Pediatric Primary Care (28 page)

a.  Partial arousal from very deep sleep, screams, thrashes during the terror, returns to sleep without fully awakening.

b.  Will have no memory of incident in morning.

2.  Nightmares: occur usually during the second half of night.

a.  Scary dream followed by complete awakening, crying and fearful after awakening; parent should reassure child.

b.  May have trouble falling back to sleep.

c.  Remembers and may talk about it in the morning.

V.  GROWTH AND DEVELOPMENT

A.  Continues to follow individual growth chart curve.

B.  Pelvis straightens.

C.  Graceful and agile with good posture.

D.  Physical.

1.  Height: grows 2-4 in./year.

2.  Weight: gains 4-6 lbs.

3.  Head: grows about 1 in./year.

4.  Blood pressure averages 100/60.

5.  Heart rate range is 73-137.

6.  Respiratory rate approximately 22-25.

7.  Twenty primary teeth; growth is mainly under the gums.

E.  Gross motor.

1.  Alternates feet when going up stairs.

2.  Rides tricycle.

3.  Dresses self, may need help with buttons.

4.  Puts on shoes.

5.  Climbs, jumps, hops.

F.  Fine motor.

1.  Holds crayon with fingers.

2.  Copies circle and cross.

3.  Draws a person with two body parts.

G.   Language.

1.  Approximately 900 words by age 3; up to 1500 by age 4.

2.  85-90 of speech understandable by people outside the family.

3.  Knows name, gender, age.

4.  Longer sentences; puts 2-3 sentences together.

5.  Uses plurals, pronouns, some prepositions (under, on, in, out).

6.  Understands concepts of big/little, up/down.

7.  Can tell you some colors

8.  Can name a friend

VI.  SOCIAL DEVELOPMENT

A.  Can separate easily from parents if they want to.

B.  Can take turns.

C.  Helps with simple chores.

D.  Needs other children to play with in order to learn socialization.

E.  Discipline method: continue with time out.

VII.  IMMUNIZATIONS (SEE
APPENDIX A
)

A.  No scheduled immunizations at this visit.

B.  Check for currency, only need if immunizations were delayed or new vaccines have come out since 2.5-year visit.

VIII.  SAFETY/ANTICIPATORY GUIDANCE

A.  Share meals as family if possible, but otherwise child should eat first and get down from table.

B.  Do not get in food fights. Offer food; if does not eat, child gets down and no food or milk until next meal.

C.  Improve (if necessary) nutritional quality of meals and snacks; limit fast food to less than once a week.

D.  Promote toilet training if not already accomplished.

E.  Limit TV viewing to 1-2 hours/day.

F.  Promote active play. Indoor: have imagination station with safe, active toys; outdoor: play with balls, jump ropes, games, etc.

G.  Consistent discipline: use as a way to learn rules, not just punishment; set limits, because if child knows limits, she/he can relax.

H.  Find ways to praise child.

I.  Encourage choices; link with consequences.

J.  Realize need for constant vigilance, supervision, patience.

K.  Safety-proof house (if not already done); reinforce safety issues.

L.  Use car seat. Continue to keep in backseat of car.

M.  Practice water safety.

N.  Use sunscreen of SPF 15 or higher.

O.  Wear helmet when riding tricycles, scooters, or other toys with wheels.

P.  Teach gun safety. Keep guns out of reach, locked, unloaded. Store ammunition and guns separately.

Q.  Teach about “good touch/bad touch.”

R.  Promote dental health; visits to the dentist and brushing 2 times a day.

BIBLIOGRAPHY

Berkowitz, CD.
Berkowitz's Pediatrics: A Primary Care Approach.
3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Burns CE, Brady MA, Dunn AM, et al., eds.
Pediatric Primary Care.
4th ed. Philadelphia, PA: Elsevier Health Sciences; 2008.

Dixon SD, Stein MT.
Encounters with Children: Pediatric Behavior and Development.
St. Louis, MO: Mosby; 2006.

Hagan JF, Shaw JS, Duncan P, eds.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Kleinman RE, ed.
Pediatric Nutrition Handbook.
6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Polen EU, Taylor DR.
Journey Across the Life Span: Human Development and Health Promotion.
Philadelphia: F.A. Davis; 2007.

Puckett, MB. et al.
The Young Child: Development from Prebirth Through Age Eight
. 5th ed. Upper Saddle River, NJ: Prentice Hall; 2008.

CHAPTER 16

Six-Year Visit (School Readiness)

Pamela Meador Nickell

I. GENERAL IMPRESSION

A.  Six-year old will be attending school perhaps for first time and is quite excited about it. The 6-year old is becoming much more independent.

II.  NUTRITION

A.  Caloric and nutrient needs.

1.  90 kcal/kg/day divided into three meals with two nutritious snacks.

2.  Limit junk food, nonnutritious foods.

3.  Refer to My Plate for serving size, food group recommendations (see
Appendix E
).

4.  Encourage family meals as often as possible.

B.  Oral hygiene.

1.  Semiannual dental visits.

2.  Regular tooth brushing twice/day.

3.  Fluoride supplement in diet or drinking water (see
Appendix B
).

4.  Discourage thumb sucking.

III.  ELIMINATION

A.  Most 6-year olds are toilet trained but may have occasional accidents.

B.  Frequency of bowel movements varies. Obtain parental input for what is normal for child; 1-3 times/day to 1 time every 2-3 days is acceptable.

C.  Normal urine volume should be similar to adult: 650-1500 mL/day.

D.  Urination frequency approximately 5-6 times/day.

E.  Approximately 5-7% have problematic enuresis.

F.  Occasional incontinence due to miscues/deep sleep not uncommon.

IV.  SLEEP

A.  8-12 hours/night.

B.  Encourage consistent bedtime routine.

C.  Occasional nightmares are normal.

D.  Night terrors/sleepwalking may emerge.

V.  GROWTH AND DEVELOPMENT

A.  Average weight gain/year: 1.8-2.7 kg (4-6 lbs) for both boys and girls.

B.  Average linear growth/year: 5 cm for both boys and girls.

C.  Well-established vocabulary.

D.  Can follow three-step directions.

E.  Moving from magical thinking to concrete operations.

F.  Mastered skills:

1.  Personal.

a.  Independent in dressing, hygiene; feeds self, monitoring only as needed.

b.  Can recite address, phone number.

2.  Fine motor.

a.  Can draw/copy shapes.

b.  Can draw a man with 6 parts.

c.  Can print some letters, numbers.

3.  Language.

a.  Can articulate needs but semantics may be incorrect.

b.  Recognizes most letters of alphabet.