CLIPP case 3. 3yo well-child visit (anemia, eczema)

Question 1

Socio-emotional milestones

Answer 1

3yo: dresses and feeds self
4yo: know gender and age; friendly to children; plays with toys/fantasy play
5yo: listens and attends; can tell between real-life and make-believe; shows sympathy for others

Question 2

Communication milestones

Answer 2

3yo: 2-3 word sentences, 75% understandable
4yo: States first and last name; sings a song; most speech clearly understandable
5yo: Articulates; Tells simple story with full sentences; Appropriate tenses and pronouns; Counts to 10; Follows simple directions

Question 3

Cognitive milestones

Answer 3

3yo: Knows name and use of “cup, ball, spoon, crayon”
4yo: Names color; Aware of gender; Plays board games; Draws person w/ 3 parts; Copies a cross
5yo: Draws person w/ 6 parts; Prints some letters and numbers; Copies squares and triangles; Ask about school!

Question 4

Physical milestones

Answer 4

3yo: 6-8 cube tower; Throws ball overhand; Rides tricycle; Copies circle
4yo: Hopes on one foot; Balances for 2 sec; Pours, cuts, mashes own food; Brushes teeth
5yo: Balances on one foot; Hops, skips; Ties knot; Mature pencil grasp; Undresses/dresses w/ min assistance

Question 5

Eczema treatment

Answer 5

• Lubrication
• High dose hydrocortisone in short bursts for outbreaks, low-dose for minor bouts
• Loratidine and cetirizine (non-sedating) or diphenhydramine and hydroxyzine (nighttime)
• Treat associated infections

Question 6

Bottle use

Answer 6

DC by 12-15 months of age, due to caries

Question 7

Child TB screening

Answer 7

Has this child had prolonged exposure to anyone homeless, incarcerated, resident of a nursing home, user of illicit drugs, HIV patient, migrant farm worker?

Question 8

Anemia screening

Answer 8

• At 12 months, and again at preschool or kindergarten entry, anytime if risk factors
• Fingerstick Hb
• Important to treat bc of CNS and cognitive defects

Question 9

Lead screening

Answer 9

• Young children (<3?) mouthing objects
• At-risk housing (pre-1970s)
• Certain immigrant groups
• Housing near busy interstate

Question 10

Anemia differential

Answer 10

• Iron deficiency: Give elemental iron 2–4 mg/kg divided once or twice daily
• Chronic blood loss (food allergies, gluten enteropathy)
• Lead poisoning
• Chronic illness (collagen vascular disease, malignancy, HIV)
• Hemoglobinopathy (thalassemia, G6PD, SCD; Mediterranean, Asian, African)
• Decreased marrow production
• Increased destruction of red cells or precursors
• Atopic dermatitis vs. psoriasis

Question 11

Allergic diathesis

Answer 11

• Atopic dermatitis
• Allergic rhinitis
• Asthma

Question 12

Atopic dermatitis

Answer 12

• Thickening and inflammation of skin
• Tends to be familial, but with multifactorial inheritance
• Often environmental (allergic) triggers
• Anything leading to itching can exacerbate

Question 13

Vitamin deficiencies in kids

Answer 13

• Vitamin D: Children should receive supplementation

- Iron: Predominant sources in toddlers are meat, legumes, and iron-fortified cereals

Question 14

First dental visit

Answer 14

-AAP: all children should be screened by six months for risk of caries

Question 15

Toddler safety

Answer 15

*Car seats: Kids older than 24 months or who have outgrown height/weight limits on their
car seat -> use forward-facing car seat in car’s back seat. Older children stay in a booster seat until they reach a height of 4 feet 9 inches.
*Firearms in the home: Preferably remove. If cannot, use safety lock, store in locked cabinet, keep ammunition in separate locked cabinet. Study showed that 52% of parents who owned guns think their children are “too smart” or “know better”; also showed that, when given the opportunity, boys 8–12 years will handle a gun (76%) and pull the trigger (48%). Consider potential suicide risk for teenagers.
*Other: Fire safety, poison control, car accidents, risk of lead poisoning

Question 16

Toddler behavior/temperament

Answer 16

*Temper tantrums
*Toilet training: Requiring assistance toileting at age 3 years is not a clear sign of
developmental delay, but may preclude attendance at child care or preschool.
*Eating habits: Food rewards and punishment may promote obesity by interfering with children’s ability to regulate their own food intake.

Question 17

ASD screening

Answer 17

*Modified Checklist for Autism in Toddlers (M-CHAT) is a validated tool for screening toddlers 16-30 months of age

Question 18

Hirschberg light reflex

Answer 18

Screening test for strabismus (eyes not properly aligned with each other)

Question 19

Cover tests

Answer 19

Determines presence and amount of ocular deviation

Question 20

Child gait variants

Answer 20

• In-toeing is most common variant seen at this
  age: Usually due to tibial torsion, +/- femoral anteversion. Tibial torsion usually spontaneously resolves by age 8 years.
• If in-toeing does not resolve by age 4 years, referral to orthopedic surgeon may be warranted

Question 21

Psoriasis in toddler

Answer 21

• Can occasionally look like eczema
• Rare in children this young
• When present, occurs as a generalized rash known as guttate (droplet-shaped) psoriasis
• Usually precipitated by strep infection

Question 22

Allergy testing

Answer 22

Radioallergosorbent test (RAST)