Health Maintenance for Infants and Children
Health Maintenance for Infants and Children
Health maintenance visits provide the physician an excellent opportunity to practice preventive medicine and establish an ongoing relationship with the child and his or her family. At each visit, the child should be evaluated for early disease processes and developmental and behavioral problems. Also, the appropriate screening tests, immunizations, anticipatory guidance, and counseling must be provided.
History and physical examination
. The initial history should be complete and include information regarding family history, social history, living environment, birth history, allergies, medications, and complete medical history, including injuries, dietary history, growth and development, behavioral problems, and a review of systems.
. The physical examination should be complete, with particular attention to those aspects appropriate for the child's age.
. A child's developmental level should be assessed at each visit.
. Measuring growth and following its progression over time can help identify significant childhood conditions. Height, weight, and head circumference should be measured at birth, at 2–4 weeks, and at 2, 4, 6, 9, 12, 15, 18, and 24 months of age. Height and weight should be measured at ages 3, 4, 5, 6, and every 2 years thereafter.
. At a minimum, all infants should be screened for congenital hypothyroidism and phenylketonuria (PKU) within the first week of life. Infants screened for PKU earlier than 24 hours after birth should be screened again before the second week of life. Screening for hemoglobinopathies, such as sickle cell disease and thalassemia, should be done for those in high-risk groups.
. Blood pressure should be measured beginning at 3 years of age and every 1–2 years thereafter during routine office visits. Hypertension in children is defined as persistent blood pressure elevation at or above the 95th percentile according to gender and age.
. Most speech and language development occurs between birth and age 3 years. Early detection of hearing impairment is therefore important. A subjective assessment of hearing, including checking for a response to noise produced outside an infant's field of vision, noting an absence of babbling at 6 months of age, assessing speech development, and inquiring about parental concerns, should be performed repeatedly, especially during the first year of life.
There is no clear consensus among authorities regarding the routine use of pure-tone audiometry for screening in normal-risk children, but it is reasonable to consider such screening (using earphones) once, at age 4 years. Hand-held audiometers are of unproved effectiveness in screening children.
. All children should be screened for a red reflex and a symmetrical corneal light reflex during the first week of life and again at 6 months of age. At age 3 years, all children should have visual acuity testing with a wall chart and be tested for strabismus using the cover–uncover test. Visual acuity testing should be repeated at 5–6 years of age.
. All children should be screened for anemia using either hemoglobin or hematocrit testing at approximately 9 months of age. The cut points for a diagnosis of anemia at this age are a hemoglobin below 11 g/dL or a hematocrit below 33.0%.
Cut points should be adjusted upward for children who live at high altitudes. Clinicians may also consider repeat screening at age 3–4 years. Cut points for this age are a hemoglobin of 11.2 g/dL or a hematocrit of 34.0%.
. There is no consensus on either the necessity or timing of screening urinalysis to detect hematuria, proteinuria, glucosuria, or occult infection. However, it may be clinically prudent to perform a screening urinalysis in preschool children. Midstream clean-catch specimens are best, and the use of a plastic bag applied to the perineum should be avoided.
. Annual tuberculosis (TB) testing is recommended for children in high-risk populations, such as those born abroad in high-prevalence countries; medically underserved, low-income populations; and individuals with medical conditions known to substantially increase the risk of TB. The Mantoux test (0.1 mL of purified protein derivative containing 5 tuberculin units injected intradermally) should be used. The test should be read in 48–72 hours by measuring the diameter of induration.
A reaction is generally considered positive if either of the following is true:
- The diameter of induration is 5 mm or greater and there is known or suspected HIV infection, close contact with an individual who has infectious TB, or a chest radiograph likely to represent old, healed TB.
- The diameter of induration is 10 mm or greater in children younger than 4 years and those at high risk for TB.
- The diameter of induration is 15 mm or greater in low-risk children.
. All children should be screened at age 12 months and, if the initial test result is less than 10 µg/dL and if resources allow, again at age 24 months. In addition, all children aged 6 months to 6 years should be assessed for risk of lead exposure using a structured questionnaire. Those with blood levels less than 10 µg/dL should be retested once a year until age 6 years.
. Universal screening of children is not recommended. Children older than 2 years who have a parent with a total cholesterol level of 240 mg/ dL or greater should be screened with a random total cholesterol. A blood cholesterol less than 170 mg/dL is considered acceptable. Such children and their families should be provided with information on risk factor reduction, and cholesterol should be measured again within 5 years. A blood cholesterol greater than or equal to 200 mg/dL is considered high. Such children should have a lipoprotein analysis. Those children with a cholesterol between 170 and 199 mg/dL should be retested and the result averaged with the previous measurement. If the average is greater than 170 mg/dL, a lipoprotein analysis should be performed. If it is less than 170 mg/dL, the child should be tested again within 5 years.
Depression and suicide
. Routine screening for depression and suicide is not recommended, but clinicians should be attentive for symptoms of depression in children. Risk factors for depression in children include a history of verbal, physical, or sexual abuse; a history of parental depression; frequent separation from or loss of a loved one; and chronic illness.
Diphtheria, tetanus, and pertussis
All children should be immunized against diphtheria, tetanus, and pertussis (DTP) at 2, 4, and 6 months of age. The fourth vaccine should be given at age 15–18 months but can be given anytime between 12 and 18 months, provided at least 6 months has passed since the third vaccination. The diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is now recommended for the entire series. This vaccine contains an acellular pertussis preparation that has many fewer side effects than whole-cell pertussis preparations. If a child younger than 7 years has a contraindication to pertussis vaccine, DT should be used. The recommended dosage of DTaP and DT is 0.5 mL, given intramuscularly.
to vaccination include encephalopathy within 7 days of administration of a previous DTP or DTaP; fever exceeding 40.5°C (104.9°F), collapse, or shock-like state within 48 hours of previous DTP or DTaP; seizures within 3 days of previous DTP or DTaP; and persistent, inconsolable crying lasting 3 hours or more within 48 hours of previous DTP or DTaP.
. Redness, swelling, or pain at injection site, fever greater than 38°C (100.4°F), and mild drowsiness, anorexia, and vomiting are common.
Haemophilus influenzae type b
All children should receive a primary series of H. influenzae type b (Hib) vaccine beginning at age 2 months. There are currently three types of conjugate vaccine licensed for infant use. Ideally, the same type of vaccine should be given throughout the entire primary series, although current recommendations do allow for some interchangeability (4). Hib vaccine is given intramuscularly.
. Previous anaphylactic reaction to the vaccine is the only specific contraindication to use of the Hib vaccine.
. Mild fever and pain, redness, or swelling at the injection site are possible side effects.
All children should receive a complete series of hepatitis B immunizations during the first 18 months of life. Infants born to hepatitis B surface antigen–positive mothers should begin receiving these immunizations at birth. All older children and adolescents at high risk for hepatitis B infections should receive a complete series of immunizations.
. History of an anaphylactic reaction to common baker's yeast and known serious adverse reaction to the vaccine are the only contraindications.
. Pain at the injection site (3%–29%) and fever greater than 38°C (100.4°F) may occur in 1%–6% of children.
Measles, mumps, and rubella.
All children should receive a series of two measles–mumps–rubella (MMR) vaccinations. The first is given at age 12–15 months. The second vaccine should be administered at age 4–6 years. Those who have not received the second dose should complete the schedule no later than age 11–12 years. It is administered subcutaneously at a dose of 0.5 mL. MMR may be given simultaneously with other childhood immunizations but at a separate site.
. Children with anaphylactic reactions to eggs and neomycin and those with immunodeficiency should not receive MMR vaccine. Pregnancy and receipt of immune globulin within the preceding 3–11 months are also contraindications.
. Fever greater than 39.4°C (103°F) may develop 5–12 days after immunization and last up to 5 days. One percent of children may develop mild joint pain and stiffness and even arthritis 1–2 weeks after receiving the vaccine. A transient rash may occur in 5% of vaccinees, and some children may experience swollen cervical and posterior auricular lymph nodes 1–2 weeks after immunization.
To eliminate the risk for vaccine associated paralytic poliomyelitis, use of an all inactivated poliovirus vaccine (IPV) schedule is now recommended. All children should receive four doses of IPV at age 2 months, 4 months, 6–18 months, and 4–6 years.
. IPV should not be administered to persons who have experienced a severe allergic (anaphylactic) reaction after a previous dose of IPV or to streptomycin, polymyxin B, or neomycin.
. All children who have no history of varicella infection should be given the varicella zoster vaccine (VZV) at 12–18 months of age. Older children who have not been vaccinated and who lack a reliable history of chickenpox should be vaccinated by 13 years of age. VZV is administered as a single 0.5-mL subcutaneous dose.
. VZV is a live attenuated preparation. Those who should not receive the vaccine include immunocompromised children, those receiving high-dose corticosteroids, individuals with a history of an anaphylactic reaction to neomycin or gelatin, pregnant women, and those with moderate or severe intercurrent illness. VZV should not be administered within 5 months of having received immune globulin or other blood products. VZV may be given to individuals who live in households with immunocompromised individuals. Vaccinees who develop a rash should avoid contact with immunocompromised individuals for the duration of the rash.
. Approximately 25% of children experience tenderness and erythema at the injection site. A generalized maculopapular or vesicular rash 1 month after immunization may occur in 5%–8% of those receiving the vaccine. Transmission of the vaccine virus from healthy individuals who have been vaccinated to others is possible but has not been documented.
. Because of hepatitis A outbreaks, hepatitis A vaccine is recommended for use in selected high-risk locales and states.
7-Valent pneumococcal conjugate vaccine (Prevnar) is recommended for all children aged 2–23 months and for children aged 24–59 months who are at increased risk for pneumococcal disease (e.g., those with sickle cell disease, HIV infection, and other immunocompromised or chronic medical conditions). The vaccine is administered intramuscularly as a 0.5 mL dose. It can also be administered at the same time as other routine childhood vaccinations in a separate syringe at a separate injection site. The vaccine should be given at age 2 months, 4 months, and 6 months, followed by a fourth dose at age 12–15 months. Children aged 24–59 months with underlying medical conditions should receive 2 doses administered 2 months apart, followed by 1 dose of 23-valent pneumococcal conjugate vaccine administered at least 2 months after the second dose.
. 7-Valent pneumococcal conjugate vaccine is contraindicated in persons known to have hypersensitivity to any component of the vaccine.
. Fever greater than 100.4° F (38° C) and local induration, tenderness, and erythema at the injection site are common. Fever is the most common reaction and occurs in 15%–25% of recipients. The rate of fevers greater than 102.2° F (39° C) appears to increase after dose 2.
Guidance and counseling
. Providing anticipatory guidance and health education surrounding issues likely to be encountered at specific ages is a cornerstone of the pediatric health maintenance visit. Clinicians should be familiar with common parental questions and be prepared to provide counseling and advice about child development, child behavior, discipline, nutrition, and safety.
Dental and oral health
. Dental and oral health counseling should be provided routinely, with referral for a dental visit occurring at 2–3 years of age. Parents should be instructed to wipe their infant's gums and teeth after each feeding with a moist wash cloth. Once multiple teeth have appeared, parents should brush their infant's teeth daily using a pea-sized amount of toothpaste. To prevent tooth decay, infants should not be permitted to nurse throughout the night or fall asleep with a bottle containing anything other than water. Infants should be encouraged to begin using a cup instead of a bottle at age 1 year.
. Age-specific safety counseling should be provided routinely. Among the safety issues to be addressed are the following:
- Sudden infant death syndrome: A sleeping infant should be positioned on his or her back and should not sleep prone.
- Always use an appropriate car safety seat for infants and small children.
- Older children should use seat belts.
- Use stair and window gates to prevent falls.
- Keep objects that can cause suffocation and choking away from small children.
- Avoid scald burns by reducing the water temperature of hot water heaters to below 120°F.
- Keep medicines and other dangerous substances locked up and in child-resistant containers.
- Always ensure that children wear safety helmets when riding bicycles.
- Smoke alarms should be installed and maintained in the home.
- Encourage parents not to keep a firearm in the home. If a gun is kept in the home, it should be stored unloaded and locked away, separately from ammunition.