Pediatric Primary Care (31 page)

c.  Cholesterol screening for children with a family history of high cholesterol or heart disease, whose family history is unknown, or who have other factors for heart disease including obesity, high blood pressure, or diabetes. Screening should take place after age 2 but no later than age 10.

J.  Respiration rate.

1.  Age 8: 22 breaths/minute.

2.  Age 10: 20 breaths/minute.

K.  Gastrointestinal system.

1.  Liver function is mature but still growing in size.

2.  Appendix: open lumen and increased size increases risk of blockage, inflammatory reaction (appendicitis).

L.  Genitourinary system.

1.  Urinary tract infections can be common, especially in girls; often asymptomatic at this age.

M.  Nervous system: essentially mature by age 10.

1.  Begins puberty.

a.  Girls.

•  Breast budding can begin as early as age 8; others not until 13, with the average being around age 10.

•  Puberty before age 8: girl should be evaluated for precocious puberty (twice as frequent in females as in males).

•  Peak growth period (height, weight, muscle mass, etc.) occurs 1 year after puberty has begun.

•  Menstruation usually begins 2 years after onset of puberty, on average just before age 13.

b.  Boys.

•  Peak growth period occurs about 2 years after onset of puberty.

•  Begin puberty about 1 year later than girls.

•  First sign of puberty in boys is enlargement of testes, thinning and reddening of scrotum. This occurs on average at age 11, but may occur anytime between 9 and 14 years of age.

•  Puberty before 9: boy should be evaluated for precocious puberty.

2.  Secondary sex characteristics.

a.  Girls.

•  Breast enlargement: 8-13 years.

•  Axillary hair: 11-13 years.

•  Pubic hair: 10-12 years.

•  Menarche: 10-16 years.

b.  Boys.

•  Genitalia enlargement: 9-13 years.

•  Axillary hair: 12-14 years.

•  Facial hair: 11-14 years.

•  Pubic hair: 12-15 years.

N. Language.

1.  Although better able to express emotions and ideas, may talk in abstract terms without fully comprehending meaning of such speech.

2.  Learning to communicate clearly with friends.

VI. SOCIAL DEVELOPMENT

A.  Needs to master balance of feelings in dealing with successes, failures.

1.  Self-concept (body self, social self, cognitive self) affects child's ability to be successful.

B.  Successful accomplishments are of high priority for child in order to build positive self-image. Should feel successful with most day-to-day skills, activities, and chores.

C.  Making friends is one of most important mid-childhood tasks.

1.  Average number of friends: about five.

2.  Sibling friendships may replace outside friends or need for them.

3.  Selects friends of similar temperament, interests.

4.  Often focus on “best friend” relationship, which can be more satisfying than large group.

D.  Increasingly seeks peer for companionship.

E.  Cliques may begin to form.

F.  Parents and teachers are important significant others and will influence behavior, self-concept.

1.  Encourage parents to share unscheduled spontaneous time with their child; time to be together, to listen, and to talk.

G.  School issues.

1.  School phobia.

2.  Learning disorders.

3.  Attention deficit hyperactivity disorder.

4.  Bullying.

5.  After school care and activities.

6.  Dealing with fears, disappointments, and stress.

7.  Parent-teacher communication.

VII. IMMUNIZATIONS (SEE
APPENDIX A
)

A.  Influenza vaccine.

1.  Annual trivalent seasonal influenza immunization is recommended for all children 6 months of age and older.

2.  Especially recommended for children with high-risk conditions such as asthma, diabetes, or neurological disorders.

3.  Live-attenuated influenza vaccine is acceptable alternative to inactivated influenza vaccine for healthy persons 2-49 years of age.

4.  Children 9 years of age and older need only 1 dose.

5.  Children < 9 years need a minimum of 2 doses of 2009 pandemic H1N1 vaccine. If H1N1 not received during last year's flu season, 2 doses of seasonal influenza vaccine needed this year.

6.  Children < 9 years who have never received the seasonal flu vaccine before will need 2 doses.

7.  Children younger than 9 years who received seasonal flu vaccine before the 2009-2010 flu season need only 1 dose this year if they received at least 1 dose of the H1N1 vaccine last year. They need 2 doses this year if they did not receive at least 1 dose of the H1N1 vaccine last year.

8.  Children < 9 years who received seasonal flu vaccine last year for the first time but only received 1 dose should receive 2 doses this year.

9.  Children younger than 9 years who received a flu vaccine last year, but for whom it is unclear whether it was a seasonal flu vaccine or the H1N1 flu vaccine, should receive 2 doses this year.

10.  Children who need 2 doses should receive the second dose at least 4 weeks after the first dose.

B.  Varicella vaccine.

1.  Children ages 7 through 18 years without evidence of immunity should receive 2 doses if not previously vaccinated or the second dose if only 1 dose has been administered.

2.  For children ages 7 through 12 years, minimum interval between doses is 3 months–but accepted as valid if the second dose was given at least 28 days after the first dose.

C.  Measles, mumps, rubella (MMR): Children not previously vaccinated should receive 2 doses or the second dose for those who have received only 1 dose, with at least 28 days between doses.

D.  Hepatitis A vaccine: recommended for children over 23 months of age who live in areas where vaccination programs target older children or who are at an increased risk for infection or for whom protection is desired; can begin vaccine at any visit with the 2 doses being given at least 6 months apart.

E.  Hepatitis B vaccine: The 3-dose series should be given to those not previously vaccinated.

F.  Pneumococcal vaccine (PPSV): To be given to children with certain underlying medical conditions, including a cochlear implant. A single revaccination should be given after 5 years to children with functional or anatomic asplenia or an immunocompromising condition.

G.  Meningococcal conjugate vaccine (MCV4).

1.  Recommended for children ages 2 through 10 years with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk.

2.  Recommended for children previously vaccinated with MCV4 or MPSV4 who remain at increased risk after 3 years (if first dose administered at age 2 through 6 years) or after 5 years (if first dose administered at age 7 years or older).

H.  Human papillomavirus vaccine (HPV): May be given in a 3-dose series to males ages 9 through 18 years to reduce their likelihood of acquiring genital warts.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A.  Nutrition.

1.  Offer nutrient-dense foods that include a wide variety of fruits, vegetables, whole grains, and nonfat or low-fat dairy foods.

2.  Stress importance of parents being good role models. Child who sees parent enjoying a wide variety of nutritious foods is more likely to want them.

3.  Encourage a healthy breakfast daily.

4.  Encourage reading food labels when shopping especially noting calories from fat, type of fat, sodium, cholesterol, vitamins, minerals, and serving size. Child can help to read the labels.

5.  Encourage family meals at home. Children who eat meals with family at home have a better quality diet.

6.  Offer healthy ways of eating when eating out is necessary and remind parents to be mindful of portion sizes.

7.  Encourage parents to closely supervise but involve child in family food preparation. Children are more likely to eat foods that they help prepare.

8.  Encourage family use of USDA's Food Guide for Kids

9.  Child may need multivitamin if not eating enough to get essential nutrients if an erratic eater or on a highly selective diet. Most healthy children eating well-balanced diet do not require supplementation.