what lab test should you do?
Fingerstick hemoglobin/hematocrit
When is screening for anemia typically done in kids?
At 12 months and again at preschool or kindergarten entry. The initial 12 mo window coincides with a period in development when diet, particularly iron sources, is often in flux.
What can falsely affect the result of spun hematocrit?
Hydration status since hematocrit still relies on blood volume.
What are the risk factors for lead poisoning?
Mouthing objects, Living in at-risk rousing, being an immigrant
What can contribute to eczema in some younger children?
Food allergy
What is a radioallergosorbent test (RAST)?
A blood test used to determine to which allergens a person is sensitized.
What is the most likely cause of anemia in an otherwise healthy child with poor nutritional intake?
Iron deficiency
Association between iron deficiency and cognitive difficulty?
It is unclear whether cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk for iron deficiency.
What are the main causes of iron deficiency anemia?
Lack of iron intake = most likely acquired cause. In rare cases, iron stores are decreased from chronic GI blood loss (eg food allergies and gluten enteropathy)
What would make lead poisoning higher on the differential?
Living in pre-1970s housing, living near a busy interstate, or was a recent immigrant.
What are chronic or severe illnesses that cause anemia?
Collagen vascular disease, malignancy, or other chronic illness.
What are causes of more severe anemia (Hgb less than 9 g/dL)?
Decreased marrow production (eg aplastic anemia), hemolytic anemias, and vitamin deficiencies (eg folate and B6) are rare in children.
How do you treat iron deficiency anemia in children?
Oral iron treatment (2-4 mg/kg/day of elemental iron divided once or twice daily)
What are some practical steps to have family take to improve a 3 yo child’s eating?
Stop giving a bottle to the child, limit his eating to mealtimes, don’t bargain with him and gradually introduce new iron-rich foods
