Pediatric Primary Care (30 page)

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.

Pulcini J. Assessing school readiness. In: Fox J, ed.
Primary Health Care of Infants, Children and Adolescents.
2nd ed. St. Louis: Mosby; 2002.

CHAPTER 17

Seven- to Ten-Year Visit(School Age)

Elizabeth Godfrey Terry

I.  OVERALL IMPRESSION

A.  Early school agers are in routine of being in school, learning; now gaining skills to get along with many different personalities.

II. NUTRITION

A.  Caloric and nutrient needs.

1.  Three full meals and 1-2 snacks a day.

2.  Consumes 1600-2400 calories/day; needs vary depending upon amount of activity and development. Or: female 1200-1600 calories (4-8 years 1200 calories; 9-13 years 1600 calories); male 1400-1800 calories (4-8 years 1400 calories; 9-13 years 1800 calories). Calorie estimates based on a sedentary lifestyle. Increased physical activity will require additional calories: by 0 to 200 kcal/day if moderately physically active and by 200 to 400 kcal/day if very physically active.

3.  Refer to My Plate for serving size, food group recommendations (see
Appendix E
).

4.  Whole grains preferred over refined-grain products; at least half the grains should be whole grains.

5.  Sweetened beverages and naturally sweet beverages, such as fruit juice, should be limited to 8 to 12 oz/day.

6.  Need at least 800-1200 mg of calcium/day.

7.  Introduce and offer fish regularly, especially oily fish such as salmon, broiled or baked, and sardines. Avoid fish high in mercury content. Remove skin from poultry prior to serving. Offer more meat alternatives, such as legumes (beans) or tofu.

8.  Serve fresh, frozen, or canned vegetables and fruits at every meal.

B.  Willing to try variety of foods from major food groups.

C.  Appetite varies according to growth, activity.

D.  May have big appetite during growth spurt and then cut back.

E.  Good internal cues regarding appetite. Parents choose types of food and beverages served and child chooses how much to eat.

F.  Beginning steps toward obesity may start if child is not allowed to listen to internal cues.

G.  19.6% of children ages 6-11 are obese. Excess caloric intake and physical inactivity strongly associated with obesity.

H.  Consider daily children's multivitamin if child is not consuming enough servings to get essential nutrients.

III. ELIMINATION

A.  Enuresis occurs in 10% of 7-year-olds and 5% of 10-year-olds.

1.  Children with this condition should receive complete exam to rule out underlying conditions such as urinary tract infections.

2.  Children with sleep apnea at greater risk for enuresis.

B.  Encopresis affects 1.5% of young school children.

IV. SLEEP

A.  Need 10-11 hours/night.

B.  Encourage and emphasize need for regular and consistent sleep schedule and bedtime routine.

C.  Make bedrooms conducive to sleep—keep TV and computers out of bedroom.

D.  Occasional nightmares or sleep disturbances such as night terrors, sleep walking.

E.  May have fear of dark or of being alone (separation anxiety).

F.  Emotional disturbances such as stress, anxiety, leading to insomnia.

G.  Difficult bedtime behavior may develop.

H.  Snoring, daytime sleepiness may be symptoms of sleep apnea.

V.  GROWTH AND DEVELOPMENT

A.  Musculoskeletal.

1.  Calculate and plot BMI once a year. BMI between 85th and 95th percentile for age and sex is considered at risk for overweight. Close supervision by healthcare provider may be considered.

2.  Development not as rapid.

3.  As body size increases, body fat relatively stable, giving slimmer appearance than preschool years.

4.  Average height increase: a little over 2 in./year.

5.  The closer to puberty, greater the chances for increased growth.

6.  Tends to be an increased growth rate between 6 and 8 years of age that may be accompanied by appearance of small amount of pubic hair.

7.  If unusually short/tall for age, may need to consider possibility of growth disorder.

8.  Appetite tends to vary due to growth fluctuations, but child should not be losing weight.

9.  Orthopedic problems of this age group:

a.  Fractures, sprains, strains.

b.  Epiphyseal separations, dislocations.

c.  Scoliosis.

d.  Avascular necrosing lesions of epiphysis.

•  Legg-Calve-Perthes disease.

•  Osgood-Schlatter disease.

10.  Motor skills improve in strength, balance, coordination.

B.  Skin.

1.  Hair may become a little darker, skin becomes more adult like.

2.  Scabies, impetigo, ringworm can be problems at this age.

C.  Teeth.

1.  Should be able to brush teeth by themselves, may still require some assistance.

2.  Brush with fluoride toothpaste after each meal but at least twice a day; floss once a day.

3.  Water supply should contain adequate fluoride, if not, consider fluoride supplement (see
Appendix B
).

4.  Eruption of permanent teeth occurs in order in which primary teeth are lost.

5.  Dental visits twice a year for exams, cleanings.

6.  Sealants as recommended.

7.  Problems with dental decay can peak during these years as well as periodontal diseases, often due to poor hygiene.

D.  Eyes: visual acuity of 20/20 although about age 8 may begin to have myopia with no overt signs except school difficulty.

1.  Evaluate regularly for visual acuity and ocular alignment (approximately every 1-2 years) at primary healthcare visits. Screening examinations should be done at routine school checks or after the appearance of symptoms. Screening emphasis should be directed to high-risk children, such as those with positive family history. Any child who does not pass screening test should have an ophthalmological examination.

2.  Children with presumed or diagnosed learning disabilities should undergo a comprehensive pediatric medical eye examination to identify and treat any undiagnosed vision impairment. Referrals should be made for appropriate medical, psychological, and educational evaluation and treatment of the learning disability.

E.  Ears: problems decrease due to further development of eustachian tubes and nasopharynx, although ear infections can still be frequent in younger school ager.

1.  Consider hearing screening if history of frequent ear infections or concerns about speech development.

F.  Throat: tonsillar tissue continues to enlarge, reaching its peak from 8-12 years when it levels off, begins to recess.

G.  Immune system: continues to mature; allergic conditions more common.

H.  Hematopoietic system: abnormal hemoglobin/hematocrit levels should not be attributed to dietary intake. Etiology should be established for any hemoglobin below 11.5 g.

I.  Heart.

1.  Murmurs are often heard in these years.

2.  Any doubt of etiology requires referral to pediatric cardiologist.

3.  Circulation.

a.  Average pulse rate:

•  Age 8: 78.

•  Age 10: 74.

b.  Average blood pressure:

•  Age 8: 105/60.

•  Age 10: 111/66.