Pediatric Primary Care (22 page)

a.  Primitive reflexes should be absent.

b.  Parachute reflex emerges.

C.  Cognitive.

1.  Object permanence more prominently developed.

2.  May look for objects and go after them.

D. Language.

1.  Combines syllables.

2.  Imitates speech sounds. Uses intonations.

3.  “Dada” and “mama” are nonspecific.

4.  Responds to name.

VI.  SOCIAL DEVELOPMENT

A.  Relationships.

1.  Beginning to indicate wants.

2.  May begin to wave “bye-bye.”

B.  Environment: conditions that foster trust and development of positive psychosocial feelings. Separation anxiety emerges. Stranger anxiety apparent.

VII.  IMMUNIZATIONS (SEE
APPENDIX A
)

A.  Make up for missed immunizations.

B.  Influenza annually.

VIII.  SAFETY

A.  Infant care activities.

1.  Always check bathwater temperature.

2.  Never leave infant alone in tub, changing table, highchair.

3.  Use sunscreen; avoid prolonged sun exposure.

B.  Environment.

1.  Use car seat consistently.

2.  Never leave infant alone in car.

3.  Avoid use of walkers.

4.  Reinforce “baby proofing”: outlet covers, door drawer latches, safety gates. Remove cords, wires, string, small objects, plastic bags from baby's environment.

5.  Keep sharp objects out of reach.

6.  Maintain smoke-free environment; use smoke alarms.

7.  Do not leave alone in room with pets or young children. Keep litter boxes away from infant's environment. Feed pets in area away from infant; do not allow infant near pet when eating.

8.  Avoid tablecloths or remove heavy/hot objects from tables with tablecloths.

9.  Keep toilet lid down, remove buckets with water.

10.  Use protective enclosures around swimming pools, hot tubs, other water sites (ponds, fountains).

11.  Provide poison control number (to be placed by telephone); syrup of ipecac no longer recommended.

12.  Keep houseplants out of reach; remove any poisonous plants.

IX.  ANTICIPATORY GUIDANCE

A.  Parent-infant interaction.

1.  Continue to encourage floor time for infant to provide opportunities to explore.

2.  Talk with infant while engaging in other activities (e.g., grocery shopping).

3.  Continue singing and movement activities with infant. Play games such as “peek-a-boo.”

4.  Encourage reading activities with picture books, infant board books.

5.  Foster infant's ability to self-soothe with transitional objects such as blanket, stuffed toy.

B.  Discipline.

1.  Discuss appropriate discipline measures aimed primarily at protecting infant from injury such as physical removal from danger.

2.  Distraction most effective to redirect behavior.

3.  Limited use of word “no.”

4.  Begin to think about rules: keep them few and simple.

5.  Consistency is key to discipline.

C.  Oral hygiene.

1.  No bottles in bed.

2.  Use soft toothbrush without toothpaste to clean teeth. Assess fluoride source and supplement as necessary (see
Appendix B
).

D.  Illness prevention.

1.  Review illness symptoms/interventions.

2.  Reinforce importance of handwashing.

3.  Use cool mist vaporizer for upper respiratory illness.

E.  When to call healthcare provider:

1.  Breathing difficulties.

2.  Seizures.

3.  Irritability.

4.  No urine output in 12 hours.

5.  Rash.

6.  Concerns.

BIBLIOGRAPHY

Burns CE, et al.
Pediatric Primary Care: A Handbook for Nurse Practitioners.
4th ed. Philadelphia, PA: W.B. Saunders; 2009.

Centers for Disease Control and Prevention.
2011 Recommendations and Guidelines: Childhood & Adolescent Immunization Schedules.
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm
. Accessed June 2, 2011.

Dixon SD, Stein MT.
Encounters with Children: Pediatric Behavior and Development.
4th ed. St. Louis, MO: Mosby; 2006.

Hagan JF, Shaw JS, Duncan P (eds)
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Porter RS, Kaplan JL.
The Merck Manual Online:
http://www.merck.com/mmpe/index.html
. Accessed June 2, 2011.

Mindell JA, Owens JA.
A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Recommendations for using fluoride to prevent and control dental caries in the United States. Morb Mortal
Weekly Rep.
2001;50:RR-14.

Samour PQ, King K.
Handbook of Pediatric Nutrition.
3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2005.

CHAPTER 12

Twelve-Month Visit

Patricia Clinton

I.  GENERAL IMPRESSION

A.  Twelve-month visit heralds onset of toddlerhood.

B.  Toddler's increasing mobility opens new worlds to explore and requires close supervision to prevent injuries.

II.  NUTRITION

A.  Caloric needs: 98-100 kcal/kg/day.

B.  Breastfeeding/formula feeding.

1.  Breastfeeding may continue, but toddler is getting majority of nutrients from table food.

2.  If formula feeding, discuss switching to whole cow's milk.

C.  Assess for risk factors, screen for iron-deficiency anemia if necessary.

1.  Birth weight 1500 grams, result of use of cow's milk or low-iron formulas during first year, low intake of iron-rich foods, low socioeconomic status.

2.  Supplement as necessary (see
Chapter 32
for more on iron-deficiency anemia).

D.  Solids.

1.  Offer infant variety of foods from all food groups.

2.  Offer liquids from cup.

3.  Limit juice to 4-6 oz/day. Limit whole milk to 16-24 oz/day.

E.  Eating habits/safety.

1.  Reinforce mealtime as family time.

2.  Three meals and two snacks/day appropriate; rule of thumb for serving size is 1 tablespoon/year of age.

3.  Toddler's attention span limits ability to sit for long periods.

4.  Foods should be chopped into small pieces. Avoid foods that may cause choking: grapes, raisins, peanuts, popcorn, raw vegetables.

5.  Encourage toddler to self-feed with spoon, cup.

6.  If breastfeeding, discuss interest in weaning to cup.

7.  If bottle feeding, weaning to cup should be started.

8.  Reassure parents that toddlers' eating patterns are inconsistent from meal to meal; think in terms of several days when reviewing recommended servings of foods.

III.  ELIMINATION

A.  Voiding and stooling pattern.

1.  Regular patterns may be established but these continue to be involuntary.

2.  Discourage toilet training until closer to 24 months; toilet training dependent on complete myelinization of pyramidal tracts in spinal cord.

IV.  SLEEP

A.Requirements.

1.  12-13 hours total/day.

2.  1-2 naps/day.

B.  Environment.

1.  Continue bedtime rituals; consistency is key.

2.  Transitional objects continue to be important.

3.  Bedtime resistance and night wakings are common.