Pediatrics 03 – A 3-year-old male well-child visit
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Your general pediatrics preceptor, Dr. Harris, asks you to start reviewing the chart on your next patient, Benjamin, who is here for his 3-year-old well-child visit.
You hear several loud “No!”‘s coming from the exam room. The nurse comes out and gives you the chart, stating: “I wasn’t able to get his height and weight because he wouldn’t cooperate. I tried to test his vision, and didn’t have any luck with that either.”
Fortunately, Dr. Harris earlier had advised you that sometimes you have to think like a preschooler when examining them, and you came prepared: You brought a handful of little cars and a bird that chirps.
You quickly scan through Benjamin’s electronic health record:
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New to practice
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Growth measures
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Height: 50th percentile
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Weight: 20th percentile
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Head circumference: 40th percentile
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Development
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Runs stiffly
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Speaks in two-word phrases
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Uses a spoon and cup
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Family History
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Mother had postpartum depression.
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Social History
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Grandma living with family.
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Father deceased in car crash.
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Lives in apartment complex built in 2002.
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Discussed
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Breath-holding
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Temper tantrums
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Age-appropriate behaviors
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Immunizations
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Reviewed vaccine record and patient is up to date including 15-month vaccines
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Hepatitis A vaccine given
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Screening
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Screening tools for development and autism (using the M-CHAT): Passed
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TB: No risk factors identified by questionnaire
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Lead: Screening questionnaire did not reveal any risk factors. Prior pediatrician documented normal hemoglobin and serum lead levels at 12 months of age.
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Labs
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Hemoglobin 11 g/dL
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Growth measures
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Height: 50th percentile
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Weight: 25th percentile
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BMI: 28th percentile
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Concerns
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Rash
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Interval history
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“Nursemaid’s” elbow (radial head subluxation) reduced in the local emergency room.
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Development
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Two- to three-word sentences
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Can kick a ball
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Imitates adults
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Medical history
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Several colds
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Diet
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Picky
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Still using bottle at night
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Discussed
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Toilet training
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Starting daycare
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Grandmother will be leaving
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Stopping bottle
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Immunizations
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Influenza vaccine given
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Screening
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Developmental screening with Ages and Stages: Passed
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M-CHAT: Passed
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TB: No risk factors identified by questionnaire
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Serum Lead: 1 microgram per deciliter (< 5 mcg/dL is considered normal)
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Labs
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Hemoglobin 11.5 g/dL
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Growth measures
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Height: 50th percentile
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Weight: 25th percentile
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BMI: 15th percentile
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Concern
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Difficulty going to sleep
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Temperament
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Unchanged: still having tantrums.
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Bedtime battles and waking at night since grandmother left.
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Screening
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Developmental screening with Ages and Stages: Passed
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Plan
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Age-appropriate behaviors related to sleep and tantrums discussed.
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Difficulties potentially linked to MGM departure.
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Mother should use consistent approach, weaning off her presence in Benjamin’s room at night.
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Plan to observe for now.
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Follow-up call – 1 month: Mom initially had difficulty letting him sleep by himself, but now mom and Benjamin sleeping well.
Given that the medical assistant was unable to check the vision and hearing for the patient, what would be your next steps in this assessment?
The suggested answer is shown below.
Letter Count: 358/1000
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Hearing is initially evaluated in the newborn period.
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Between birth and age 3, children are evaluated by asking the parent if they have concerns about vision or hearing.
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Instrument based vision screening, with a photoscreener, should start at 1 year
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Vision screening using a chart begins at age 3 years.
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Hearing evaluation through audiometry begins at age 4 years.
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Children who cannot cooperate with testing by age 4 are more likely to have developmental delays. (For these children, you may need to refer for formal audiology and/or ophthalmology for screening, especially if developmental delays are suspected.)
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Donahue SP, Baker CN; Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics; Procedures for the Evaluation of the Visual System by Pediatricians. Pediatrics. 2016;137(1):10.1542/peds.2015-3597. doi:10.1542/peds.2015-3597.
Recommendations for Preventive Pediatric Health Care. Bright Futures/American Academy of Pediatrics. https://www.aap.org/en-us/Documents/periodicity_schedule.pdf (PDF). Accessed July 21, 2021.
Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics January 2016, VOLUME 137 / ISSUE 1. http://pediatrics.aappublications.org/content/pediatrics/137/1/e20153596.full.pdf (PDF). Accessed July 21, 2021.
From your awareness of Benjamin’s age and careful review of his chart, you recognize that there are some particularly relevant issues to cover.
First, are there any issues left from Benjamin’s previous visit that should be reviewed?
The suggested answer is shown below.
Letter Count: 67/1000
Behavior: Benjamin’s challenging temper tantrums.
Nutrition: Benjamin was previously noted to be a “picky” eater. This is a common issue that can relate to overeating of a particular food and an overall poor quality diet.
Dental hygiene: Benjamin is at risk for dental caries due to use of bottle at age 2.
History of maternal depression: It is important to continue to follow up on mother’s mental state and on how she is relating to Benjamin.
What other topics will be important to cover at this health maintenance visit?
The suggested answer is shown below.
Letter Count: 126/1000
Nutrition, exercise, sleep, toileting, social environment, dental care, and safety are all topics that are important to cover.
Social
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The social environment plays a major part in how children develop.
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It is necessary to understand the family context before giving advice.
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To enter this arena, ask about changes and family stressors in a non-threatening way.
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Nutrition
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Preschoolers can suffer from poor nutrition. Inadequate fruit, vegetable, and iron intake is quite common.
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Calcium and vitamin D deficiencies are also common, and should be supplemented if patients are at risk for deficiencies.
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Exercise
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According to the American Academy of Pediatrics (AAP) guidelines, “Active Healthy Living: Prevention of Childhood Obesity through Increased Physical Activity”: “Toddlers should be allowed to develop enjoyment of outdoor physical activity and unstructured exploration under the supervision of a responsible adult caregiver. Such activities include walking in the neighborhood, unorganized free play outdoors, and walking through a park or zoo.”
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Having quality play environments is optimal at this age.
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Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity.
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Toilet Training
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Toddlers at age 3 may not have achieved full toilet “independence” – especially toddlers with intense, willful temperaments.
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Requiring assistance toileting is not a clear sign of developmental delay at this age, but may preclude attendance at child care or preschool.
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Dental
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The American Association of Pediatric Dentists (AAPD) and the AAP both state that all children should be seen within six months of the first tooth eruption or by 1 year of age. Additionally, the AAP states that all children should be screened by 6 months old to see if they are at a higher risk of developing caries. Your community, however, may not have a pediatric dentist. Also, many general dentists feel that the first visit should be at age 3 years. This is an unresolved issue between general and pediatric dentists.
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It is recommended that children have fluoride varnish applied after tooth eruption, every 3-6 months, until 6 years.
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See the AAPD policy statement about “early childhood caries,” the diagnostic term that has replaced “baby bottle tooth decay” or “milk bottle caries.”
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Also see the AAPD policy statement about “the dental home,” advocated for children at higher risk of dental caries.
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Safety
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Car seats are often used inappropriately; toddlers are moved too soon to booster seats.
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The AAP recommends that “children remain in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat.” Most car seats allow for rear caing until 2 years or older.
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Older children should stay in a booster seat until they reach a height of 4′ 9″ (142 cm).
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In the toddler years, overall safety issues become increasingly important because of the increased independence, inquisitiveness, and motor skills of preschoolers.
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Injuries are a major morbidity in the preschool years and safety information should include water safety and avoiding hazardous household chemicals.
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Child Passenger Safety. Pediatrics. https://pediatrics.aappublications.org/content/142/5/e20182460. Accessed July 21, 2021.
Hagan JF, Shaw JS, Duncan P, Eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition, American Academy of Pediatrics. 2017. Promoting Physical Activity (PDF). Accessed July 21, 2021.
Policy on the Dental Home. Council on Clinical Affairs. Reference manual. (37)6. Adopted 2001. Revised 2018. http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf. Accessed July 21, 2021.
Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options. Council on Clinical Affairs. American Academy of Pediatric Dentistry. Adopted 2000. Revised 2016. http://www.aapd.org/media/Policies_Guidelines/P_ECCUniqueChallenges.pdf. Accessed July 21, 2021.
Promoting Safety and Injury Prevention. Bright Futures. American Academy of Pediatrics. https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_Safety.pdf (PDF). Accessed July 21, 2021.
Developmental assessment of most preschoolers is a process of both observing the child and taking a history from the parent. The American Academy of Pediatrics guidelines for developmental assessment draws distinctions between (1) surveillance, the process of recognizing children who may be at risk of developmental delays, (2) screening, the use of standardized tools to identify and refine that recognized risk, and (3) evaluation, the process of identifying specific developmental disorders that are affecting a child.
Developmental Surveillance
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A form of developmental assessment – often in the form of play activities – incorporated into the exam.
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Helps to determine areas of concern, prompting further evaluation, if necessary.
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Performed at every encounter with the family.
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Evidence continues to mount that developmental surveillance alone inadequately identifies developmental delays.
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One standard, recognized source for health maintenance information for children is Bright Futures from the American Academy of Pediatrics. This comprehensive document provides an evidence-based synthesis of the best available information on what to expect at each age. Remember, the behaviors identified for each age in Bright Futures are what MOST kids at that particular age will do; these are simply descriptions of expected behaviors, not a developmental screening test.
Developmental Milestones for 3-, 4-, and 5-Year-olds by Domain
Developmental monitoring involves a careful review of progress in each of several different developmental domains. There are several different screening tools, and you may note slight variations in the delineation of the domains and tasks depending on the tool used. Additionally, some tables present milestones that 50% of children can perform at each specified age, while others present milestones that 75% or 90% of children can perform. The table below is based on Bright Futures Surveillance of Development – these milestones generally represent the mean or average age of performance of these skills, when available.
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3-year-old |
4-year-old |
5-year-old |
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Socio-emotional |
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Communication |
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Cognitive |
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As children get ready for school, the developmental milestones shift to more cognitive processes. Asking the parents about school performance is as important as the following milestones:
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Motor |
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Developmental Screenings
Pediatricians do not, in general, perform definitive developmental evaluations, but do perform screening tests to determine which children must be fully assessed.
The AAP recommends routine developmental screening through a validated tool at 9, 18 and 30 months. They recommend routine screening for autism at 18 and 24 months. Developmental Evaluations
Less than 3 years old: Children of this age with suspected developmental problems should be evaluated by one or more of the following (the choice may be determined by which specialists are available in the community):
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Early Childhood Intervention (ECI) – each state is mandated to provide developmental assessments and services for those children at risk for or determined to have developmental delays
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A developmental-behavioral pediatrician
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A child psychiatrist or child psychologist
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Early childhood learning specialists
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Ages 3 to 5 years: If problems are detected early, services provided by the school system for 3- to 5-year-olds can often help these children catch up to their peers.
Hagan JF, Shaw JS, Duncan P, Eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition, American Academy of Pediatrics. 2017.
Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics. <a href=”Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening” target=”_blank”>Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening</a>. Accessed July 21, 2021.
Benjamin is on his mother’s lap, and she is reading to him. Dr. Harris introduces you: “Good morning, Mrs. Jones. I think it is wonderful that you used the time while waiting to read to Benjamin! I’d like to introduce you to the medical student working with me today. If it’s OK with you, I will leave her to talk with you both and examine Benjamin, and I will be back afterward.”
She agrees, and Dr. Harris leaves the room.
The first priority is to establish the relationships between you and Benjamin and his mother in order to have a productive well-child visit. How would you proceed? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Give a toy to Benjamin. “Benjamin, why don’t you relax and play for a minute, while I talk with your mother.”
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B. Smile and ask Benjamin, “Would you like to be on your mother’s lap, so that you are more comfortable?”
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C. Tell Benjamin, “I understand that you are scared. This is not going to hurt you, though, so you have nothing to fear.”
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D. Tell Benjamin’s mother, “Sometimes 3-year-olds have a hard time cooperating at visits to the doctor. We will do the best that we can.
> The correct answers are A, B, D.
We do not know that Benjamin is scared. Also we do not yet know if we will need to do a procedure such as immunization that may be painful.
At 3 years of age, some children can be cooperative at the pediatrician’s office, some are wary still, and some still need a lot of parental reassurance.
Smiling and talking with the child in a pleasant, reassuring, calm voice is an outstanding strategy, rather than just talking and interacting with his mother.
Giving the preschooler a fun activity to do while obtaining a medical history is effective; just giving a couple of crayons and drawing on the table exam paper can engage the child so that he is cooperative.
In order to avoid scaring a toddler, it is important to give them time to warm up and feel comfortable before getting too close to them or examining them.
Many parents are embarrassed when their children act up at the office, but reassuring that it is normal childhood behavior will allow the parent to relax more.
While Benjamin draws with a crayon, you begin taking a history:
DEEP DIVEGiving Feedback to ParentsMrs. Jones says, “See, look at this rash. I have put moisturizing cream on it almost every day – and over-the-counter hydrocortisone 1% cream for the past couple of weeks, but he keeps scratching at it, especially at night.” (Minor parts of the exam like this often occur during the early part of the visit, especially if the parent has a key concern.)
What is the etiology of Benjamin’s rash?
The suggested answer is shown below.
Letter Count: 26/1000
Eczema (atopic dermatitis)
Eczema has been called “the itch that rashes,” because there is a cycle of irritation leading to scratching, leading to the rash. Educate parents that anything leading to itching (even a child’s rubbing his face on Mom’s sweater) can exacerbate eczema.
Eczema and Allergies
Although eczema often occurs without a history of allergies, such a history would support an atopic diathesis and should prompt you to ask additional questions about allergic triggers and asthma symptoms.
Family History
While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear environmental (allergic) triggers.
Differential Diagnosis
Sometimes eczema may be confused with the other common inflammatory rashes:
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Contact Dermatitis: This is very common in children and can be the result of any irritants including new products that they are using or something they came in contact with while playing.
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Scabies: This is an infection from mites that presents with a non-specific rash that is extremely itchy. Multiple family members may have similar rashes.
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Psoriasis: Although psoriasis can occasionally first look like eczema, it is rare in young children. When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection.
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Seborrhea: This should also be part of the differential diagnosis, especially in early infancy (e.g., cradle cap). It is unusual to have a new case of seborrheic dermatitis at age 3.
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Treatment
The basic tenets of the treatment of eczema are:
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Protecting skin by performing frequent daily moisturizing
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Using topical anti-inflammatories in short bursts
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Treating associated skin infections aggressively
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Pharmacological Treatment
In developing an effective treatment plan, it is important to understand what treatment has been used already and with what results.
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Topical steroids |
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Topical calcineurin inhibitors |
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Antihistamines |
Remember that sometimes simply prescribing antihistamines can help with the itch, which in turn can prevent scratching and worsening of the rash.
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Atopic Dermatitis: Skin-Directed Management. Pediatrics. https://pediatrics.aappublications.org/content/134/6/e1735. Accessed July 21, 2021.
Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol.2014;70(2):338-351. doi:10.1016/j.jaad.2013.10.010.
You let Mrs. Jones know that you will discuss Benjamin’s rash with Dr. Harris and then continue asking about the interval history.
DEEP DIVEToilet TrainingDawson G. et al. Preschool Outcomes of Depressed Mothers: Role of Maternal Behavior, Contextual Risk, and Children’s Brain Activity. Child Development 2003; 74(4):1158-1175.
American Academy of Pediatrics. Family Pediatrics: Report of the Task Force on the Family. Pediatrics. 2003;111(6):1541-1571S. https://pediatrics.aappublications.org/content/pediatrics/111/Supplement_2/1541.full.pdf. Accessed July 21, 2021.
Evidence-Based Interventions for Depressed Mothers and their Young Children Sherryl H. Goodman and Judy Garber. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5342914/. Accessed July 21, 2021.
National Scientific Council on the Developing Child. National Forum on Early Childhood Program Evaluation: Maternal Depression Can Undermine the Development of Young Children, 2009. http://developingchild.harvard.edu/wp-content/uploads/2009/05/Maternal-Depression-Can-Undermine-Development.pdf (PDF). Accessed July 21, 2021.
Benjamin has become bored and is jumping around the room. You know time is at a premium. Because picky eating has been a concern in the past, diet history is your next priority. You bring out the miniature cars from your pocket for Benjamin and ask his mother a few more questions.
Clearly Benjamin’s mother is struggling a lot with his eating, and you feel a bit overwhelmed about how to respond. You tell Mrs. Jones, “These are important nutritional concerns. I will share them with Dr. Harris.”
Considering the information Benjamin’s mother has just given you, what do you believe are the most important nutritional issues for Benjamin?
The suggested answer is shown below.
Letter Count: 175/1000
Inadequate vegetable and iron intake.
Excess milk and juice intake.
Using a bottle at sleep, which greatly increases his risk for early childhood caries.
Sipping on juice throughout the day.
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Inadequate nutrition |
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Milk and juice intake |
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Early childhood caries |
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Control battles about food |
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DEEP DIVEFluorideBaker, RD et al. Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age). Pediatrics, 2010; 126(5): 1040-1050. Accessed July 21, 2021.
Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC. Maternal feeding practices and childhood obesity: a focus group study of low-income mothers. Arch Pediatr Adolesc Med. 1998;152(10):1010-1014. doi:10.1001/archpedi.152.10.1010.
Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis–United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. 2005;54(3):1-43..
Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107(5):1210-1213. doi:10.1542/peds.107.5.1210.
Faith MS, Dennison BA, Edmunds LS, Stratton HH. Fruit juice intake predicts increased adiposity gain in children from low-income families: weight status-by-environment interaction. Pediatrics. 2006;118(5):2066-2075. doi:10.1542/peds.2006-1117.
Fox MK, Condon E, Briefel RR, Reidy KC, Deming DM. Food consumption patterns of young preschoolers: are they starting off on the right path?. J Am Diet Assoc. 2010;110(12 Suppl):S52-S59. doi:10.1016/j.jada.2010.09.002.
Policy on the use of fluoride. Council on Community Affairs. American Academy of Pediatric Dentistry. Revised 2018. https://www.aapd.org/research/oral-health-policies–recommendations/use-of-fluoride/. Accessed July 21, 2021.
Before beginning Benjamin’s physical exam, you quickly review the most relevant aspects:
General Tips
Listen with your stethoscope first in case he/she starts crying. If the exam needs to be truncated due to the child’s behavior, then you should focus on:
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Neurodevelopment
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Monitoring previously recognized findings
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New findings identified by parents, and
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Physical problems common in preschoolers for which intervention may be helpful
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Exam Area |
Possible Findings |
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General Appearance |
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HEENT |
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Eyes |
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Neck |
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Cardiac |
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Lungs |
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Abdomen |
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Skin |
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Musculoskeletal |
Link to more information about intoeing: http://www.massgeneral.org/ortho-childrens/conditions-treatments/intoeing.aspx |
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Genitals |
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Neurologic |
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Strabismus refers to misalignment of the eyes. Strabismus can lead to amblyopia, or poor visual development if not managed. Two methods of assessing presence and degree of strabismus:
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The Hirschberg light reflex (corneal light reflex) Hirschberg simulator
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The cover/uncover test
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Abnormal cover test
Childhood Eye Examination Videos. American Family Physician. https://www.aafp.org/afp/2013/0815/p241.html. Accessed July 21, 2021.
Pediatric Vision Screening. American Family Physician. https://www.aafp.org/afp/2017/1215/od1.html. Accessed July 21, 2021.
Although clinicians often start with the cardiopulmonary exam in young children, Benjamin now seems comfortable and eager to move around. You decide to start with the most active part of the exam, the neurodevelopmental exam. You have already observed some important data:
Language: Age-appropriate. Speaks in short paragraphs; most words are understandable.
Fine motor: Grips crayon appropriately.
Gross motor: Enjoys hopping on one foot. Shows how he can “leap like a frog” and walk on his heels and toes. All age-appropriate. Normal muscle tone.
Cognitive: Drawing (person with three body parts) is typical for a 3-year-old.
With these findings and your observance of normal facial mobility and eye movements, you have found no abnormalities in Benjamin’s neurodevelopmental exam. Adding an assessment of reflexes (in a child with previously normal exams and no neurological concerns today) completes your exam, but is unlikely to yield new findings.
A neurodevelopmental exam should include assessment of the following developmental domains:
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Language (speaks in short sentences; 75% of language is intelligible to a stranger)
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Fine motor (holds a pencil or crayon; copies a circle)
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Gross motor (hops; can ride a tricycle)
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Cognitive (draws a person with three body parts)
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Do not forget to ask the caregiver about concerns in any of these areas.
Additionally, check:
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Cranial nerve function (observing for normal, symmetric facial mobility and eye movements)
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Muscle tone
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Gait
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At this point, Benjamin is comfortable enough to cooperate with measurements and vital signs:
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Weight is 13.4 kg (29.5 lbs) (25th percentile)
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Height is 95 cm (37.4 in) (50th percentile)
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BMI is 14.8 (10th percentile)
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Temperature is 36 Celsius (96.8 F)
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Pulse 110 beats/minute
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Respiratory rate is 22 breaths/minute
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Blood pressure is 80/50 mmHg
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You continue with the least invasive and engaging activities of the physical exam. You listen to his heart and lungs first, followed by his abdominal and GU exam, concluding with the HEENT exam.
General appearance: Well appearing, no dysmorphic features.
Head, eyes, ears, nose and throat (HEENT): Normocephalic. Red reflex positive bilaterally. Extraocular movements intact. No strabismus noted with cover/uncover test. Normal nares. Tympanic membranes pearly, no retraction. Moist mucous membranes. Visible dental caries. Neck: No masses or lymphadenopathy.
Cardiac: Normal S1, S2; regular rate and rhythm; no murmur. Femoral pulses equal bilaterally.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nondistended, nontender. No palpable masses.
GU: Circumcised. Both testes palpated.
Skin: Mildly erythematous excoriated patches on anterior trunk and antecubital fossae.
Other than dental caries and eczema, no significant findings.
Benjamin enjoys sharing your “tools” with you during your exam. He particularly likes the notion of “looking for elephants” in his ears.
You remember that Dr. Harris wants you to review safety issues and try to provide families with guidance.
Which of the following safety issues are important to discuss with the parents of a 3-year-old? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Car accidents
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B. Falls
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C. Firearms in the home
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D. Fire safety
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E. Poisonings
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F. Rear-facing car seat
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G. SIDS
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H. Swimming-pool safety
> The correct answers are A, B, C, D, E, H.
Based on Benjamin’s age, height, and weight, he should be put in a front-facing car seat in the back seat. Rear-facing seats are recommended until at least 2 years of age and until the child outgrows the seat, so a smaller 3 year old may still be in a rear facing seat (F). By definition, SIDS (G) affects children under 1 year of age (infants).
Important causes of injury in a toddler include:
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Car accidents
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Swimming pools
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Falls
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Firearms
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Poisonings
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Fires
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At every opportunity, parents should be counseled about avoidance of accidents.
The Injury Prevention Program (TIPP) was started in 1983 by the AAP to help pediatricians prevent injuries in their patients. “TIPP is designed to provide a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries-behaviors that are effective and capable of being accomplished by most families.” The program includes an AAP policy statement, safety surveys for parents to complete, age-appropriate safety information for parents, and a schedule of safety counseling for pediatricians.
View the TIPP information for a 3-year-old.
When you ask about safety you learn that Benjamin’s mother has a gun in the home, and that she and Benjamin live near a busy road. You note that because they live alone, Mrs. Jones purchased a handgun “for protection.”
What advice would you give about guns in the home?
The suggested answer is shown below.
Letter Count: 335/1000
Fortunately, you had observed Dr. Harris counsel a parent in a similar situation earlier this week.
The AAP has recommendations about gun safety that you are able to share with the family. Having a gun in the home increases the risk for injuries. The only way to completely prevent accidental injury due to the gun is to remove the gun from the house as recommended by the American Academy of Pediatrics. For families that choose to have guns, either for work or protection, the recommendation is to keep the gun locked, unloaded, and with ammunition locked separately from the gun.
Benjamin’s mother responds that she was in fact somewhat worried about bringing the gun into the home and will think about your advice.
The most effective strategy for discussing gun safety with families is “gun-neutral,” meaning to present the facts on how to be safest without having an opinion on if families should have a gun at home.
It is important to discuss that children are not able to appropriately reason or understand guns from a developmental standpoint and that increases the risk of injuries. In a study from 2003, the authors found that 52% of parents who owned guns thought that their children were “too smart” or “knew better,” even though only 40% had given specific instructions to their children regarding guns. In this survey only 12% of parents who owned guns locked them.
Another study from 2001 found that, when given the opportunity, boys ages 8 to 12 would handle a gun (76%) and pull the trigger (48%). Parents’ opinions about whether or not their child would handle a gun were not predictive of which boys would handle the gun.
Azrael D, Cohen J, Salhi C, Miller M. Firearm Storage in Gun-Owning Households with Children: Results of a 2015 National Survey. J Urban Health. 2018;95(3):295-304. doi:10.1007/s11524-018-0261-7.
Connor SM, Wesolowski KL. “They’re too smart for that”: predicting what children would do in the presence of guns. Pediatrics. 2003;111(2):E109-E114. doi:10.1542/peds.111.2.e109.
Jackman GA, Farah MM, Kellermann AL, Simon HK. Seeing is believing: what do boys do when they find a real gun?. Pediatrics. 2001;107(6):1247-1250. doi:10.1542/peds.107.6.1247.
You excuse yourself to find Dr. Harris and present what you have learned about Benjamin so far. Together, you review his medical record to determine whether he needs any immunizations or screening tests:
Hypercholesterolemia: No risk factors for hypercholesterolemia (no family history of high cholesterol or coronary heart disease before age 55).
Tuberculosis: No risk factors.
Lead exposure: No risk factors. Normal serum lead levels at 12 and 24 months.
Immunizations: Up to date. [However, if it were influenza season, he should also receive the influenza vaccine.]
You decide that Benjamin’s areas of concern are:
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Eczema
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Nutrition
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Dental health
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Safety
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Behavior
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Which evaluations are appropriate today? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
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A. CBC
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B. Fingerstick hemoglobin/hematocrit
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C. Lead level
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D. PPD
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E. Radioallergosorbent test (RAST)
> The correct answer is B.
Benjamin’s picky eating puts him at risk for anemia.
A CBC (A) provides information about anemia, but is more costly and inconvenient than a hemoglobin test.
Fingerstick hemoglobin (B) is recommended as a screening test for anemia at 12 months for all children and at any age if risk factors for iron deficiency are present.
Lead screening (C) was already done when Benjamin was younger, and the results were normal. He does not have any risk factors for lead poisoning.
A PPD (D) is not necessary, as Benjamin has no risk factors for tuberculosis.
A radioallergosorbent test (RAST) (E) is a blood test used to determine to which allergens a person is sensitized. Although this information might help Benjamin’s mother avoid exposure to allergens that trigger his eczema, RAST testing is not indicated at this time. If he does not respond to topical steroids, RAST testing may be considered. For some younger children, food allergy can contribute to eczema, but this is less common by the preschool years. For most children a clear allergen is never found.
No level of lead exposure is considered safe. Lead exposure, even at low levels, is a causal risk factor for cognitive impairment and behavioral difficulties in children.
Children living in lead-contaminated environments are at greatest risk for having elevated blood lead levels between 6 and 36 months, largely because of the normal mouthing behavior and increasing mobility that occur during this developmental stage. In addition, lead absorption is higher in younger children than in older children and adults. Iron deficiency, which is common in toddlers, increases lead absorption.
Common sources of lead exposure include:
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House paint used before 1978 – and particularly before 1960. Deteriorating paint produces lead-containing dust, particularly during renovation.
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Soil
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Plumbing, pipes
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Hobbies, occupational exposures
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Imported toys, ceramics, candy, cosmetics
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Folk remedies
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The American Academy of Pediatrics emphasizes that primary prevention (removal of environmental sources of lead) should be the focus of policies and physician advocacy to protect children from lead toxicity.
At an individual level, current AAP policy recommends blood lead testing for
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All children 12 to 24 months of age in areas where more than 25% of housing was built before 1960 or where the prevalence of blood lead levels higher than 5 μg/dL in children is 5% or greater.
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Individual children who live in or regularly visit homes/facilities built before 1960 that are in poor repair or have been renovated within the past six months.
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All recent immigrants to the country because of the increased risk.
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Screening based on local guidelines.
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Typically, screening for anemia is done at 12 months and again at preschool or kindergarten entry.
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The initial 12-month window coincides with a period in development when diet, particularly iron sources, is often in flux.
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If there are risk factors for anemia, then testing may be done at any visit.
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Results of a screening hemoglobin can be known immediately.
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Spun hematocrit still relies on blood volume, and hydration status can falsely affect the result.
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TB risk factors:
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Spending time with an individual known or suspected to have TB disease
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Being infected with HIV or another condition that weakens the immune system
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Having symptoms of TB disease
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Living in (or coming from) a country where TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia)
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Living somewhere in the U.S. where TB disease is more common (e.g., a homeless shelter, migrant farm camp, prison or jail, and some nursing homes)
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Use of injected illegal drugs.
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If an individual has any of the above risk factors, a PPD should be placed and read by a medical professional in 48 to 72 hours for children under 2. Children older than 2 can be tested with an IGRA test (quantiferon)
Baker RD, Greer FR; Committee on Nutrition American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age).Pediatrics. 2010;126(5):1040-1050. doi:10.1542/peds.2010-2576.
Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule). American Academy of Pediatrics. https://www.aap.org/en-us/Documents/periodicity_schedule.pdf (PDF). Accessed July 21, 2021.
Prevention of Childhood Lead Toxicity. American Academy of Pediatrics, Council on Environmental Health. http://pediatrics.aappublications.org/content/early/2016/06/16/peds.2016-1493. Accessed July 21, 2021.
Dr. Harris orders a hemoglobin test. It is drawn by the nurse who brings the result to you.
Capillary hemoglobin: 9.5 g/dL (100 g/L)
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Normal range between 6 months old and 6 years old: 10.5-14 g/dL (105-140 g/L)
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Associated reference ranges in conventional and SI units.
Benjamin is anemic.
What is the most likely cause of Benjamin’s anemia?
The suggested answer is shown below.
Letter Count: 15/1000
Iron deficiency
Given Benjamin’s poor nutritional intake, the most likely cause of anemia in this otherwise healthy child is iron deficiency.
Epidemiology
Nationally among preschoolers, deficient iron stores may occur in up to 35% of low-income children (versus only 7% in other preschoolers), with up to 10% having iron-deficiency anemia.
Association with Cognitive Difficulty
Studies have shown an association between iron deficiency in infancy and later cognitive deficits. It is unclear whether cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk for iron deficiency.
Causes
Lack of iron intake is the most likely acquired cause of iron-deficiency anemia.
Excessive ingestion of cow’s milk (drinking more than 24 oz of milk daily) in young children is an important risk factor for iron deficiency due to the low concentration and bioavailability of iron in cow’s milk. Children with excessive milk intake are also at risk for occult intestinal blood loss.
In rare cases, iron stores are decreased from chronic GI blood loss (e.g., food allergies and gluten enteropathy).
Therapy
In children whose anemia is mild, many providers will provide a trial of iron rather than do any further workup at this point. If the hemoglobin recovers to the normal range after a trial period, that is sufficient evidence of iron-deficiency anemia.
In children of Mediterranean, Asian, or African descent, hemoglobinopathies should be considered, including:
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alpha thalassemia
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sickle cell disease
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In these cases, the child’s newborn screening hemoglobin electrophoresis would have been abnormal.
Other causes are rare in children and present with a more severe anemia (Hgb less than 9 g/dL (90 g/L)):
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Decreased marrow production (e.g., aplastic anemia)
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Hemolytic anemia
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Vitamin deficiencies (e.g., folate and B6)
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Unusual acquired causes of anemia include chronic or severe illnesses:
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Collagen vascular disease
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Malignancy
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Other chronic illnesses
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Two classification schemes are frequently employed to narrow down the differential diagnosis in anemia:
Size Classification: The first uses the MCV and/or the peripheral blood smear to classify the size of the red blood cell as microcytic, normocytic, or macrocytic. Although it can be quite helpful, the system is imperfect. Since MCV values in children vary with age, the age-specific MCV values must be used. Even so, certain conditions do not fit neatly into one category. (For example, the anemia of inflammation/chronic disease and of lead poisoning can be microcytic or normocytic, and the anemia seen with liver failure can be normocytic or macrocytic.)
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Microcytic |
Normocytic |
Macrocytic |
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Mechanism Classification: The second categorizes anemia by its mechanism. In this system, if a patient’s hemoglobin is low, it is due to one of three basic reasons:
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He/she is either not making adequate amounts (decreased production).
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It is being destroyed (increased destruction).
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The body is losing it from somewhere (blood loss).
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This system is intuitive and reliable, but more difficult to categorize:
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Reticulocyte count |
Mechanism |
Possible causes |
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Low |
Decreased production |
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High A high reticulocyte count indicates that the patient is able to adequately make red cells and is trying to compensate for the anemia, suggesting the cause to be either blood loss or destruction |
Increased destruction
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High A high reticulocyte count indicates that the patient is able to adequately make red cells and is trying to compensate for the anemia, suggesting the cause to be either blood loss or destruction. |
Blood loss |
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Eden AN. Preventing iron deficiency in toddlers: A major public health problem. Contemporary Pediatrics. 2003;20(2):57-67.
Falk H. International environmental health for the pediatrician: case study of lead poisoning. Pediatrics. 2003;112(1 Pt 2):259-264..
Glaser, DW. Anemia in Case Based Pediatrics For Medical Students and Residents, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, November 2014. http://www.hawaii.edu/medicine/pediatrics/pedtext/s11c01.html. Accessed July 21, 2021.
You have already discussed gun safety and eczema treatment. As you think over your history and physical you identify several other issues that you need to address.
The remaining issues are all related:
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Probable iron-deficiency anemia
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Poor nutrition
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Dental caries
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Food battles
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You can best help Benjamin by helping his mother change her interactions with him about food:
You can make long-term differences in a child’s health only by working as a team with the parent. In two-parent families, or when extended families are also caring for the child, all members must be engaged and educated about necessary changes.
Rather than focusing on the details of the child’s diet, try to leverage a few key changes involving the eating process. To change a child’s nutrition patterns:
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Provide the parent with straightforward, simple strategies that can be implemented sequentially.
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Provide support and reassurance that the child’s reactions will subside if the parent’s approach remains consistent.
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Try to prepare the parent for handling future challenges.
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The child will benefit by having a loving, predictable environment with appropriate boundaries.
And, of course, always offer availability to assist the family in developing additional strategies if needed.
What practical steps would you take today in addition to oral iron treatment (given as 2 to 4 mg/kg/day of elemental iron divided once or twice daily)?
The suggested answer is shown below.
Letter Count: 338/1000
One step would be counseling Benjamin’s mom about decreasing his milk intake. Milk can cause anemia through multiple mechanisms including microscopic GI bleeding as well as poor iron availability from milk.
In addition, Vitamin C increases the absorption of iron, so recommending he take the supplements with either a vitamin C supplement (or multivitamin) or Vitamin C rich foods can help.
Four steps toward improving a toddler’s nutrition:
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Stop the bottle now. If a toddler is still using a bottle, this should be stopped. It is helpful to actually have the toddler and the caregiver jointly discard the bottle in the trash to show him it is gone for good. Usually children stop their requests for the bottle after a few days.
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Limit the child’s eating to three meals and two snacks, stopping the food and drink grazing. If the child is thirsty, give him water, not juice. Limiting the amount of juice a toddler drinks may improve his nutrition in several ways. For one, when he is drinking juice or milk, his appetite for solids is blunted. He needs adequate solids for energy and vitamins.
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No bargaining or cajoling. The child should eat at time-limited meals. He needs to have his hunger ultimately drive his choices, and only healthy options should be provided. Dessert should never be held as an incentive for “good” eating.
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Gradually change his diet content by introducing new foods he is likely to try and slowly decrease the quantity of old favorites.
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You and Dr. Harris return to the examining room and explain to Mrs. Jones that Benjamin’s current eating patterns have resulted in a mild anemia and have also put him at risk for developing cavities. “Besides treating his anemia with iron, we want to improve his eating to prevent any further problems.”
You review with her the four suggestions from the previous page. Dr. Harris warns her, “We expect Benjamin to initially object a lot, but then become used to the new rules. You know, it is OK to be more stubborn than he is, even if he has a tantrum!
You also discuss the benefit of fluoride varnish to help decrease his risk of dental caries. Mrs. Jones agrees to have the varnish applied to Benjamin’s teeth today in clinic.
Dr. Harris schedules a recheck of the anemia, eating behaviors, and eczema in six weeks, and tells Mrs. Jones to let him know if she has trouble getting him to take his iron. Dr. Harris advises Mrs. Jones that the iron supplement may cause dark stool and/or constipation but that these are normal side effects of the iron.
He encourages her to schedule a visit for Benjamin with the dentist to address his cavities.
Dr. Harris tells her that the prescriptions for iron and for hydrocortisone 2.5% ointment have been submitted to her pharmacy.
Dr. Harris reminds you of the importance of treating iron deficiency because of its potential cognitive impact. You find a list of iron-rich foods and send it to Mrs. Jones. Accessed July 21, 2021.
A couple of months later you run into Dr. Harris in the hospital. You inquire about how Benjamin has done. Dr. Harris is pleased to tell you:
“Changing his feeding and stopping the bottle and sippy cup went surprisingly smoothly. He refused his iron, but started to eat more meat so I changed him to multivitamins with iron. His mother said she appreciated the list of iron-rich foods you sent her. She was pleased that he now likes broccoli with dip and several other healthy foods. When I saw Benjamin last week, his Hgb was 11.5 g/dL (115 g/L).”
Associated reference ranges in conventional and SI units.
Iron for your toddler. Kaiser Permanente. chrome-extension://gphandlahdpffmccakmbngmbjnjiiahp/https://thrive.kaiserpermanente.org/care-near-you/northern-california/sanfrancisco/wp-content/uploads/sites/11/2017/01/IronReHandoutToddlers.pdf (PDF). Accessed July 21, 2021.
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This case has been reviewed and updated by the Aquifer Pediatrics editorial course board.
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References updated.
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Otoscopic examination teaching video link added ( if OK with Mike )
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Answer modification made to test selection at end of visit.
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No major teaching point changes.
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Upon completion of the case, the student should be able to:
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Discuss the importance of identifying parent concerns in order to set priorities for a well-child visit.
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Describe the components of a preschool health supervision visit, including common concerns, key elements of health promotion, recommended screening, and immunizations.
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Demonstrate ability to measure and assess growth, including height/length, weight, and body mass index using standard growth charts.
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List normal developmental milestones at 3, 4, and 5 years of age.
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Identify eczema and discuss principles of management.
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Describe key elements of the physical exam for a well-child visit in early childhood, including tests to identify strabismus.
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Discuss strategies for modifying the elements of the well-child visit to match the child’s level of comfort and cooperation.
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List common causes of injury in early childhood.
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Discuss age-appropriate anticipatory guidance about safety in preschoolers, including recommendations for addressing firearms in the home.
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Summarize risk factors and screening for tuberculosis, lead poisoning, anemia.
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List potential causes of anemia in a preschool aged child.
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Outline an approach to the assessment of anemia in children
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Describe an initial approach to the management of suspected iron deficiency anemia.
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List common dietary issues in early childhood.
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Discuss strategies for counseling parents on making dietary changes in preschoolers.
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A 3-year-old boy is brought to the clinic by his parents for follow-up of iron deficiency anemia. His diet consists mostly of sweet, bland, low-texture foods. He drinks 32 ounces of milk daily from a bottle. In addition to prescribing oral iron supplementation, what is the best advice to give the parents concerning this patient’s diet?
- A. Bribe the patient to eat healthy food
- B. Continue bottle-feeding
- C. Encourage eating small amounts of food throughout the day
- D. Gradually introduce new foods and slowly decrease his old favorites
- E. No change is needed since he is on the optimal diet for his age
A 3-year-old girl is brought to the clinic by her mother for a health maintenance visit. While waiting for the pediatrician, the child notices another child waiting and joins her in play. Developmental history reveals that the patient can draw a circle when taught how, but cannot draw a person with 3 body parts. She can string items together, but cannot hop on one foot. During the visit, when asked her name, the child answers correctly. Which of the following best describes this child’s development?
Choose the single best answer.
- A. Advanced motor skills
- B. Advanced language and communication skills
- C. Age appropriate development
- D. Delayed cognitive skills
- E. Delayed social-emotional skills
A 5-year-old girl is brought by her mother to the clinic for a well-child visit. Medical history is significant for three upper-respiratory infections in the past year. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. Review of systems is otherwise unremarkable. She lives with her mother and father in a home built in 1985. Her height is at the 50%tile, weight is at the 50%tile and BMI is at 60%tile. Vital signs are normal. Physical examination is normal. Lab studies today show a hemoglobin of 10.0 g/dL. Her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia?
- A. Chronic blood loss
- B. Chronic illness
- C. Hemoglobinopathy
- D. Iron deficiency
- E. Lead poisoning
A 4-year-old boy is brought to the clinic by his mother for developmental evaluation. She is concerned that he is delayed when compared to the children of her friends. Although he can catch a large ball, he cannot button some buttons, or hop on one foot. Which of the following set of developmental milestones most closely matches those expected of a 4 year old child?
Choose the single best answer.
- A. Holds crayon between fingers and thumb
- B. Uses a fork
- C. Jumps off the ground with both feet
- D. String items together
- E. Kicks a ball
Thank you for completing Pediatrics 03: 3-year-old male well-child visit.
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Answer Comment
While vision screening is recommended to start at 3 years, many patients cannot yet do chart based screening. All children should be given two tries at separate visits before referring them to a specialist for an exam. So in this case, the vision testing can be repeated at the next visit as long as the parents don’t have any specific vision concerns today.