Monitoring of children’s health Prof.Dr. Emel Gür İ.Ü Cerrahpaşa Tıp Fakültesi Çocuk...

Monitoring of children’s healthMonitoring of children’s health

Prof.Dr. Emel Gür

İ.Ü Cerrahpaşa Tıp Fakültesi

Çocuk Sağlığı ve Hastalıkları ABD

Sosyal Pediatri Bilim Dalı

ExaminationExaminationMaintanceMaintance

ImprovementImprovementof healthof health

To prevent diseases and disabilities Early diagnosis and treatment To prevent deaths of babies and children Support to families for healthy raising of

children

AimAim

Prevention of diseases

Follow up of growth and development

Appropriate feeding according to age

Immunisation

Support to families

Health education

Consultancy

Family planning

Early diagnosis and treatment

History

Physical examination

Lab. tests

Activities

Steps in monitoring of childrens Steps in monitoring of childrens healthhealth

Follow up Meeting and history

Examination of growth and development

Detailed physical examination

Screening

Immunisation

Health trainning and counseling

Mother’s questions

Determination of the next appointment

Monitoring of the growthMonitoring of the growth

Aim; to follow up the health, to detect health problems in its early stage , to prevent malnutrition

At each examination weight, height and head circumference sholud be correctly measured, standart growth curve should be evaluated and it sholud be interpreted in the right way

Parents should participate actively in the examination of growth

Periods in the monitoring of babies and Periods in the monitoring of babies and childrenchildren

AGE GROUPS PERIODS OF MONITORING

FİRST 48 H ONCE

15. DAY ONCE

41. DAY ONCE

2 - 12 MONTHS 2, 3, 4, 6, 9, 12. MONTH

1 – 3 YEARSWITH THE PERIOD OF 6 MONTHS

≥4 YEARSWITH THE PERIOD OF 1 YEAR

Bebek ve Çocuk İzlem Protokolü. T.C Sağlık Bakanlığı AÇSAP Genel Müdürlüğü. Genelge 2008/45.

Growth curves for Turkish childrenGrowth curves for Turkish children

Weight curves for Turkish childrenWeight curves for Turkish children

Marked curves of children’s weightMarked curves of children’s weight

good dangerous

attention catch up of growth

Monitoring and support of developmentMonitoring and support of development(Guide for monitoring of chidren’s development)(Guide for monitoring of chidren’s development)

Is there any worry about child’s development, hearing, talking, understanding, use of hands and body movements?

Can your child explain what he wants? What is your child understanding? What is he doing with his hands and fingers, what is the way

he is making his body movements? What is the way he communicates with the family members

and foreigners? Can you give us information about the way he is playing

games?

Screening of developmentScreening of development

Screening of developmental problems is useful for monitoring of risk infants

Denver II is a reliable screening test for the children at their first 6 years of life

Development, personal and social inteligence,fine and rough motor skills and language are examined by Denver II test

Screening of Early ChildhoodScreening of Early Childhood

Strabismus

Vision problems

Hearing problems

Interruption of growth

Child abuse

Teeth problems

Cornea reflex

Allen, Snellen tables

OAET Measurement of growth

and weight

History , inspection, physical examination


Screening of newbornScreening of newborn Hypothyroidism Phenylketonuria Hydrocephalus Cleft palate Congenital heart

deseases Hernies Undescended testis Hypospadias

Serum T4/TSH Guthrie Measurement of head

circumference Physical examination Physical examination Physical examination Physical examination Physical examination

ScreeningScreeningRoutine screening History Inspection Physical examination Laboratory tests Sensorial tests Additional screening (family history, ethnicity etc..)

Screening of school-age Screening of school-age childrenchildren

Scoliosis

Parasitosis

Behaviorial disorders


Stool smear

History , examination

Screening of NewbornScreening of Newborn

Newborn Screening ProgramsNewborn Screening Programs

Phenylketonuria screening program, which has been implemented in 22 cities by support of the Turkish Republic ministery of health since 1987, was carried out by Istanbul University Faculty of Medicine, Hacettepe University Faculty of Medicine, Cumhuriyet University Faculty of Medicine, Dokuzeylül University Faculty of Medicine in 74 cities.

General newborn screening programs in Turkey; 1993 Phenylketonuria 2007 Congenital hypothyroidism 2008 Biotinidase deficiency Since 2006 Newborn metabolic screening tests are being

analysed at Ankara central laboratory and İstanbul Hıfzıssıhha Institute.

Time of taking blood sample Time of taking blood sample for newborn screening testsfor newborn screening tests

Blood should be taken in the first 48-72 h, after first enteral feeding (appsolutely before child is being discharged)

For the PKY ve biotinidase screening at least 48 h enteral feeding (75 kcal/kg/day)

Blood sample taken in the first 24 h can give a false negative result for PKY and biotinidase; for hypotiroidism it can give a false positive result

Total parenteral nutrition can lead to falce negative results

If the blood sample was taken too early or before feeding, it should be repeated in 1-2 weeks

Taking blood sample Taking blood sample for newborn screeningfor newborn screening

•Heel should keep warm (max. 42 C, heated by wet towel for 3 min) and under the level of hearth

•It should be cleaned by 70% isopropyl alcohol and left to dry

•Plantar face of the heel is punctured at its media or lateral side by steril lancet (at depth of 2.0-2.4 mm)

Use of Guthrie cards Use of Guthrie cards at newborn screeningat newborn screening

The first drop of blood is cleaned by gauze, later drops make contacts with Guthrie cards an by this way 5 marked areas are fullfilled (heel should not be squeezed, carton should not be suppressed )

•Front and rear side of the card’s marked section should be filled out completely. However, blood should be absorbed at only one side.

•Blood sample should be dried at horizontal position at room temperature at least 3 hours.

•There should not be any contact at card’s marked section before and after taking blood sample.

Right blood sample

Unequal spread of blood

Blood clots at sample

Wrong filled circles

Poor saturation

Recording and delivery Recording and delivery of Guthrie cardof Guthrie card

• ID, address, name of hospital , number of sample , date of birth date of blood sampling, prematurity, transfusion, time and way of feeding should be written on Guthrie card.

• Card should be covered in an envelope and immediately delivered to City Health Council , Center of Public Health (Fatih Grup Başkanlığı ) and Refik Saydam Hıfzısıha center.

• Screening status should absolutely be recorded at file of the baby.

Screening of Screening of Phenylketonuria Phenylketonuria

Frequency 1/10 000 (Turkey: 1/4 500)

Each year 250-300 patient, from 20-25 persons one is carrier

Caracterized by sever motor-mental retardation

Detected by fluorescent immunoassay (FIA)

In the case of positive result test should be repeated (FIA, enzyme, paper chromatography, HPLC, Tandem mass spectrometry)

Ozalp I, Coşkun T, Tokatli A, Kalkanoğlu HS, Dursun A, Tokol S, Köksal G, Ozgüc M, Köse R. Newborn PKU screening in Turkey: at present and organization for future. Turk J Pediatr. 2001;43 (2):97-101.

FLOW CHART FOR PHENYLKETONURİA

BLOOD SAMPLE

İNAPPROPRİATE BLOOD SAMPLE

APPROPRİATEBLOOD SAMPLE

REPEATED BLOOD SAMPLE

SCREENING LAB.FA LEVEL

( FIA METHOD)

≤2 mg/dl 2.1 – 3.9 mg/dl ≥4 mg/dl

REPETEAD BLOOD SAMPLE

≤ 2 mg/dl ≥ 2.1 mg/dl

DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISMHPLC method FA>120µmol/L and FA/tirozin>2 follow; FA>360 µmol/L treatment.i

3 day

72 h

3.-5.day

NORMALAccess to lab3-5 day

72 h

Access to lab. 2-3 day

Biotinidase deficiency General frequency 1:60 000

Turkey 1:11 763 (117 case/year)

Convulsion, hypotonia, ataxia, vision, and hearing loss, skin rash, mental retardation, acidosis, coma, death

Screening is performed by colorimeric test

If biotinidase deficiency is +, the spectrophotometric test is performed

Baykal T, Huner G, Sarbat G, et al. Incidence of biotinidase deficiency in Turkish newborns. Acta Paediatr, 1998;87(10):110-3.Tanzer F, Sancaklar M, Büyükkayhan D. Neonatal screening for biotidinase deficiency: results of a 1-year pilot study in four cities in central Anatolia. J Pediatr Endocrinol Metab. 2009;22(12):1113-6.

FLOW CHART FOR BİOTİNİDASE DEFFİCİENCY

BLOOD SAMPLE3.-5. DAY

UNAPPROPRİAE BLOOD SAMPLE APPROPRİATE

BLOOD SAMPLEREPETEADBLOOD SAMPLE

SCREENİNG LAB.(colorimetric method)

ENZYMEACTİVİTY (+)

REPETEAED BLOOD SAMPLE

ENZYME ACTİVİTY ↓ or (-)

DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISMSpectrophotometric method <3.5U/L (enzyme activity as %)

Enzyme activity <%30 partial, <%10 total enzyme defficiency

ENZYME ACTİVİTY (+)

ENZYME ACTİVİTY ↓ or (-)


72 h


72 h

HypothyroidismHypothyroidism Frequency of 1/3500-4000 (World), Turkey : 1/2700

Severe growth retardation and mental retardation

Heel blod sample for screening: TSH and T4 level

TSH; primary and compensated hypothyroidism is recognized, central hypothyroidism is skipped (low false positivity)

T4; primary, secondary, tertiary hypothyroidism, TBG deficiency, hipertiroksinemi, slow rise in level is diagnostic for con. hypothyroidism (compensated hypothyroidism could be skipped)

Yordam N, Calikoğlu AS, Hatun S, Kandemir N, Oğuz H, Tezic T, Ozalp I. Screening for congenital hypothyroidism in Turkey. Eur J Pediatr.1995;154(8):614-6.Update of newborn screening and therapy and congenital hypothyroidism. Pediatrics 2006;117(6):2290-303.

Lafranchi SH. Newborn screening strategies for congenital hypothyroidism: an update. J Inherit Metab Dis. 2010 Mar 2. [Epub ahead of print]

FLOW CHART FOR CONGENİTAL HYPOTİROİDİSM

BLOOD SAMPLE

INAPPROPRİATEBLOOD SAMPLE

APPROPRİATEBLOOD SAMPLE

REPEATEDBLOOD SAMPLE

SCREENING LAB. TSH level

<15 mlU/L 15-50 mlU/L >50 mlU/L

REPEATED BLOOD SAMPLE

<15 mlU/L

NORMAL

≥15 mlU/L

APPROPRIATE LAB. Serum T4 <10µg/dl;TSH>10mlU/L

CONSULTATION OF SPECIALISTDEPARTMENT FOR

PEDIATRICENDOCRINOLOGY

Accessto lab.2-3 day

72 h

3.-5.day

Accessto lab.3-5 day

72 h

Developmental dysplasia of the hip

DDH frequency 1.49% Should be screened at all newborns by physical examination It should be repeated at each examination till child start to

walk Ortoloni and Barlow test are reliable at first 3 months Restricted abduction at hip is the most reliable after 3

months of age Ultrasound is helpfull before 4 months of age, X ray is

helpfull for diagnosis after 6 months of age Children with positive signs should be refered to ortopedist For risk infats ultrasound is suggested at the period of 4-6

weeks (breech birth, musculo-skeletal deformities, positive family history etc.)

Examination of the hip jointExamination of the hip joint

Barlow maneuver Subluxation, unstable hip

Ortoloni maneuverDislocated hip

Examination of the hip jointExamination of the hip joint

Restricted hip abduction (<60º)

Prevention of developmental hip displasiaPrevention of developmental hip displasia

Keeping hip at abduction and slightly flexion , keeping knee at flexion is the most appropriate position for the normal development of the hip joint

Swaddle and supine positions are not recommended (side position is also risky)

Keeping legs with upside down position increase the risk

Baby diapers bond should be wide ; clothes should not be narrow

Appropriate carriage (baby sling)

Iron defficiency anemia Iron defficiency anemia Frequency of 40% among toddlers in our country For term babies at 4-6 months, for preterm babies at 2-3 months

of age iron storage is becoming sufficient . İf iron defficiency lasts more then 3 months, it can lead to serious

problems of development In countries with frequency of more than 10%, for term healthy

babies it is recommended to check up Hb/Hct at the age of 6-12 months

In our country iron is given profilactic (1mg/kg) to all term born children (breastfeeding and feeding with cow milk), starting at the age of 4 months and continuing for 1 year. Among preterm born children profilaxy starts at the age of 2 months.

Control Hb should be taken at the age of 9 months Hb< 11 g/dl : treatment with iron and after 1 month control.

Treatment should be continued at least for 3 months. Hb controlu should be made at adolescence

Urinary tract infectionsUrinary tract infections Frequency: females 3%, males 1.1% The main reason for the chronic renal insufficiency at

underdeveloped and developing countries Diagnosis and treatment on time is very important Screening should be performed in the age of 5 year and

in adolescency Screening should be performed at fresh sample of urine

by stick test In the case of positive result, mycroscopic examination

should be made Detail examination of urine and urine culture should be

taken at those with symptoms of infection

Screening for congenital heart diseasesScreening for congenital heart diseases

The half of the congenital heart diseases could be detected at the first newborn physical examination

The early diagnosis makes prevention of heart failure, hypoxemia, infective endocarditis

It should be examined at all newborns by history and physical examination

Cardiovascular system should be carefully examined at each examination

Femoral artery pulse palpation, auscultation of heart are very important screening methodes

EKO screening is recommended for all babies at risk at 16. GH

HypertensionHypertension

Frequency at children: 1-3% Important for the heart, brain, kidney, eye complications For healthy children tansion should started to be measured

at the age of 3 years, and later on it should be measured at each examination

Measurement should be made at sitting position Cuff height should be 80-100% of the mid-upper arm

circumference or two thirds of the length of the upper arm Hypertension; blood pressure above 95 percentile according

to patients age and sex

Measurement of the arteria pressureMeasurement of the arteria pressure Resting for 3-5 min. before measurement

Measurement should be made at sitting position (for infants supine position)

Cuff should be put at supported right upper arm

Cuff should be placed at two thirds of the length of the upper arm, it should surround complitely circumference of the arm

Cuff should be placed 2 cm above the fossa cubitalis

A stethoscope should be placed on palpable brachial artery pulsations

Measurement of the arteria pressureMeasurement of the arteria pressure

Cuff should be inflated 20-20 mm above sistolic blood pressure and should be deflated with the speed of 2-3 mmHg/sec.

Sistolic blood pressure: point of the 1. korotkoff sound

Diastolic blood pressure: point of 5. korotkoff sound disappears

If the BP is high: it should be measured on the other arm and the other leg and measurement should be repeated 1 week later

Examination of the blood pressure Examination of the blood pressure measurementmeasurement

At least three measurements of blood pressure According to sex and age;

BP<90p= Normal: no need for folow up TA=90-95p.=borderline. No symptoms: follow up. TA=90-95p with symptoms: evaluation (urine, hemogram, urine culture, elektrolyts,

urea,creatinine, uric acid , renal ultrasound, EKG ) TA>95 p =HT: advanced evaluation at hospital

Hyperlipidemia

Atherosclerotic changes begins at childhood age . Annual risk evaluations should be done at all children after age of two Histories such as coronary artery and cerebrovascular deseases or any

sudden death caused by cardiological reasons before age of 55 at family should be interpreted.

T. cholesterol level>240 status of mother or father. Histories such as obesity, hypertension, diabetes or smoking at child. Cholesterol and lipid levels should be checked at children with risk

factors. Lipoprotein analysis should be done at children with t. cholesterol

level>200 mg/dl. Diet programs should be carried out once in each 5 years if LDL<110

mg/dl , once in each year if LDL=110-129 mg/dl , continuously if LDL>130 mg/dl.

Hearing ScreeningsHearing Screenings The frequency of hearing loss is %1-3 at normal babies, %2-4 at

babies remained in intensive care. Age of application to a health care institution is 3.8 years in our

country. A serious two-sided hearing loss influences speech and cognitive

development negatively Aim is to determine the hearing loss before third month. Initiation of treatment before sixth month has a significant effect at

language development. Newborn and infants should be screened with histories and physical

examinations in a subjective way ; subjektif, childrens at pre-school period (3-4-5 years) should be screened with hearing tests in an objective way.

It is recommended that hearing tests should be done intermittently till the end of the period of adolescence.

Hearing screenings at healthy infantsHearing screenings at healthy infants

*Newborn : Auropalpebral reflex, recoil,moro reflex

* First Month : recoil ,interruptions at feeding

* 3-4 months : Begins to turn head toward the sound source

* 4-7 months : Turns head completely toward the sound source

* 9-13 months: Finds directly source and direction of the sound

*21-24 months :Replies with short sentences against to the people who warns orally.

Children with risk factors for hearing loss

Sensorineural hearing loss history at family Birth weight <1500 g Low apgar score (1.min<5, 5.min<7) Intrauterine infection, bacterial meningitis Ventilation more than 5 days . Hyperbilirubinemia requiring blood exchange Use of ototoxic drugs AOM with effusion lasting along 3 months Syndromes accompanying with hearing loss. If otoacoustic emission test (OAE ) and brainstem evoked potentials

(ABR)should be carried out at risky children, hearing loss can be reduced at %20 percentage , this should be carried out for all children at first 48 hours .

OAE should be carried out at all babies in first 48 hours after birth.

OAE test reflects the sound energy originated at cells in the inner ear ; and measured by microphones at outer ear.

If OAE test fails , repeating after two months, If repeating fails too, then auditory brainstem responses ( ABR ) test should be carried out.

Audiometric hearing test should be done to all children in pre-school age (4 years old)

Objective Hearing Screening

Screening of visionScreening of vision

Strabismus 2-6%, refraction disorders 20%,

amblyopia 2-4% Amblyopia; loss of visual acuity ≥ 2/10 or difference

between eyes ≥2/10 In the first 3 months permanent strabismus, after 3. month

of age permanent and temporary strabismus is patological and it is the most common reason for amblyopia

If strabismus was not treated in the first 6 years it leads to amblyopia, after 12 years of age amblyopia could not be treated.


*0-3 months red reflex

cornea reflex

inspection

* 6-12months red reflex

cornea reflex

inspection

*3 and 5 years

visual acuity

red reflex

cornea reflex

inspection

*Abnormal

assymetric

constutional disorder

*Abnormal

assymetric


* Reduced

abnormal

assymetric



Newborn; response of the baby to mother’s face 2-3 months; focus on objects 4-5 months:attention to toys and enviroment 6. month: following moving objects VEP, optokinetic nystagmus 3-4-5 years; test for visual acuity Visual acuity should be periodically examined

until the end of adolescence

Red ReflexRed Reflex

• Ophthalmoscopic examination for red reflex among newborns

*red reflex examination should be repeated in a few months

*white reflection; retinoblastoma, retrolental fibroplasia, lens opacities, congenital cataract,(TORCH)

Corneal reflex(Hirschberg testi )

Health educationHealth education Good communication (non-verbal and verbal

communication) To focus attention, to show empathy Avoidance of authoritarian attitudes Talking with precise and clear language First praising right behaviors, then correcting mistakes Suggestions should be appropriate to families level Suggestions should be appropriate to child’s age İt should be checked out if suggestions are understandible Practical applications Written educational materials(brochure etc.)

First evaluationFirst evaluation(7-15. day)(7-15. day)

Benefits of breatfeedingBreastfeeding counselingUmbilical cord care, bath, clothesCleanning the skin, prevention of diaper rashCauses of crying, frequency of urine and defecationImportance of hand-washing, the hazards of smokingBed for baby, sleeping position, rhythm of sleeping (15-18 h)Disandvantages of swaddling and teatAt 15 day of life D vit. (400 ıU/day) for 1 yearBaby should not be left alone with children under 10 years oldwith

2-4. months evaluation2-4. months evaluationRelations between baby and parents or siblingsImportance of play and talk with babyGrowth and development, breastfeeding and

problemsVaccines, the importance and reactionssleeping ( at least 16 h per day, 2-3 times a day)Baby care, crying causesDefecation (consistency is more important than

number)Risk for aspirationFamily planning (1.5- 2 months control)

6-9. month evaluation6-9. month evaluationHarmony in the familyExamination of growth and developmentcontinuation of breastfeedingVaccines, the importance and reactionsCare and hygienesleeping (12-14 h, at least 2 times a day) Importance of playing with babyAdditional feeding, eating using a spoon and glassFall from a height, hot water, sockets, water-filled

containersCare of milk teeth

1 year evaluation1 year evaluation Introduction to family table (3 main meals, 2 snacks)Encourage self-feedingsleeping (at least once at daylights)Brushing teeth with a soft brush without toothpasteMeasures to be taken to prevent accidentsSetting rules and discipline, praise and reward

constraintWish for independence should not be supressed but

should be supervisedThere could be a lack of appetite, no need for force

2-3 year evaluation2-3 year evaluation

Importance of introducing a child to a family table Balanced nutrition Loss of appetite Adequate consumption of milk Accidents discipline (prize, penalty) Time for sleeping (once a day) Teeth care, visiting dentist Playing games under control Toilet habits

4-5. year evaluation4-5. year evaluation Balanced feeding, importance of conversations at family

table Friends, playing games (under control) Answering questions about sexuality Dental care(brushing teeth with fluoride toothpaste for

children), visiting dentist sleeping (sleeping at daylight not necessary) Support for pre-school education Name, surname, address and telephone number should be

taught Child should be worned regarding foreigners Household and responsibility Traffic rules

6-11 year6-11 yearSleeping patterns (going to bed at 20.00-21.00

o’clock, totally 9-10 hours of sleeping)Balanced feeding, prevention of snack between

meals, importance of breakfasttooth brushing (twice a day), visiting dentistAnswers to questions about sexualitySchool adjustment, learning problemsTV, computer games (1 hour per day)Education regarding child abuse preventing accidentsHabits of reading books

12- 21 year evaluation12- 21 year evaluation

Healthy communication Respect for private life TV, computer games, internet usage should be supervised Smoking, substance use, sleeping (8-10 h), regular exercişse(at least 3 times a week)) Balanced feedşng (3 meals) Brushing teeth, visiting dentist (twice a year) No weapons at home, preventions of accidents Questions and issues related to sexuality, encourage the education and development of new skills

In our country;

0-1 years old 60%

1-5 years old 70% children benefit from “monitoring of children’s health “

RecommendationsRecommendations

“Monitoring of children’s health “ outpatient departments should be increased;Those departments should be integrated to general child outpatient departments;“Monitoring of children’s health “ service including health education and education of parents;It should be understood as ‘ missed opportunities’

Monitoring of children’s health Prof.Dr. Emel Gür İ.Ü Cerrahpaşa Tıp Fakültesi Çocuk...

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Transcript of Monitoring of children’s health Prof.Dr. Emel Gür İ.Ü Cerrahpaşa Tıp Fakültesi Çocuk...