Pediatric Health Promotion Plan

Milestones

Newborn (birth to 4 weeks)

· Communicates through cries, vision 8-12 inches

Infant (4week-12 months)

1 month-

· GM: Lifts chin when prone, turns head when supine, largely reflex

· FM: hands with tight fist, hands to mouth

· Hearing fully developed, grunts, startle reflex, fixates on faces, recognizes parents voice

2 month

· GM: Lifts chest & head when prone, turns head when supine. Head bobs if held upright

· FM: Tracks past midline (by 4 months), makes eye contacts. Opens and closes hands, hold hands together.

· Coos, alerts to voice and sound. Social smile begins (by 6 months). Recognizes parents face.

4 month

· GM: Props on wrists when prone. Holds head up, rolls front to back (by 6 months should see).

· FM: Tracks to 180’, Grasp, shakes rattle, places items in mouth, reaches for objects.

· Teething starts, “converses” in responsive manner to person/parents. Laughs out loud. Looks around-curious (near and distant vision). Smiles spontaneously. Sees color.

6 month

· GM: Starts to sit unsupported (by 9 months). Crawls (by 8months).

· FM: Reaches with one hand and transfers hand to hand

· Babbles, giggles/laughs and listens by nine months, recognizes strangers. 7 months begins to reach out hands in anticipation of being picked up, 8 months should be sitting unassisted, distinguishes different shapes.

9 month

· GM: Pulls to stand, cruises, crawls

· FM: Pincer grasp, bangs blocks together, holds bottle

· Babbles (‘Da-da, Ma-ma’ by now), imitates sounds (understands 1-3 words), responds to name (by 12 months), waves “bye-bye” , reciprocates gestures (by 12 months), uses sound to get attention, stranger anxiety. Object permanence.

Toddler (1 year-3 year)

12 month

· GM: Stands alone, first step by some, (walks few steps alone by 18 months).

· FM: primitive marks on paper. Finger feeds.

· 1 word immature jargon (begins to use 1-2 word jargon through 2cd year), points finger in purposeful direction, pat-a-cake, imitates, follows 1 step commands with gesture

15 month

· GM: Walks carrying objects, stoops and recovers, climbs on furniture.

· FM: Scribbles, 3-4 cube tower (up to 2 year), turns pages, uses spoon and cup

· 3-6 words, says ‘No’ correctly, single step commands w/o gestures

18 month

· GM: Walks up steps with hand held, runs, throws ball

· FM: Scribbles, 4 cube tower minimum

· 10-25 words, points to people and at least three body parts when named, combines language with gestures. Helps in house, removes clothing, imaginative play begins

2 year

· GM: Walks down step uses rail. Throws ball overhead. Kicks ball. Jumps, walks on toes, alternates feet going up stairs

· FM: Lines cubes up as train, imitates circle and/or line. Turns paper pages in books, 6-8 cubes tower, can turn knobs and open doors.

· >50 words 50% intelligible, 2 word phrases, pronouns, can recite parts of familiar book, follows series of independent commands, takes off clothing, parallel play. Washes and dries hands, puts on clothing, imitates adult activities.

3-5 year (preschool)

· GM: Runs, jumps, skips, rides tricycle, stand on one foot, constantly in motion. Throws overhead by 5 years.

· FM: Can draw intersecting lines (cross, plus sign).

School age (5 years-12 years)

· GM:

· FM: draws 6 part man (stick figure) beginning at 5 years. Lace shoes.

Adolescent (13 years- 18 years)

· Depending on circumstances stage can be 13-20 years of age.

Immunization Schedule

Direct CDC link with catch up schedule included

Birth

Hepatitis B (HepB) 1st dose

Screening- ( B.F. Preventive Service link )

· ‘Newborn Screening’ (usually in hospital prior to discharge w/repeat testing in 9 states at 1-2wks)

· Hearing birth to 1 month

· Vision screening at visits to 3years

**All screening just for start them, make sure to check on follow up screenings using the B.F. (Bright Futures) recommendations.

1month-2months

Hepatitis B (HepB) 2cd dose

2 month-1st dose

Rotavirus (RV): RV1 (2-dose series- If any dose in the series is either RotaTeq or unknown, default to 3-dose series.)

Diphtheria, tetanus, acellular pertussis (DTaP <7years)

Haemophilus influenzae type b (Hib)

Pneumococcal conjugate (PCV13)

Inactivated poliovirus (IPV <18 yrs)

4 month-2cd dose

Rotavirus (RV): RV1 (2-dose series)

Diphtheria, tetanus, acellular pertussis (DTaP <7years)

Haemophilus influenzae type b (Hib)

Pneumococcal conjugate (PCV13)

Inactivated poliovirus (IPV <18 yrs)

Screening-6mth

· Risk for Anemia (screen only)

· TB screen Q6 months until 2yo then annual.

Starting 6 months

Inactivated poliovirus (IPV <18 yrs), Hepatitis B (HepB) 3rd dose (6-18 months)

RV5 (3-dose series)

Diphtheria, tetanus, acellular pertussis (DTaP <7years)

Haemophilus influenzae type b (Hib) (6-15 months, can give 4th dose at 12 months if 3rd dose given at 6 months).

Screening- 9month ( B.F. Preventive Service link )

· Developmental-Behavioral

· Finger stick Anemia test

· Lead test or screening test

12-18 months

Pneumococcal conjugate (PCV13)

Measles, mumps, rubella (MMR)

Varicella (VAR)

Hepatitis A (HepA)-2 dose series

Start of annual

Influenza (IIV okay at 6 months) or (LAIV okay at 2 years) 1 or 2 doses

Screening-

· Visual screen annually 3-6yo, then

· 8yo,10yo,12yo,15yo,18yo

· Visual acuity-Preschool age 3-5yo

15 months

Diphtheria, tetanus, acellular pertussis (DTaP <7years)

Screening- 18month visit ( B.F. Preventive Service link )

· Risk for Anemia (screen only)

Screening- 2-2.5yr visit ( B.F. Preventive Service link )

· Developmental-Behavioral

· Risk for Anemia (screening only from age 2 to age 21).

· Finger stick Lead test or screening recommended.

11-12 years

Tetanus, diphtheria, acellular pertussis (Tdap ≥7 yrs)

Human papillomavirus (HPV)

Meningococcal (MenACWY-D ≥9 mos, MenACWY-CRM ≥2 mos)

Meningococcal B (high risk group)

Pneumococcal polysaccharide (High risk group)

Screening- Adolescence ( B.F. Preventive Service link )

· Adolescent alcohol and substance use

· Cervical Dysplasia-The first Pap test approximately 3 years after onset of vaginal intercourse, but no later than age 21. Screening should be done annually with conventional Pap test or liquid-based cytology until age 30. After age 30, Pap tests may be done every 2 to 3 years after 3 normal tests.

16 years

Meningococcal (MenACWY-D ≥9 mos, MenACWY-CRM ≥2 mos) 2cd dose

Screening for STD-

· All sexually active women <25 get chlamydia screening and all sexually active youth get gonorrhea and chlamydia testing annually. High risk-include HIV/Syphillis yearly and change chlamydia to 3-6months testing intervals. See bright futures for discussion on high risk groups.

**no child should ever have these so if see please suspect child abuse.

Physical Growth & Safety

Birth-1 year:

· Weight gain 7-8 pounds

· Length 19-21 inches

· Vital signs- Temp 37.5, P 120-140, R 30-60, BP 80/40

Document

· Length-for-age and Weight-for-age

· Head circumference-for-age and Weight-for-length

5th to 95th percentile for normal growth and 3rd to 97th for abnormal encounters that specialist use. Link to 5-95th percentile link- Click here

Safety-

· Never leave a child alone on a changing table, bed, or sofa. Children can fall as soon as they can roll over.

· Use gates on stairways and install window guards on all windows above the first floor as soon as your baby can crawl.

· Never leave small objects within your baby's reach.

· Never carry hot liquids or food, or cook, while holding your child.

8 to 12 months:

· Keep pins and other sharp objects off the floor and out of your baby's reach.

· Install safety plugs in wall sockets.

· Remove easily overturned lamps and dangling electrical cords.

· Place soft adhesive bumpers on the corners of sharp-edged furniture.

· Place a gate across stairways to keep the baby from falling down stairs.

· Keep medicines and poisons in a locked cabinet. Install child locks on cabinets.

· Be sure baby furniture and toys are painted with lead-free paint. Buy age-appropriate toys that are too large to swallow.

· Never leave your baby alone in the bath; keep one hand on the child at all times.

12 to 36 months:

· Secure doors that lead to stairways, driveways, and storage areas.

· Never leave a child alone in a bathtub, wading pool, or other body of water.

· Lock medicines away immediately after use.

· Lock kerosene, pesticides, and toxic cleaning products in a safe place.

· Buy age-appropriate toys that are too large to swallow.

· Don't leave your child alone around burning fireplaces, heaters, or other hot appliances.

· Provide constant supervision.

· Store dangerous tools and gardening equipment in a locked shed or cabinet.

· Keep matches and cigarette lighters locked up and out of sight.

Toddler (1-3 year)

Document-Length-for-age and Weight-for-age. Head circumference-for-age and Weight-for-length

· Stage-Autonomy vs shame

· Gains 5-6 pounds a year in this stage.

· Head circumference gains 2cm

· Round belly

· Respirations slow slightly

· HR 90-110

· BP 99/64

· Brain develops to 90% adult size

· Begins to control urine/bowels with increased sphincter control

· 8 new teeth (canines, and molars)

· 5th-95th percentile growth charts link- Click here

Safety-

· Teach your child the right way to use simple kitchen tools and appliances.

· Teach bicycle safety rules and traffic dangers.

· Start swimming lessons. Never leave a child unsupervised around a pool or other body of water, even if the child has had swimming lessons.

Preschooler (3-5 year)

· Stage- Initiative vs Guilt

· P 85

· BP 100/60

· Voiding is frequent (9-10 times daily)

· Weight slows down to 4.5 pounds a year

· Height gain of 2-3.5 inches

· All teeth by now

· 5-95th percentile link- Click here

School Age (5-12)

· Stage- Industry vs inferiority

· Weight 3+ pounds

· Height 1-2 inches

· Brain growth by age 10 complete

· Posture more erect

· P 70-80

· BP 112/60

· Secondary sex characteristics develop

· Deciduous teeth lost and permanent erupt

· 5-95th percentile link- Click here

Safety-

· Insist that your child wear a helmet when cycling or other appropriate times. Children should wear helmets and wrist and kneepads while skating and skateboarding.

· Teach proper use of more complex kitchen appliances.

· Be sure your child uses well-fitting, well-maintained sports equipment when practicing or playing a game.

· Teach your child basic first aid and what to do in an emergency.

Adolescent (13 years- 18 years)

· Stage-Identity vs Roll (13-20 years)

· Sexual maturity females 12-18

· Sexual maturity males 14-20

· Onset puberty followed by cessation of body growth

· Early-most girls 1-2 inches taller then boys

· Boys grow 4-12 inches, gain 15-65 pounds

· Girls grow 2-8 inches and gain 15-55 pounds

· P 70

· RR 20

· BP 120/70

· Second set of molars by 13 and wisdom teeth or 3rd molars by 18-21 years of age.

· 5-95th percentile link- Click here

Tanner stages-

Pubic Hair Scale (both males and females)

· Stage 1: No hair

· Stage 2: Downy hair

· Stage 3: Scant terminal hair

· Stage 4: Terminal hair that fills the entire triangle overlying the pubic region

· Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh

Female Breast Development Scale

· Stage 1: No glandular breast tissue palpable 

· Stage 2: Breast bud palpable under areola (1st pubertal sign in females)

· Stage 3: Breast tissue palpable outside areola; no areolar development

· Stage 4: Areola elevated above contour of the breast, forming “double scoop” appearance

· Stage 5: Areolar mound recedes back into single breast contour with areolar hyperpigmentation, papillae development and nipple protrusion

Male External Genitalia Scale

· Stage 1: Testicular volume < 4 ml or long axis < 2.5 cm

· Stage 2: 4 ml-8 ml (or 2.5-3.3 cm long), 1st pubertal sign in males

· Stage 3: 9 ml-12 ml (or 3.4-4.0 cm long)

· Stage 4: 15-20 ml (or 4.1-4.5 cm long)

· Stage 5: > 20 ml (or > 4.5 cm long)