Discuss the history that you would take on this child in preparation for the well-child visit. Include questions regarding her growth and development that are appropriate for her age.

As primary care providers for the pediatric population, it is our responsibility to monitor children’s overall physical, psychosocial, and cognitive development. Onset of sequential developmental milestones prepares the child for the next phase (Burns, Dunn, Brady, Starr, & Blosser, 2013, p. 44). In preparation for each well-child visit, the provider should look at the immunizations, having the parent complete a developmental survey, looking at the child’s growth chart, and any past notes for the child (Burns et al., 2013, p. 51). We will look at 12 month old well child visit to our virtual patient, Asia.

Brief summary of previous well child visits:

When we review the immunization records, PEDS developmental screening form completed by Asia’s mom, and her growth and development, everything seemed right except that, Dr. Clark during Asia’s Physical exam incidentally noted an abdominal mass in her RUQ and pallor in the conjunctiva, nail beds, and mucous membranes without lymphadenopathy, splenomegaly, or jaundice. He performed a differential diagnosis among the most probable causes of RUQ mass and pallor in a 9-month-old infant; analyzing the results of imaging studies, bone marrow pathology, bloodwork, and urinary catecholamine values, Dr. Clark concluded that the final diagnosis of Asia was a Neuroblastoma Stage 4S disease, which carries a favorable outcome. Hay, Levin, Abzug, and Deterding, (2014) argued that “For children with stage 1, 2, or 4S disease, the 5-year survival rate is 80%–100%”(p.962) The prognosis and treatment options were discussed and evaluated by a group of professionals and the pediatric hematology-oncology specialist. Her family decided that the best option for Asia will be the surgical resection of the tumor, due to the large size of it (English, Knoebel, & Clark, 2017)

Preparation for the 12 months Asia well-child visit:

Asia and her mom are here today for her 12 months well child visit checkup; before I see her I review the consultant notes from the pediatric hematology-oncology specialist: “Tumor was confirmed to be Stage 4S and lower-risk: She did not have the MYC-N gene amplification and had favorable histology”( English et al., 2017). It is very important to know how Asia is doing since her last visits at 9 months, especially after her surgery. Her recovery process is also important as well, and if she had any other illnesses or problems, since the previous visit. Although the American Academy of Pediatrics (AAP) mandates developmental screening at the 9-month, 18-month, and 30-month checkups, many offices do this screening at every well-child visit. Asia’s mom completed the PEDS developmental screening form today and I note that she does not have concerns. Her mom observes that Asia can sit and play for long time holding different toys, picking up and putting in and out of the containers. She begins to learn how to hold a cup and stand by herself, as well as taking steps when she holds her hands. She even participates in games like peek-a-boo. Burns et al. (2013) stated that “Fine motor development allows older infants to entertain themselves for extended times. They hold objects of different sizes and pick up small objects using the sides of the fingers and eventually a fine pincer grasp” (p.65).

During the12 months child visit we need to prepare to observe and assess the following:

Developmental milestones: The gross motor milestones: if she can stand alone or walk holding one or two hands; fine motor milestones: if she has developed a fine pincer grasp. It is also important to evaluate language and social adaptive areas, asking her mom, or observing, if the child says one or two words, like “dada” and “mama”, and if she interact with us in the office playing with a ball or other toys (Burns et al., 2013.p.65).

Growth: to know how the child is growing we need to review the infant weight, length and head circumference and plot the measurements on the growth chart. The infants gains about 1 pound (0.5 kg) per month, between 11 and 12 months, and is more noticeable by parents the growth spurts (Burns et al., 2013.p.65).

Diet history: In this area it is important to explore if Asia’s mom began to follow a routine for feeding her child such as breakfast, lunch, and dinner, with the corresponding snacks in the midmorning and afternoon; how many calories Asia’s eats every day, if she has a well-balanced diet, if she has preferred food, and if she likes to eat by herself. It is also important to know if she uses a cup to drink milk or water. In addition, it is essential to explore if the parent has noted any difficulties with child’s feeding. In this period of infant’s life, they do not have a full dentition, for that reason food choices should be limited to soft or pureed foods or foods that turn soft when chewed (Burns et al., 2013.p.65).

Other important aspects to explore in the health child visit are the bowel and bladder elimination patterns. According to Burns et al. (2013) healthy children demonstrate an extremely wide range of elimination patterns, and primary care providers (PCPs) have a responsibility to help parents understand what “normal” behavior is and what constitutes a problem (p.202).

Other questions that should be asked are about sleep routine, if any problem exists, if the baby struggles during bed time, how many hours of sleep they get during night time, and if she takes the midmorning and afternoon naps. Most children sleep about 13.9 hours at 1 year old. Usually between 12 and 24 months they have a morning nap, but the afternoon nap may persist until the child is 4 or 5 years old (Burns et al., 2013.p.258).

Social History: It is important to know if Asia still lives at home with her mom, dad, and the oldest brother, if she continued to attend daycare and who would take her home. Also, we need to assess environmental risks, such as: if anybody smoke in a house or in the car, if they have guns in their home, if they use gates for top and bottom of the stairs, if they use the car safety seat and how they place it. It also important to know of the parents have history of drug or alcohol abuse. Lastly, it is important to explore lead exposure.

Physical Exam: Asia has a particular situation that we need to take care; she had surgery with resection of her Neuroblastoma. Although she will be observed closely for her pediatric oncologic for the next several years, we need as PCP to also observe her closely. It is essential to perform a complete physical exam with special attention in her abdomen, how her incision is healing. Always check for hepatosplenomegaly, lymphadenopathies, or any mass on her to make sure that the metastatic lesions resolve and that the primary tumor does not recur. Neurological exam is also very important on these patients. According to Lacayo and Davis, (2016) tumors that arise from the para spinal sympathetic ganglia can grow through the spinal foramina into the spinal canal, and impinge on the spinal cord. This may result in the presence of neurologic symptoms, including weakness, limping, paralysis, and even bladder and bowel dysfunction. After completion of therapy, successfully treated patients require follow-up care and close surveillance for any signs or symptoms of recurrent disease. Follow-up care includes monitoring of urinary catecholamine’s, physical examination, and diagnostic imaging. Because most recurrences occur during the first 2 years following treatment, most protocols recommend close follow-up care during this interval (Lacayo & Davis, 2016).

Describe the developmental tool to be used for Asia, its reliability and validity and how Asia scored developmentally on this tool. Is she developmentally appropriate for her age?

The developmental tool that was used for Asia’s assessment was the Parents' Evaluation of Developmental Status (PEDS). PEDS relies on parent-completed questionnaires to gather information about how a child is developing. It is used to gather information about specific areas of child development and to see if further evaluation may be needed. The developmental screeners was developed for English-speaking families, but there are forms available in 14 different languages, takes under 30 minutes for parents to complete and is a useful tool, because the ability to complete the questionnaire is not set at a high standard level of reading.

The PEDS tool obtains the same results consistently, under the same conditions, with the same children. This means that PEDS have Interrater Reliability, different raters agree when they are screening the same children; Test-Retest Reliability, when the developmental screener was given two times, with a two-week period in between administrations, the scores met the criteria for adequate consistency, and Internal Consistency Reliability. The items that are intended to reflect the same set of skills or behaviors have strong relationships. The PEDS was compared with 14 other developmental assessments and screeners. Experts agree that the PEDS does a good job at reflecting what it is supposed to be measuring, showing that PEDS has a strong Validity. There were strong relationships between many of the developmental areas of the PEDS and developmental areas of the comparison tools aimed at measuring the same skills and behaviors (U.S. Department of Health and Human Services, 2014)

After Asia’s mother filled out the PEDS form, it was clear that she did not have any concerns with her. During assessment, there did not appear to have any delays noted. Asia appears to be developmentally appropriate for her age.

What immunizations will Asia be given at this visit; what is the patient education and follow-up?

Immunizations will Asia be given at this visit:

We checked Asia’s immunization record, and according to the Centers for Disease Control and Prevention (CDC), (2017) she will be given the following vaccines at today’s visit:

1. Hib #4
2. PCV13 #4
3. IPV # 3
4. MMR #1
5. Varicella #1
6. Hep A #1

Patient education and follow-up:

We provide the parents with the bright futures patient handout, 12 month visit, which encourages parents to establish routines for sleep time during night time, and for naps. It is also encouraged to have a simple routine that includes reading a book before bedtime, and to make sure that this time is calm. Avoid having your child watch TV and videos until 2 years old, and never to watch anything scary. Respect your child fears and have strangers approach slowly. Start family traditions such as going or a walk together, reading. Keep rules short and simple, use short time out when the child’s behaving poorly and praise them for a good behavior. Make sure that the places for the child stays are safe. Always use the car safety seats, rear facing until the child is 2 years old, or until she reaches the weight or height allowed for the car safety manufactured. Supervise your child all the time or leave her with a mature adult. Keep away small objects, plastic bags, poisons, medications, knives, scissor, and never have a gun in the home or if you have must have one , storage it in a safe place unloaded and locked. We educate parents, also, about routines for feeding their child such as, having their child eat during family mealtime, encouraging them to feed themselves and avoiding small , hard food that can cause choking,. Lastly, we encourage eating healthy foods and maintaining a balanced diet. By 12 months, it is important that you take your child to the first dental visit and make sure they are brushing their teeth twice a day (Hagan, Shaw, & Duncan, 2017).

It is important to provide anticipatory guidance to the parent, on the child’s developmental status, the knowledge of the parent for upcoming milestones, and educating them regarding realistic expectations and normal development (Burns et al., 2013, p. 53). It is also important to provide handouts from Bright Futures to the parent helps provide family-focused care and empower the parent in their child’s development (Burns et al., 2013, p. 9).

Follow up : At 15 months well child visit

Anticipatory Guidance :( what to expect at their child’s 15 month visit)

In this visit we will talk about:

Their child’s speech and feelings, getting a good night sleep, temper tantrums, and discipline. In addition, we will provide information on caring for their child’s teeth, healthy foods, and nutritional needs of their child, as well as encouraging their child to play and participate in different activities. The parents should also read to their child daily with appropriate vocabulary, No television viewing for children younger than 2 years. Keep the home safe for their child.

Burns et al. (2013) stated that “Education helps parents learn about infant development, what activities promote healthy development, and what the parent can do to provide secure, safe relationships in an environment that supports their child's development”(p.53).

References:

Burns, C. E., Dunn, A. M., Brady, M., A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed). Philadelphia, PA: W.B. Saunders Company. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-08024-8/

Centers for Disease Control and Prevention.(2017, Feb 6). Birth-18 years & "catch-up" immunization schedules. Retrieved from https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

English, R., Knoebel, E., & Clark, E.( 2017, Jun 21).Infant well child(2,6 and 9 months)-Asia. Retrieved from https://www.med-u.org/

Hagan, J. F., Shaw, J.S., & Duncan, P.M.(2017). Bright futures guidelines for health supervision of infants, children, and adolescents (4th ed.).Elk Grove Village, IL: American Academy of Pediatrics.

Hay, W. W., Levin, M. J., Abzug, M. J., & Deterding, R. R. (2014). Current diagnosis & treatment: Pediatrics (22nd ed.). New York, NY: Lange Medical Books/McGrawHill, Medical Pub. Division.

Lacayo N.J.,& Davis, K.L.(2016, Mar 17).Pediatric neuroblastoma clinical presentation. Retrieved from http://emedicine.medscape.com/article/988284-clinical

U.S.Department of Health and Human Services. (2014, Mar).Birth to 5: Watch me thrive! A compendium of screening measures for young children. Retrieved from https://www.acf.hhs.gov/sites/default/files/ecd/sc...