PREVENTIVE PEDIATRIC

HEALTH CARE

Rowena Uy Gulane, MD, MPA, FPPS

Training Officer, Department of Pediatrics
Sacred Heart Hospital
Urgello St, Cebu City
 Get to know me…
• Doctor of Medicine, UV Gullas College of Medicine
• Post-Graduate Internship, Sacred Heart Hospital
• Pediatrics Residency Training, Sacred Heart Hospital
• Medical Officer, Saint Anthony Mother and Child Hospital
• Diplomate Philippine Pediatric Society Medical Specialist, SAMCH
• Chair, Department of Pediatrics, SAMCH
• Master in Public Administration, Cebu Institute of Technology – University
• Faculty Member, UV Graduate School, MBA-HA
• Fellow Philippine Pediatric Society
• Training Officer, Department of Pediatrics, Sacred Heart Hospital
 References
1. Preventive Pediatric Health Care Handbook 2016

2. Age-Appropriate Screening Tests: What

Every Pediatrician Should Know
Ma. Cecilia D. Alinea, MD, MHPEd
Clinical Associate Professor, Pediatrics
College of Medicine – Philippine General Hospital
University of the Philippines Manila
 OBJECTIVES
• Gain awareness of the different age-
appropriate screening tests
• Understand the importance of the different
age-appropriate screening tests
• Apply the different age-appropriate screening
tests in practice
 What is Health Screening?
• Commission on Chronic Illness, WHO (1961) “the
presumptive identification of unrecognized disease or defect by
the application of tests, examinations, or other procedures
which can be applied rapidly”
• A disease is rendered a good candidate for
screening if:
(1) Substantial morbidity or mortality occurs if it is untreated
(2) Its prevalence warrants testing in an apparently healthy
population
 Goals of Screening
• Case finding – identifying a previously unknown or
unrecognized condition in apparently healthy or asymptomatic
persons to be able to:
(1) perform additional testing
(2) offer pre-symptomatic treatment to those so identified
• Surveillance
(1) monitor the incident or prevalence of a disease in a
defined population over time
(2) compare the incidence or prevalence among different
populations
 Significance
• Case finding – early detection, intervention and
prevention of morbidity and mortality
• Surveillance – monitoring the impact of, and
allocating resources to, prevention programs
• Counseling
- Communication process by which individuals and
their family members are given information about
the nature, risks, burden, and benefits of testing,
and the meaning of test results
What diseases
should be
screened?
How safe are
these tests?
10 principles for evaluation of screening programs (Wilson
and Jungner, WHO, 1968)

• The condition being screened for should be an

important health problem
• The natural history of the condition should be
well understood
• There should be a detectable early stage
• Treatment at an early stage should be of more
benefit than at a later stage
• A suitable test should be devised for the early
stage
10 principles for evaluation of screening programs (Wilson
and Jungner, WHO, 1968)

• The test should be acceptable

• Intervals for repeating the test should be
determined
• Adequate health service provision should be made
for the extra clinical workload resulting from
screening
• The risks, both physical and psychological, should
be less than the benefits
• The costs should be balanced against the benefits
 When to perform screening
• Infancy – prenatal, newborn at birth, 2-4 days old,
1st, 2nd, 4th, 6th, 9th, 12th, 15th, 18th, 24th month
• Early childhood – 3rd, 4th, 5th year
• Middle childhood – 6th, 8th year
• Early adolescence – annually from age 10 to 13
• Middle adolescence – annually from age 14 to16
• Late adolescence – annually from age 17 to 19
 What to perform
• Prenatal visit & counseling e. Iron supplementation
f. Vitamin A supplementation
• History: initial/interval g. Deworming

• Developmental surveillance • Anticipatory Guidance

a. First dental visit
• Screening for atopy b.
c.
Nutrition counseling
Physical activity
• Physical examination d.
e.
Injury & poisoning prevention
Prevention of child maltreatment
• Measurements f. Counseling on exposure on lead & other toxicants
a.
b.
weight & length/height
head circumference
• Procedures for patients at risk
a. CBC
c. blood pressure
b. Urinalysis
• General procedures c. Work-up for sexually active adolescents
d. Mantoux test
a. Screening for Inborn Errors of Metabolism
b. Screening for hearing impairment
c. Screening for eye/visual defects
d. Immunization
 CASE#1: 2-day old baby for discharge

• Bb. Francis was born FT, 38 weeks by PA, 3000g, AGA, cephalic
via NSD, live baby boy, AS 9,9
• Assisted by an obstetrician, in a tertiary hospital
• Mom is a 26 year old G1P0, no maternal problems, had regular
prenatal check ups
• At birth, baby had good cry and activity, fair to good suck
during EINC and upon rooming in with mom
• After 48 hours, the baby is for discharge
• Mom still fairly confident with ability to breastfeed
• What screening test/s should be performed prior to
discharge?
History: The Prenatal Visit, Education and Counseling

• Education and counseling on Essential Intrapartum and

Newborn Care (EINC or Unang Yakap) and breastfeeding must
begin during the prenatal period.
• EINC includes a series of time-bound interventions at the time
of birth and emphasizes the step-by-step performance of a
sequence of 4 core actions:
(1) Immediate and thorough drying of the newborn
(2) Early skin-to-skin contact between mother & newborn
(3) Properly-timed cord clamping and cutting, and
(4) Non-separation of newborn and mother for early
breastfeeding
History: The Prenatal Visit, Education and Counseling

Unnecessary intervention in newborn care

Routine suctioning Application of various
substances to the cord
Early bathing Giving pre-lacteals or artificial
milk formula or other breast
milk substitutes
Foot printing Routine separation from the
mother
History: The Prenatal Visit, Education and Counseling

Inform mothers of the following:

• Colostrum is the perfect first food for the newborn.
Latching-on & breastfeeding must be initiated during
the first 30 minutes to one hour after delivery of the
infant.
• Exclusive breastfeeding up to 6 months
• Continued breastfeeding up to 2 yrs and beyond after
introduction of complementary foods
• Rooming in, Kangaroo Mother Care
• Newborn screening, hearing screen and immunizations
with Hepatitis B vaccine & BCG
History: The Prenatal Visit, Education and Counseling

• Parent’s education / profession

• Attitude regarding the pregnancy
• Planned disciplinary method/child rearing approach
• Financial security
• Family support system
• Exposure to or prevention of neglect, maltreatment
or violence
• Family history of genetic/chromosomal abnormality
& developmental disability
 History: Prenatal Visit, Education and Counseling

• Injury prevention
• Environmental toxicants like lead
• Deleterious effects of alcohol intake
• Exposure to teratogens
• Take folic acid-rich foods & supplements
• Tetanus toxoid immunization
 History: Newborn to 2-4 days old
• Every infant should be evaluated
(1) Right after birth – breastfeeding encouraged
(2) Within 2-4 days of birth / 2-4 days of discharge –
check for feeding and jaundice
• Breastfeeding infants should receive formal
breastfeeding evaluation, mothers should receive
encouragement and instruction
• Newborn infants discharged less than 48 hours
after delivery must be examined within 48 hours of
discharge
 Hospital Stay for Healthy Term Newborns

• Length of stay should be long enough to:

(1) Allow identification of early problems
(2) Ensure that the family is able and prepared to care for the
infant at home
(3) Accommodate the unique characteristics of each mother-
infant dyad
• Input from the mother and her obstetrician should be
considered before a decision to discharge a newborn is made
• All efforts should be made to keep mothers and infants
together to promote simultaneous discharge
 Measurements
• Anthropometrics (weight and length/height) – done every
health supervision visit
• Head circumference measurement – taken from birth till 2
years old
• The WHO Child Growth Standards are used as reference
standard for weight, height and head circumference.
• Interpretation of growth points are based on Z-scores
(standard deviation scores) and not on percentile scores.
• Weight-for-length/height is a reliable growth indicator even
when the age is not known.
 Measurements
• If a child is <2 y.o.- measure recumbent length
• If child is ≥2 y.o. and able to stand – measure
standing height
• In general, standing height is ~0.7 cm less than
recumbent length
• If a child <2 y.o. will not lie down for measurement
of length, measure standing height and add 0.7 cm
to convert it to length.
• If a child ≥2 y.o. cannot stand, measure recumbent
length and subtract 0.7 cm to convert it to height.
 WHO Child Growth Standards
• Head Circumference For Age for Girls:
Birth to 5 yrs
• Weight for Age for Girls: Birth to 2 yrs
• Weight for Age Girls 2-5 yrs
• Weight for Age Girls 5-10 yrs
• Length for Age for Girls: Birth to 2 yrs
• Height for Age Girls 2-5 yrs
• Height for Age Girls 5-19 yrs
• Weight for Length Girls: Birth to 2 yrs
• Weight for Height Girls 2-5 yrs
• BMI for Age for Girls: Birth to 2 yrs
• BMI for Age Girls 2-5 yrs
• BMI for Age Girls 5-19 yrs
• Head Circumference For Age for Boys:
Birth to 5 yrs
• Weight for Age for Boys: Birth to 2 yrs
• Weight for Age Boys 2-5 yrs
• Weight for Age Boys 5-10 yrs
• Length for Age for Boys: Birth to 2 yrs
• Height for Age Boys 2-5 yrs
• Height for Age Boys 5-19 yrs
• Weight for Length Boys: Birth to 2 yrs
• Weight for Height Boys 2-5 yrs
• BMI for Age for Boys: Birth to 2 yrs
• BMI for Age Boys 2-5 yrs
• BMI for Age Boys 5-19 yrs
Measurements
Z-Score Interpretation
1. A child in this range is very tall.
Tallness is rarely a problem
unless it is so excessive that it
may indicate an endocrine
disorder such as a growth-
hormone-producing tumor.
Refer a child in this range of
assessment if you suspect an
endocrine disorder (e.g. if
parents of normal height have a
child who is excessively tall for
his or her age.)
Z-Score Interpretation
2. A child whose weight-for-age falls in
this range may have a growth problem,
but this is better assessed from weight-
for-length/height or BMI-for-age.
3. A plotted point above 1 shows
possible risk. A trend towards the 2 z-
score line shows definite risk.
4. It is possible for a stunted or severely
stunted child to become overweight.
5. This is referred to as very low weight
in IMCI training modules. (Integrated
Management of Childhood Illness)
 Physical Examination
• Critical component of a visit to a pediatrician by an
infant, child, adolescent, or young adult
• Purpose and scope of the PE are clear to the parents
and patient if old enough to understand
• Perform an age-appropriate exam, with infant totally
unclothed and older children undressed and suitably
draped (gown or drapes)
• Practice privacy and minimize child’s discomfort
 Screening for Atopy
• Any child with a family history of atopy (asthma,
atopic dermatitis, allergic rhinitis, drug / food
allergy) who presents with recurrent / persistent
symptoms of 1 or more of the following should be
closely monitored, investigated or referred to the
subspecialist(s) when warranted:
❖Respiratory symptoms: chronic cough with or
without wheezing, shortness of breath, chest
tightness, trouble sleeping due to coughing, fatigue,
problems with feeding or grunting during infancy
 Screening for Atopy
❖Nasal symptoms: frequent sneezing, rhinorrhea,
itchiness, nasal congestion
❖Ocular symptoms: bluish, brownish discoloration
around both eyes, puffiness under the eyes,
redness and tearing, itchiness
❖Skin symptoms: dryness and itchiness
❖Gastrointestinal symptoms: itchiness of the roof of
the mouth and throat, colic, vomiting, stomach
cramps, diarrhea and bloody stools
 Visual Screening
Help identify children who may benefit from early
interventions to correct or improve vision

• Examination of the eyes and visual system at birth and throughout

childhood and adolescence during health supervision visits
• High risk children requiring prompt referral for specialized eye
examination/s by a pediatric ophthalmologist:
(1) Premature infants (Retinopathy of prematurity)
(2) With family history of congenital cataracts, retinoblastoma,
strabismus, amblyopia, congenital glaucoma, metabolic/genetic
diseases, and developmental/neuralgic abnormalities
• Ocular history, visual assessment, external inspection of the eye and
lids, ocular motility, pupil and red eye reflex examinations
 Hearing Screening Delay in
Goal of Early Hearing detection and Intervention (EHDI): To
maximize linguistic competence and communic
literacy development for
Delay or children who are deaf / hard of hearing
Absent or ation,
failure in
lack of cognition,
detecting
opportunit reading
Deafness /
ies to learn and socio-
Hard of
language emotional
hearing
developme
ntrisk
Incidence of congenital hearing impairment is 1-3 per 1000, higher in high
infants at 2-4 per 100
In the Philippines, hearing impairment is the 3rd leading cause of disability (13%
of all disabled persons)
 Neonatal Hearing Screening
• Republic Act No. 9709 (The Universal Newborn
Hearing Screening and Intervention Act of 2009)
include the following:
• Section 5: “Obligation to Inform – Any health
practitioner who delivers, or assists in the delivery,
or a newborn in the Philippines shall, prior to
delivery, inform the parents or legal guardian of the
newborn of the availability, nature and benefits of
hearing loss screening among newborns or children
3 months old and below.”
 Neonatal Hearing Screening
• Section 6: “Obligation to Perform Newborn Hearing Loss
Screening and Audiologic Diagnostic Evaluation – All infants
born in hospitals shall be made to undergo newborn hearing
loss screening before discharge, unless the parents or legal
guardians of the newborn object to the screening. Infants not
born in hospitals should be screened within the first three (3)
months after birth.
• (+) result – undergo audiologic diagnostic evaluation to allow
follow-up, recall and referral for intervention before the age of
6 months; provided that audiologic diagnostic evaluation shall
be performed by Newborn Hearing Screening Centers duly
certified by DOH.”
 Neonatal Hearing Screening
• Hearing of all infants should be screened at no later than 1
month of age
SCREENING OUTCOME IMMEDIATE STEPS TO TAKE
Fail / Refer / Do not pass at screening <1 month of age Comprehensive audiologic evaluation at
NO LATER than 3 months of age
Confirmed hearing loss Intervention done NO LATER than 6
months of age
• Lower scores in mean total language, cognitive, and personal-
social quotients if intervention done after 6 months of age
• Ongoing surveillance of communicative development
beginning at 2 months of age during well-child visits in the
medical home
 Newborn Screening (NBS)
• Newborn Screening Act of 2004 (Republic Act No.
9288) Article 3 Section 54 states “Obligation to
Inform. Any health practitioner who delivers, or
assists in the delivery of a newborn in the
Philippines shall, prior to delivery, inform the
parents or legal guardian of the newborn of the
availability, nature & benefits of NBS.”
• Ideally done immediately after 24 hours from birth
 Newborn Screening (NBS)
• Allows timely medical intervention for diagnosed
patients, reducing morbidity and mortality caused
by certain congenital anomalies
• At least 33,000 newborns can be saved annually
from mental retardation and death through NBS
(NIH, 2004)
• Philippine incidence: CH – 1:3,004; CAH – 1:10,604;
PKU – 1:388,367; Gal – 1:310,694; and G6PD
deficiency – 1:50 (Padilla, 2012)
• Expanded newborn screening (28 disorders) has
been made available since December 2014
 Immunization
• Every health supervision visit is an opportunity to update a child’s immunization status
 Critical Congenital Heart Disease (CCHD) Screening

• Median age of diagnosis: 6 weeks old

• Delayed or missed diagnosis occurs in 7 per 100,000 livebirths
can result in death or injury to infants (Aamir, 2007)
• NB hospitalization provides critical window for CCHD
identification (ductus arteriosus dependent lesions) (Mahle, 2009)
• Adding pulse oximetry to NB assessment will enhance CCHD
detection
• Pulse oximetry after 24 HOL
- readily available, non-invasive, & painless technology, can be
incorporated into NB routine assessment
 Nutrition Counseling (Breastfeeding)
Benefits of Breastmilk
• Safe, sterile and always available
• With perfect nutrients to fully sustain the growth and
development of the baby from birth to 6 mos; after 6 mos, still
a good source of nutrients when given with adequate
complementary foods
• Easily digested & absorbed; efficiently used by the baby’s
immature system
• Contains antibodies & substances which protect the baby
against infection
• Contains fats (DHA) which enhance brain development and
intelligence of the baby
 Nutrition Counseling (Breastfeeding)
Advantages of Breastfeeding
• Promotes emotional bonding between baby
and mother
• Protects the mother’s health against cancer
(breast, uterus, ovaries), obesity and post-
partum hemorrhage
• Promotes early return to pre-pregnancy
weight
• Gives the family big financial savings
 Correct Breastfeeding Techniques
• Support the baby’s head & the entire
body throughout the feeding; the
head, back & hips should be facing
the breast & aligned in a straight
manner.
• Maintain the position of the baby in
such a way he is “face to face”,
“chest to chest” & “tummy to
tummy” with the mother.
• Support the breast with the hand of
the opposite arm in a C-hold
position: thumb above, 4 fingers
under the breast.
• Stimulate the infant to open the
mouth wide by stroking the corner of
the baby’s lips; check that the chin
touches the breast & the lower lip in
turned outward.
• Ensure that the baby grasps the
entire nipple plus one inch of the
surrounding areola.
• Allow the baby to suck 15 to 30
minutes per breast to extract both
foremilk and hindmilk.
• Empty the breast around 8 to 10
times or more a day to ensure
adequate milk supply.
 Nutrition Counseling (Breastfeeding)
Breastmilk Expression and Storage
• Express breastmilk by hand or
by using a breast pump when
breastmilk supply is abundant &
when the mother is planning to
go back to work.
• Store in sterile polypropylene
(cloudy hard plastic) containers,
properly labeled with the date
& time of breastmilk collection.
Recommended Breastmilk Storage
Period
Room temperature (<25 C) 4 hours
Room temperature (>25 C) 1 hour
Refrigerator (4 C) 8 days
Freezer compartment of a 2 weeks
1-door refrigerator
Freezer compartment of a 3 months
2-door refrigerator
Deep freezer with constant 6 months
temperature (-20 C)
Discharge and Follow-up of Healthy Term Newborns

The Philippine Society of Newborn Medicine lists the following

minimum criteria for discharging newborns <48 hours:
• Uncomplicated antepartum, intrapartum & postpartum courses
for mother & NB
• Vaginal delivery, singleton, completed 37 weeks, AGA
• Normal & stable vital signs during the preceding 12 hrs
(RR<60/min, CR 100- 160/min, axillary temp 36.5-37.4ºC properly
clothed in an open crib)
• Has urinated & passed at least one stool
• Has documented proper latch, milk transfer, swallowing, infant
satiety and absence of nipple discomfort
Discharge and Follow-up of Healthy Term Newborns

The Philippine Society of Newborn Medicine lists the following

minimum criteria for discharging newborns <48 hours:
• Normal physical examination
• No evidence of significant jaundice in the first 24 hours of life
• Educability and ability of the parents to care for their child
(recognize signs of illness, care of the umbilical cord / skin /
genitalia, maternal confidence in feeding her infant and
parents’ understanding of the importance of follow-up visit or
emergency consultation)
• Must follow-up within the next 48 hours
 Discharge and Follow-up of Healthy Term Newborns
• The purpose of the Follow-Up Visit
is to:
• Assess the infant’s general health,
hydration, & presence / degree of
jaundice; weigh the patient;
identify new problems; & obtain
historical evidence of adequate
urination and defecation patterns
for the infant.
• Reinforce maternal or family
education in infant care,
particularly regarding infant
feeding.
• Review the outstanding results of
laboratory tests performed before
discharge.
• Perform screening tests if not yet
done and other tests that may be
clinically indicated, such as serum
bilirubin.
• Suggest and encourage
compliance to recommend
schedule of periodic follow-up and
preventive care.
 SUMMARY:
NEWBORN AGE TILL TIME OF DISCHARGE

• History
• Measurements – anthropometrics
• Physical examination
• Screening for atopy
• Procedures – Newborn screening, Vision and
Hearing screening, Critical Congenital Heart
Disease screening, Immunization
• Nutrition counseling
CASE#2: 12-month old baby coming in for immunization

• Timmy, 12 months old, was brought to your clinic for

immunization updates, last visit in clinic was at 6 months old when
you administered his 3rd IPV / DPT / Hib / Hep B
• Had occasional cough and colds which spontaneously resolved
• Active and playful
• Mom has issues on what to feed, child-proofing at home
• Aside from HISTORY, MEASUREMENTS, PHYSICAL EXAM, AND
IMMUNIZATION, what other screening tools should you perform
at this time?
 Developmental / Behavioral Assessment

• Developmental surveillance should be incorporated at every

well-child preventive care visit
• Any concerns during surveillance should be promptly
addressed with standardized developmental screening tests
• Screening tests should be administered regularly at the 9-,18-,
and 30-month visits
• Early identification of developmental problems should lead to
further developmental and medical evaluation, diagnosis, and
treatment, including early developmental intervention
 Preventive Dental Care
• First dental visit – recommended to be done at the
time of eruption of the first tooth and no later than
12 months of age.
• During the first dental visit, the dentist will assess:
❑The child’s general health, growth & behavior
❑Oral hygiene and periodontal health
❑Risk for developing oral disease
❑Provide education on infant oral health and
evaluate and optimize fluoride exposure
 Preventive Dental Care
• Twice daily use of fluoride-containing toothpaste is recommended as a
primary preventive measure.
• Use recommended amount of fluoride toothpaste
• Supervise young children while brushing and taught to spit out the
toothpaste & avoid rinsing after brushing

Age Group Fluoride Minimum Amount of Amount of

Concentration Daily Use Toothpaste to be Fluoride (~mg)
(ppm) Used
<6mos - <2yo 1000 ppm Twice daily Smear 2.5mm 2 x 0.125 =
0.125g 0.25mg
2 – 6 yo 1000 ppm Twice daily Pea size 5 mm 0.25g 2 x 0.25 =
0.50mg
6yo and above 1000 ppm Twice daily Full length of bristle 2 x 0.50 = 1.0mg
10-20mm
0.5 – 1.0g
 Preventive Dental Care

• Topical Fluoride Treatment

– Professionally applied topical fluoride proves to prevent
or reverse enamel demineralization
– Children at moderate caries risk should receive fluoride
treatment at least every 6 months
– High caries risk – more frequently
• Other Anticipatory Measures
– Guidance on oral hygiene and proper diet
– Cleanse teeth with washcloth or soft brush to reduce
bacterial colonization
– Dental floss reduce interproximal caries
 Hemoglobin/Hematocrit Testing
• Universal screening for anemia at 12 months old
– Determination of Hb concentration
– Assessment of risk factors associated with ID/IDA
• 1-3 years of age additional screening at any time if (+) risk of
ID/IDA, including inadequate dietary iron intake
• Hb <11.0 mg/dl at 12 months further evaluation for IDA
required to establish it as a cause of anemia Risk factors associated with
ID/IDA
• Low socioeconomic status
• High risk of dietary ID do further testing for ID • History of prematurity or LBW
• Exposure to lead
• Exclusive breastfeeding
• Additional screening tests for ID/IDA as needed: >4mos old w/o iron
supplementation
• Weaning to whole milk not
serum ferritin (SF) Additional risk factors
rich in iron
• Non-iron fortified
• Feeding problems complementary foods
• Poor growth
• Inadequate nutrition in infants
with special health care needs
 Iron Supplementation (DOH)
TARGETS PREPARATION DOSE/DURATION
Low birth Drops: 0.3 ml once a day to start at two
weight 15mg elemental iron/0.6 months of age until 6 months
ml when complementary foods are
given
Infants Drops: 0.6 ml once a day for 3 months
6-11 months 15mg elemental iron/0.6
ml
Children Syrup: 1 tsp once a day for 3 months or
1-5 years 30mg elemental iron/5 ml 30mg once a week for 6 months
with supervised administration
Adolescent girls Tablet: One tablet once a day
10-19 years 60mg elemental iron with
400mcg folic acid (coated)
 Vitamin A Supplementation (DOH)

Targets Preparation Dose / Duration

Infant 100,000 I.U. 1 dose only
6-11 (One capsule is given anytime between
months 6-11 month but usually given at 9
months of age during the measles
immunization)
Children 200,000 I.U. 1 capsule every 6 months
12-59
months
 Deworming (DOH)
• Recommended for all children aged 1-12 years
Albendazole
12-23 months 200mg Single dose every 6 months
24 months & above 400mg Single dose every 6 months
Mebendazole
12 months & above 500mg Single dose every 6 months

• Either drug taken ON FULL STOMACH

CONTRAINDICATIONS
Severe malnutrition Abdominal pain
High grade fever Serious illness
Profuse diarrhea Previous hypersensitivity to
antihelminthic drug
 Lead Screening
• Lead remains a common, preventable environmental health
threat.
• Lead is an ubiquitous environmental toxicant that can attack
many different organs systems.
• Among children, the best studied effect of lead exposure is
cognitive impairment.
• Pediatricians should:
A. provide anticipatory guidance to parents to prevent lead
exposure (primary prevention)
B. increase efforts to screen children at risk to find those with
elevated BLLs (secondary prevention)
 Lead Screening in the Philippines
• Elevated blood lead levels (BLL) associated
with:
– Proximity to lead acid battery recycling or repair
activities (Suplido et al 2000)
– Consumption of certain foods (Zhang et al 1998)
– Playground soil (Sharma et al 2000)
• Do targeted screening for children living in
high-risk environments
 Screen at any age
High index of suspicion
Tuberculous Testing based on history and PE

• Using 5 TTU PPD or 2TU-RT23 test read at 48-72 hrs,

regardless of BCG status, an induration (not erythema) of >5
mm is considered positive in the presence of any of the
following:
– History of close contact with a known or suspected
case of TB
– Clinical findings suggestive of TB
– Chest x-ray suggestive of TB
– Immunosuppressed condition
• In the absence of the above factors, an induration >10 mm is
considered positive.
 SUMMARY:
INFANCY TO 12 MONTHS OLD
• History
• Measurements – anthropometrics
• Physical examination
• Sensory screening – Visual acuity and Hearing screening
• Developmental/Behavioral assessment and surveillance
• Procedures – Hemoglobin/Hematocrit screening, Iron
supplementation, Vitamin A supplementation, Deworming,
Immunization
• Preventive Dental Care
• Others: Lead exposure screening, Tuberculous screening
 Case#3: 18 month old with cough and colds

• Brianna, 18 months old, was brought to your clinic

due to cough and colds of 2 days duration. Mom
also asked if you could check her immunization
record because they have not been regularly
visiting since she turned 1 y.o.
• Mom is also concerned that her toddler can only
say “tatatata” and “papa” and can’t even say
“mama” to her.
• After thorough evaluation and counseling re: Viral
URTI, what other screening tools should you
perform on Brianna?
 Developmental / Behavioral Assessment

• Developmental surveillance is a process by which the health

care professional recognizes the children who may be at risk of
developmental delays.
• At every well child visit, this has 5 components:
1. Eliciting and attending to the parent’s concerns about their
child’s development
2. Maintaining a developmental history
3. Making accurate & informed observations of the child
4. Identifying the presence of risk & protective factors
5. Documenting the process and findings
 Developmental Surveillance and Screening

• The Philippine Society for Developmental and Behavioral Pediatrics

(PSDBP) recommends that developmental screening be done at
specified ages particularly 9, 18 and 30 months and every year
thereafter.
• Developmental screening is the process of administering a
standardized tool designed to identify children who are at risk of
developmental disorders.
• Done when surveillance activities detect risks & anytime when
parents express concerns about their child’s development.
• Children diagnosed with developmental disorders are identified as
children with special health care needs, and chronic-condition
management should be initiated.
 RED FLAGS in Areas of Development

AGE SOCIO-EMOTIONAL RED FLAGS

6 months Lack of smiles or other joyful expressions
9 months Lack of reciprocal (back-and-forth sharing of) vocalizations, smiles, or
other facial expressions
12 months Failure to respond to name when called
Absence of babbling
Lack of reciprocal gestures (showing, reaching, waving)
15 months Lack of proto-declarative pointing or other showing gestures
Lack of single words
18 months Lack of simple pretend play
Lack of spoken language/gesture combinations
24 months Lack of two-word meaningful phrases (without imitating or repeating)
Any age Loss of previously acquired babbling, speech, or social skills
RED FLAGS in Areas of Development

AGE RECEPTIVE LANGUAGE RED FLAG

2 months Does not alert or quiet to sound
6 months Does not turn to the source of sound
10 months Does not respond to own name
12 months Does not follow verbal routines/games
15 months Does not understand simple questions
Does not stop when told “NO”
Does not understand at least 3 different words
18 months Does not point to 3 body parts
Does not follow simple commands
30 months Does not follow 2 part commands
36 months Does not answer simple questions
RED FLAGS in Areas of Development

AGE MOTOR RED FLAGS

4 months Lack of steady head control while sitting
9 months Inability to sit
18 months Inability to walk independently
RED FLAGS in Areas of Development

AGE EXPRESSIVE LANGUAGE RED FLAG

6 months Does not coo
10 months Does not babble
12 months Absence of nonverbal purposeful messages (show objects)
14 months Absence of pointing
16 months Does not say 3 different spontaneous words
24 months Vocabulary of not more than 35-50 words
Does not produce 2-word phrases
36 months No simple sentences
42 months Intelligibility to unfamiliar adult at <50%
54 months Not able to tell or retell a familiar story
60 months Not fully intelligible to an unfamiliar adult
>72 months Not fully mature speech sounds
 Child Maltreatment
• Defined by the WHO as “ all forms of physical
and/or emotional ill-treatment, sexual abuse,
neglect or negligent treatment or other
exploitation, resulting in actual or potential harm to
the child’s health, survival, development or dignity
in the context of a relationship of responsibility,
trust and power.”
• There is NO one risk factor that is predictive of child
maltreatment and there is NO one characteristic
that defines resiliency of a child to traumatic
experiences.
 Child Maltreatment
• It is important to recognize and report on going child
maltreatment (Republic Act No. 7610).
• All hospitals should have a protocol in the handling of women
and child abuse cases.
• Based on the current understanding of early child
development, it is clear that stable family units can be a
powerful source of protection for children.
• Good parenting, strong attachment between parents and
children, and positive non-physical disciplinary techniques are
likely to be protective factors.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 1. Learn the Facts
• Majority of sexual offenders of children are
family members, friends & neighbors people
that the child & the child’s family trust.
• Boys, in almost the same frequency as girls, are
also being sexually abused.
• Few girls report the abuse, but boys tend not to
report at all.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 2. Minimize the opportunity for sexual abuse by
eliminating or reducing one-adult/ one-child
situations.
• More than 80% of sexual abuse cases occur in situations where a
child is left alone with an adult or an older youth.
• School organizations, clubs, sports teams, faith groups must
eliminate situations of one-adult/ one-child.
• Talk to your child when he/she returns from an outing. Notice the
child’s behavior and whether the child can tell you with confidence
how the time was spent.
• Tell the adults who care for your child that you and your child are
educated about child abuse. Be that direct.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 3. Talk about it
• Teach your children what parts of their bodies others should
not touch. Do not be afraid that you are teaching them about
“sex.” You are protecting them. Mention that the abuser can
be a family member, a friend or an older youth.
• Children are afraid to “tell” an abuse. The abuser shames the
child, tells the child that his/her parents will be angry, confuses
the child about what is right or wrong, or threatens the child or
a family member. Break the barrier by talking openly about it.
• If a child seems uncomfortable or resistant to being with a
particular adult (an uncle or a ninong) ask why.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 4. Stay Alert
• Learn the signs of sexual abuse.
• Physical signs are not common.
• Emotional & behavioral signs are more common
such as “too perfect” behavior, withdrawal,
depression, unexplained anger or rebellion, running
away, failing in school, unusual interest in or
knowledge of sexual matters, fear of a person,
intense dislike at being somewhere or with
someone.
• Know the textmates of your child.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 5. Act on any Suspicion of Abuse.
• The future well-being of a child is at stake.
• Have the courage to report suspected abuse.
• Do not close your eyes & pretend that it will go away.
• If the child is not helped, the abuse will continue.
• It is the duty of hospital administrators, doctors,
nurses, government teachers and employees of
government agencies to report abuse.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 6. Learn How to React to the Knowledge of Abuse
• Offer support:
• Believe the child & make sure the child knows you
believe in him/her/ very few reports of child abuse are
not true.
• Thank the child for telling you and for having the
courage to do so.
• Encourage the child to talk but don’t ask leading
questions.
• Seek professional help.
 “7 Steps to Protect Children”
Child Protection Unit Network, Inc.
Step 7. Get Involved
• Use your voice & your vote to make your community
a safer place for children.
• Ask what schools or organizations in your community
have child abuse prevention policies & help with their
creation.
• Demand that the government put their resources
into protecting children from sexual abuse and into
responding to reports of sexual abuse.
 CASE#4: 24-month old toddler who is a
“picky eater”

• Daryl, 2 year old boy, was brought to your

clinic for his health supervision visit and also
because he “doesn’t eat much”
• Active, really “chubby” (Wt 14.5kg, Lt 88.5cm),
prefers to play and explore the whole day
• What screening tool/s will you perform on
Daryl?
 Body Mass Index (BMI)
Weight in kilograms divided
• Researches show: by height in meters squared

(1) BMI is moderately correlated with more direct

measures of body fat
(2) BMI appears to be as strongly correlated with
various metabolic and disease outcomes
• Inexpensive and easy-to-perform method if
screening weight category (underweight, normal
or healthy, overweight, and obesity)
• Calculated and plotted at least annually
 Body Mass Index (BMI)
• Universally assess children for obesity risk to
improve early identification of elevated BMI,
medical risks, and unhealthy eating and physical
activity habits
• Integrate with growth pattern, familial obesity, and
medical risks to assess obesity risk
• Screen for current medical conditions and for
future risks, and assess diet and physical activity
behaviors
 Complementary Food
• Must be:
• Timely – introduce at 6 months of age
• Adequate – provides sufficient energy, protein &
micronutrients to sustain growth: use PSPGN
Dietary Food Guide Pyramid as a tool
• Safe – hygienically prepared & stored; feed using
utensils, NOT bottles and nipples
• Properly fed – meal frequency & feeding methods
suitable for age (guide or self-feeding using clean
hands, spoon & fork, cups & bowls; using locally
fresh & natural foods)
 Complementary Food
How to Introduce:
• Begin with one new food at a time to be given for 3
days.
• Start with lugaw or cereals, fruits or vegetables in any
order, giving 1-2 teaspoons a day.
• Start with pureed foods at 6 months of age.
• Introduce “finger foods” around 8 months; lumpy or
chopped foods at 10 months; table food at 12 months
of age
• Feed 6-8 m.o. infant 2-3 times a day; 9-24 m.o. infants
3-4 times a day.
 Complementary Food
How to Introduce
• Give additional nutritious snacks once or twice a day.
• Offer a variety of foods to improve the quality of food intake;
avoid drinks with low nutrient value (sweet beverages).
• Do not add salt to the infant’s diet before one year of age.
• Give supplements of iron, zinc, calcium, & vitamin B12, if diet is
primarily plant-based.
• Practice responsive feeding. Feed infants directly & assist older
children. Feed slowly & patiently. DO NOT force-feed; make
feeding a pleasurable experience.
 Physical Activity
• Physical activity, along with a well-balanced healthy diet, is a
major principle to healthy living.
• Can be in the form of sports & games, dance, physical
recreational activities, household chores & other lifestyle
related physical activities
• Age-appropriate physical activities for children & adolescents
for 60 minutes daily or on most days of the week are the
current recommendations.
• Educate parents and discourage children from prolonged
periods of sedentary activity (TV viewing & computer games)
for periods greater than two hours per day.
CASE#5: 3 year old girl coming in for her annual flu shots

• Kyla, 3 years old, was brought to your clinic for her

yearly flu shots
• The mom has observed that she’s much too glued
to her iPad
• Loves to run indoors, eats french fries a lot, usually
sits down to play with her gadget
• Nanny uses iPad to pacify her when she gets into a
tantrum and her parents are not around
• What screening test/s will you perform on Kyla?
 Eye and Vision Screening

Age Things to Check Refer

3 years Vision Test: LEA Symbols – at LEA < 20/40 or > 1 line difference
least 20/40 (0.5)
Inspection:
White shiny conjunctiva
Clear cornea
Ocular motility:
Alternate cover test or
Symmetrical/central corneal
reflex
Steady and aligned eyes
Ophthalmoscopy: Red
Orange Reflex
between eyes
Dry / frothy conjunctiva
Opacities
Any eye movement on alternate
cover test
Unequal/non-central corneal reflex
Jiggly eyes and misaligned eyes
Absent / Dull / asymmetric ROR;
Leukocoria
 Measurements
• Body mass index (BMI) should be computed for those
at high risk even before age 2, and annually from age
2 thereafter
• The Pediatric Nephrology Society of the Philippines
recommends routine blood pressure measurement
for children starting 3 years old.
• However, it must be done on all ill patients and all
patients at risk ( those with a history or conditions
that can predispose to hypertension, or in the
presence of PE findings suggestive of a possible
vascular involvement) regardless of age.
 Blood Pressure
• The National High Blood Pressure Education
Program of the National Heart, Lung and Blood
Institute crafted blood pressure percentile
tables based on age, gender and height
percentile.
• Until we have our own population-based blood
pressure levels of Filipino children, these
tables may be used to interpret the blood
pressure levels of our patients.
US CDC-NCHS Growth Chart for Boys (Stature of Age:
to be used in locating Blood Pressure Percentile of
Children & Adolescents)
 How to Use the BP Tables:
a) Determine the height percentile of the patient using the US
CDC-NCHS growth charts.
b) Measure & record the patient’s SBP and DBP.
c) Use the correct gender table for SBP and DBP.
d) Find the child’s age on the column at the left side of the
table. Follow the age row horizontally across the table to
intersect with the vertical column of the child’s height
percentile.
e) Find the SBP on the left columns of the table and the DBP on
the right columns.
f) Find the corresponding BP percentile on the vertical column
to the right of the age column.
 Blood Pressure
• Normotensive – BP <90th percentile for age, gender
and height percentile.
• Encourage healthy diet, sleep and physical activity
for children with normal blood pressure.
• Prehypertension in children – average SBP or DBP
levels ≥90th but <95th percentile
• Prehypertension in adolescents – BP ≥120/80
• Counseling on physical activity, diet management if
obese must be done.
 Blood Pressure
• Medical investigation for the presence of factors
might need pharmacologic therapy (chronic
kidney disease, diabetes mellitus, heart failure
of LVH) must likewise be done.
• Hypertension is defined as average SBP and/or
DBP ≥95th percentile on 3 or more occasions.
• Hypertensive patients must be referred to the
subspecialist for further investigation and
management.
 Conditions under which children <3 years old should
have BP measured

• History of prematurity, very low birth weight, or other neonatal

complication requiring intensive care
• Congenital heart disease (repaired or unrepaired)
• Recurrent urinary tract infections, hematuria or proteinuria
• Known renal disease or urologic malformations
• Family history of congenital renal disease
• Solid-organ transplant
• Malignancy of bone marrow transplant
• Treatment with drugs known to raise BP
• Other systemic illness associated with hypertension (neurofibromatosis,
tuberous sclerosis, etc.)
• Evidence of increased intracranial pressure
 SUMMARY: 1-3 YEARS OLD
• History
• Measurements – anthropometrics
• Physical examination
• Sensory screening – Visual acuity screening and
Hearing screening
• Developmental / Behavioral assessment and
surveillance
• Procedures – Body mass index, Blood pressure
• Nutrition counseling
• Prevention of child maltreatment
 CASE#6: 18 year old young lady for school entry
clearance

• Jenny, 18 years old, was brought to you for medical

clearance since she is transferring to another school
for logistic reasons
• Friendly and fun-loving, drives a car, average grades
in school
• Activities: eat out in fast foods, social networking,
minimal physical activities
• What screening test/s will you administer to this
adolescent ASIDE FROM HISTORY, MEASUREMENTS, PHYSICAL
EXAM, DEVELOPMENTAL SURVEILLANCE, AND IMMUNIZATION?
 Dyslipidemia Screening
• Critical observational studies: clear correlation
between lipoprotein disorders and onset and
severity of atherosclerosis in children, adolescents
and young adults
• Universal screening at 9-11 years of age
• Identification of children with dyslipidemias, which
place them at increased risk for accelerated early
atherosclerosis, must include a comprehensive
assessment of lipids and lipoproteins
 Adolescent Health Care
• The Philippine Society of Adolescent Medicine
Specialists, cognizant of the rapid physical,
cognitive and psychosocial changes occurring
in each adolescent patient, recommends an
annual health screening and preventive
services for this special population.
• During the annual visit, the adolescent should
undergo the following:
 Adolescent Health Care
(1) Complete history-taking to screen for risks and
protective factors using the tool HEEADSSS which
means:
• 1.1 H – home
➢ Present living arrangement / Any recent changes / Relationships between
patient & parents? Siblings? Between parents? Is there anything in the
family that the patient would like to change?
• 1.2 E – education / employment
➢ Is patient currently in school? Out of school? Employed? Where? Favorite
subject? Average last grading / semester? Any problems with classmates
or teachers? Ever been truant/suspended/expelled from school? What
are the patient/s future education/employment goals?
 Adolescent Health Care
• 1.3 E – eating
➢ Does the adolescent have eating disorders like anorexia, bulimia, or
binge eating? What are his/her favorite foods? Is there enough food for
the whole family?

• 1.4 A – activities, including media and internet exposure

➢ What does the patient do in spare time? What is he/she good at
(hobbies/interests)? How much time does he spend watching TV,
playing computer games & using the internet? Whom does the patient
spend time with? Any close friends? Are the patient’s friends attending
school?
 Adolescent Health Care
• 1.5 D – drugs
➢ Do the adolescent’s friends use tobacco, alcohol, drugs? Details of drug
use: how / why did he/she get started? What drugs / how frequent /
amount? How has use affected daily activities? Friends use/sell drugs?
• 1.6 S – sexuality / sexual activity
➢ Does the patient have any questions regarding appearance or changes
in his/her body? Sexual orientation? Does the patient have
girl/boyfriend? Started dating? Ask what a typical date is like? Is the
adolescent sexually active? If yes: age of sexual debut, number of
partners; use of contraception; paternity or pregnancies & outcome?
STD/use of force or coercion / sex in exchange for money or drugs? Any
history of sexual or physical abuse?
 Adolescent Health Care
• 1.7 S – suicidality / depression
➢ Is the adolescent ever sad or tearful? Unmotivated? Hopeless? Lonely?
Why? Has he ever thought of hurting others? Hurting himself? Has a
suicide plan? (if suicidal ideation is present, assess seriousness and
need immediate referral)

• 1.8 S – safety
➢ Does the adolescent use seat belts/helmets? Is he a member of a
fraternity or gang? Does he carry a weapon for protection? Is there a
firearm in his home?

• Recommended another S – strength / spirituality

 Adolescent Health Care
(2) Physical Examination
• Done in privacy and preferably by a health care
provider that is of the same gender as the teen patient.
In addition to the routine PE, the following should be
done:
2.1 Tanner Staging / Sexual Maturity Rating
2.2 Breast Examination
2.3 Examination of the spine and shoulders. Check for scoliosis
and kyphosis.
2.4 Inspection of the genitals and anus. A more thorough
examination is warranted in symptomatic patients.
 Adolescent Health Care
(3) Laboratory Tests
• 3.1 Complete Blood Count (or at least
Hemoglobin/Hematocrit) at every stage of
adolescence
• 3.2 Urinalysis on first encounter
• 3.3 Vaginal wet mount, PAP smear for sexually
active females
• 3.4 Serologic test for syphilis for sexually active
males. Non-culture test for gonorrhea and
Chlamydia for both male and females who are
sexually-active
 Adolescent Health Care
(4) Immunization Update
• Refer to Immunization of Teens and Pre-teens
2016 (7 to 18 years old)
 Immunization of Teens and Pre-teens 2016
(7 to 18 years old)
Vaccine Range of Dose(s) Schedule of Immunization Route of Precautions & Contraindication
Recommend needed Administ
ed Age ration

Hep B Unvaccinated 3 0,1,6, months IM Severe allergic reaction to vaccine

Vaccine 7-18 y.o. component, moderate to severe illness
Hep A Unvaccinated 2 2nd dose given at least 6 mos IM Severe allergic reaction to vaccine
Vaccine 7-18 y.o. from the 1st dose component, moderate to severe illness

MMR Unvaccinated 2 4 wks interval between doses SC Severe allergic reaction to vaccine
7-18 y.o. component, Pregnancy,
immunosuppression, recent receipt of
Incompletely 1 2nd dose given anytime but at
blood products, moderate to severe
vaccinated 7-18 least 4 wks from 1st dose
illness
y.o.
Varicella Unvaccinated 2 Minimum interval between SC Severe allergic reaction to vaccine
Vaccine 7-12 y.o. doses is 3 months component, Pregnancy,
immunosuppression, recent receipt of
Unvaccinated 2 Minimum interval between
blood products, moderate to severe
≥ 13 y.o. doses is one month
illness
Incompletely 1 Anytime: 7-12 y.o. at least 3
vaccinated 7-18 mos from 1st dose, 13 y.o at
y.o. least 4 wks from the 1st dose
Influenza 9-18 y.o. Annually Begin immunizing in February IM/SC Severe allergic reaction to vaccine
Vaccine component, moderate to severe illness,
history of Guillain-Barre syndrome
following a previous dose
 Immunization of Teens and Pre-teens 2016
(7 to 18 years old)
Vaccine Range of Recommended Dose(s)
Age needed
HPV: Bivalent HPV Females: 9-18 y.o
Quadrivalent HPV Females: 9-18 y.o
Males: 9-18 y.o
Bivalent/ 9-14 y.o
Quadrivalent HPV
Alternative schedule
for girls 9-14 yrs
Td/Tdap Unvaccinated 7-18 y.o.
Incompletely vaccinated 7-
18 y.o.
Fully vaccinated 7-18 yo
(Fully vaccinated defined as 5
doses of DTaP or 4 doses of
DTaP if the 4th dose was
administered on or after the
4th birthday)
Dengue tetravalent 9-45 years old
vaccine
Schedule of Route of Precautions &
Immunization Administr Contraindication
ation
3 0, 1 and 6 months IM Severe allergic reaction to
vaccine component, moderate
3 0, 2 and 6 months to severe illness, if found to be
pregnant after starting
2 0, 6 months immunization delay remaining
doses until completion of
pregnancy
3 0, 1, and 6 months Tdap IM Severe allergic reaction to
preferably as the 1st vaccine component, moderate
dose the Td for the to severe illness
remaining doses
1-2 One dose Tdap then Td
for remaining dose
1 1 dose Tdap then Td
every 10 years
3 0, 6 and 12 months SC Same as above
 Adolescent Health Care
(5) Anticipatory Guidance and Counseling
• 5.1 Self breast examination for females
• 5.2 Healthy Lifestyle: physical activity, diet,
avoidance of alcohol, smoking, drug use
• 5.3 Sexual behavior & the risk of acquiring STDs
including HIV
• 5.4 Injury & accident prevention: use of sports
protective gear, seat belts, no driving under the
influence of alcohol, no smoking in bed, no hand
gun use.
 Gynecologic Examination/ Done without pressure and
approached as a normal part
Cervical Dysplasia Screening of routine health care

• Assess pubertal status, document physical findings, and know when

to refer to a gynecologist for further evaluation/management
• Most common concerns are related to:
– Pubertal development
– Menstrual disorders such as dysmenorrhea, amenorrhea, oligomenorrhea,
DUB
– Contraception
– Sexually transmitted and non-sexually transmitted infections
• Most adolescents do not need an internal examination involving a
speculum or bimanual examination
• Routine screening for cervical dysplasia at age 21 years and older
 Sexually Transmitted Infections (STI) /
HIV Screening
• Pediatricians’ roles: prevent and control HIV infection by
promoting risk-reduction counseling and offering routine HIV
testing to adolescent and young adult patients
• Most sexually active youth do not feel that they are at risk of
contracting HIV and have never been tested
• US CDCP recommends
1. universal & routine HIV testing for all patients who are 13 to 64 years old
2. routine screening for all adolescents at least once by 16 to 18 years of age
for prevalence of HIV in the patient population is more than 0.1%
• In areas of lower community HIV prevalence, routine HIV testing is
encouraged for all sexually active adolescents & those with other
risk factors for HIV
 SUMMARY: ADOLESCENTS
• History
• Measurements – anthropometrics
• Physical examination
• Sensory screening – Visual & Hearing screening
• Developmental / Behavioral assessment and
surveillance
• Procedures – HEEADSSS, Dyslipidemia screening,
Gynecologic exam/ Cervical dysplasia screening,
Sexually transmitted infection / HIV screening
• Oral health
SUMMARY OF PREVENTIVE
PEDIATRIC HEALTH CARE
 SUMMARY
• Timely, age-appropriate screening is beneficial to
children of all ages
• Main goals: case finding and surveillance
• Performed for early identification of the disorder, early
intervention and reduction of morbidity and mortality
• Screening includes history, physical examination,
measurements, sensory screening, and procedures
• Outcomes/results from screening tools should be
interpreted correctly for further testing, referral to a
subspecialist, or immediate intervention
It all boils down to PREVENTIVE CARE