Pediatric Primary Care (32 page)

10.  Some children may still be picky eaters at this age so may have to slightly adjust portions or food groups in order ensure adequate intake; may eat more at snack times than at regular meals.

11.  Healthy snacks 1-2 times a day can include:

a.  Fresh, canned, frozen vegetables or fruits. Keep cut-up veggies such as celery sticks, cucumber slices, or broccoli in the refrigerator. Try frozen grapes or bananas for fun treat.

b.  Cold skim or 1% milk with whole-grain sugar-free cereal, peanut butter sandwich, or crackers with hummus.

c.  Fruit smoothie made with fresh fruit, skim milk, ice, and a dash of vanilla or cinnamon.

d.  Non fat or low-fat yogurt or cheese.

e.  Air-popped or unbuttered popcorn.

f.  Baked tortillas or pretzels with salsa.

g.  Chocolate skim milk made at home to control the amount of sugar.

h.  Low-fat frozen yogurt, fruit juice bars (without added sugar).

12.  Encourage healthy eating behaviors including no snacking in front of TV. Parents should model these behaviors.

B.  Sleep.

1.  Stay consistent in routine activities such as daily mealtimes, playtimes, bedtime, wake-up time.

2.  Avoid caffeine/other stimulants; limit food, drink before bedtime.

3.  An hour or so before bedtime, begin a relaxing routine such as warm bath then a story in quiet bedroom.

4.  Bed should only be used for sleeping, not for watching TV or homework. TVs and computers should be kept out of bedrooms.

5.  Children who are overtired/have interrupted sleep may be more likely to have sleep disturbances such as night terrors.

C.  Growth and development.

1.  Musculoskeletal.

a.  Need an hour or more of a variety of age-appropriate daily physical activities including team/individual sports, family activities, free play, walking, bicycling, chores, walking up and down stairs. Parents should model, prioritize, and promote regular physical activity.

b.  Limit total amount of screen time (TV, computer) to < 2 hours a day.

c.  As they approach puberty, children tend to put on a little more weight, which is normal.

d.  Increases in BMI percentiles should be discussed with parents but in nonjudgmental, blame-free manner.

e.  Because fractures are common in this age group, children should wear appropriate protective sports gear but also consume adequate calcium to decrease risk of fractures.

2.  Skin.

a.  30 minutes before going outside, on both sunny and cloudy days, thickly apply broad-spectrum UVA-UVB sunscreen with SPF 15+ to all exposed areas of body, especially ears, nose, face, neck, shoulders, hands, and feet.

b.  Suggest using sunscreen or sunblock with zinc oxide or titanium dioxide for areas that easily burn.

c.  Reapply sunscreen every 2 hours and after swimming or sweating heavily, regardless of whether sunscreen is waterproof.

d.  Use cool, comfortable clothing, especially clothes with a tight weave, to cover the body and protect from the sun.

e.  Wear a wide-brimmed hat to shield head, face, ears, and neck.

f.  Encourage sun avoidance between 10 a.m. and 4 p.m. when UV rays are the strongest. Seek shelter, shade, or umbrellas when out during those times. Remind that UV rays reflect and bounce back from sand, water, concrete, and snow so even in shade sun protection is needed.

3.  Teeth.

a.  Dental visits twice a year for exams, cleaning.

b.  Brush teeth at least twice a day with tartar-control, fluoride toothpaste; floss once a day.

c.  Still may need some help with brushing.

d.  Verify water source for adequate fluoride.

e.  Care of baby teeth as important as permanent teeth. Early loss of baby teeth due to caries or accidents can lead to spacing issues with premature rupture of permanent teeth resulting in orthodontic issues.

f.  Discuss importance of wearing mouth guards, helmets while playing sports.

4.  Eyes.

a.  Wear sunglasses with 100% UVA-UVB protection whenever outside, in car.

b.  All youth in organized sports should be encouraged to wear appropriate eye protection and especially when engaged in high-risk sports and activities such as basketball, baseball/softball, lacrosse, hockey, paintball, BB gun, or when around yard debris. Mandatory protective eyewear for athletes who are functionally one-eyed and for athletes whose ophthalmologists recommend eye protection after eye surgery or trauma.

c.  Warn about dangers of fireworks to eyes; enjoy fireworks displays put on by professionals.

5.  Puberty.

a.  Encourage honest, age-appropriate discussions about sex with child using accurate terminology and listening carefully to child's questions so parent only gives as much information as child requires.

b.  Concerns of girls about puberty:

•  Menstruation.

•  Breast development.

c.  Concerns of boys about puberty:

•  Voice change.

•  Wet dreams.

•  Involuntary erections.

•  Breast enlargement.

•  One testicle lower than other.

6.  Cognitive and social development.

a.  Very sensitive to views of others.

b.  Appreciate having rules.

c.  Begin to have strong internal gauge of right and wrong.

d.  Friendship and teamwork are important parts of this stage of development.

e.  Eager for more independence but frustrated by what they cannot accomplish since they are still in the process of mastering skills. Important to have sense of achievement, accomplishment to build strong self-esteem.

f.  Encourage an appropriately challenging academic schedule and a balance of extracurricular activities. This is determined by child's unique needs, skills, and temperament.

g.  Encourage exploration of activities and interests in a balanced way without the pressure of having to excel in everything.

h.  Encourage parents to promote child activities that are fun, increase self-confidence, and involve friends.

D.  Safety.

1.  Auto.

a.  Children should be properly secured at all times while traveling in car.

b.  Children should ride in booster seats until the vehicle safety belts fit correctly, when they are 4 ft 9 in. tall. This may not be until they are 8 to 12 years of age. Can move to safety belt when child can place his/her back firmly against vehicle seat back cushion with knees bent over vehicle seat cushion. Lap belt must fit low and tight across upper thighs. Belt should rest over shoulder and across chest.

c.  Shoulder belt should never be placed under arm or behind child's back.

d.  Children younger than 12 years should never ride in front seat.

e.  Keep all doors locked while in motion.

f.  Never leave young children alone in car.

g.  Children should not ride in truck beds or any other area of vehicle that does not have seat and seat belt.

h.  Children lack judgment, coordination, reflexes to drive other motorized vehicles such as mopeds, snowmobiles, mini-bikes, ATVs.

2.  Bicycle safety. Children who ride bikes should:

a.  Wear helmets at all times. Helmets should meet safety standards of the Consumer Product Safety Commission (CPSC;
www.cpsc.gov
). Helmets should fit properly; parents may want to bring them in to check for proper fit. Parents should wear helmets as well to serve as a good role model.

b.  Know basic road rules such as obey all traffic signs/lights, stop and look both ways at intersecting points such as driveways/streets, ride in single file or on bike paths, ride in same direction as traffic.

c.  Should not wear loose-fitting clothing, strings, ties that could get caught in bike chain or parts.

d.  Wear shoes with laces tied.