Q9: Preventive Pediatric Health Care Secondary Prevention

Mary Anne D. Chiong, MD • Involves measures in which a condition or its

Flerida G. Hernandez, MD
Ma. Philomena G. Lopez, MD
Department of Pediatrics
Faculty of Medicine and Surgery
University of Santo Tomas
Preventive Pediatric Health Care
• At the core of the field of pediatrics
• Consists of efforts by physicians to avoid rather than
cure disease and disability in children through health
Tertiary Prevention
promotion and prevention activities
• Evolved into regularly-scheduled visits (well-child
care) to assure adequate nutrition, detect and
immunize against infectious diseases, and observe
the child’s development, among many others
precursor is identified early and effective treatment
instituted for remediation of the condition before
progression or for elimination of the precursor
Examples:
Screening programs for adolescent scoliosis
Screening for lead levels
Treatment of streptococcal sore throat with appropriate
antibiotics
• Directed at ameliorating or halting disabilities
Examples:
Physical therapy for a child with cerebral palsy
Chest physiotherapy in a child with cystic fibrosis

Tasks of Preventive Pediatric Health Care Health Promotion and Anticipatory Guidance
• Disease detection • Shift the focus to wellness and to strengths of the
• Disease prevention family
• Health promotion • An opportunity to help the family address
• Anticipatory guidance relationship issues, to broach important safety topics,
to access community services, etc.
Disease Detection
• Accomplished by both screening and surveillance Prenatal Visit, Education and Counseling
Examples:
Anemia A. Breastfeeding
o Surveillance is accomplished through taking
B. Newborn care and procedures at birth
a dietary Hx and seeking signs of anemia on
PE Rooming in
o Screening is by hematocrit or hemoglobin Newborn screening
tests Hearing screening
Development Immunization with Hepatitis B and BCG
o Surveillance relies on the observation of
parents and watchful eyes of health C. Anticipatory guidance to prevent injury and child
1
providers maltreatment
o Screening uses a structured developmental
1. Information regarding parents’ education, profession,
screening tool
attitude towards pregnancy, planned disciplinary/
Disease Prevention child-rearing approach, financial security, family
• Includes primary, secondary, and tertiary levels of support system
prevention 2. Injury prevention and potential exposure to
• Can occur at the level of the individual, the family or environmental toxicants like lead
the community 3. Deleterious effects of smoking and alcohol intake on
• Benefit comes from risk reduction the fetus

Levels of Prevention D. Tetanus toxoid immunization for the mother

• Must be started or continued during pregnancy
Primary Prevention • Schedule:
st
• Measures directed at avoiding disorders before they TT1 at 1 contact
begin TT2 at least 4 weeks after TT1
• Emphasis on those who are at increased risk to TT3 at least 6 weeks after TTe
develop a condition or a disease TT4 at least 1 year after
TT5 at least 1 year after
Examples:
Chlorination and fluoridation of water E. Maternal nutrition to include folic acid supplementation
Tetanus immunization
Counseling parents about keeping poisons and drugs out
of reach

rainwater@mymelody.com || 1st semester, AY 2011-2012

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Recommendations for Preventive Pediatric Health Care Screening for Inborn Errors of Metabolism
• Should be performed on all newborns after 24 HOL
At birth: but not later than 3 days after birth
Colostrum - the perfect first food for the newborn • A newborn that must be placed in ICU may be
Latching-on and breastfeeding - must be initiated during exempted from the 3-day requirement but must be
the first 30 minutes to one hour after delivery tested by 7 days of age
Minimum criteria for discharging newborns before 48 hours Screening for Hearing Impairment
1. Uncomplicated ante-, intra-, and post-partum courses • Recommended for all newborns, whether high-risk or
for both mother and newborn non-high risk, no later than one month of age
2. VSD, singleton, completed 37 weeks, AGA • Those who do not pass screening should have
3. Normal and single VS during the preceding 12 hours complete audiological evaluation at no later than 3
4. Has urinated and passed at least 1 stool months of age
5. Has documented proper latch, milk transfer,
swallowing, infant satiety and absence of nipple Screening for Visual Defects
discomfort. • Should be done at least once for all children at
If not breastfed, has tolerated at least 2 feedings with preferred ages (at birth, 6 months, 3 years, 5 years)
documented coordinated sucking, swallowing, and • Screening at birth includes:
breathing while feeding o Checking for steady eyes
6. Normal physical examination o White lustrous conjunctiva
st
7. No evidence of significant jaundice in the 1 24 HOL o Pupillary reflex
8. Educability and ability of parents to care for their child o Clear cornea
9. Must follow-up within the next 48 hours o Non-droopy eyelids
o Red orange reflex
Complete History and Physical Exam • Comprehensive ophthalmologic exam for the ff:
• Every infant must be totally appraised at birth, daily 1. Premature (<32 weeks) and/or LBW
until discharge and at each child visit (<1500kg)
Developmental Surveillance 2. Infants with metabolic disorders
• Should be done at each child visit from birth to 19 3. Family history of retinoblastoma
years old 4. Family history of congenital cataract
5. History of maternal infection (rubella) or
Measurement of Weight and Length/Height genitourinary infections (STD)
• Should be done at each child visit from birth onwards 6. History of squinting
7. History of visual difficulties
Measurement of Head Circumference 8. Vitamin A deficiency or history of night
• Should be done at each child visit from birth to blindness
3 years old 9. Children with impairments (CP, Down’s
Measurement of BP syndrome, hearing impairment, etc.)
• Must be routinely done starting age 3 years • The ff. are to be checked in detail during specified ages:
• Must be performed also in: Age Things to check Refer
6 mos Equal/central Non-central unequal
o All ill patients
corneal reflex corneal reflex
o Patients at risk regardless of age,
Fixes and follows Blank stare
with history and PE suggestive of possible 3 years Equal/central Non-central unequal
renal and vascular causes of HPN corneal reflex corneal reflex
LEA at least 20/40 LEA at least 2-/40 (0.5)
Screening for Atopy (0.5) or >1 line difference
Any child with a family history of atopy who presents with between eyes
recurrent/persistent symptoms of 1 or more of the following 6 years Equal/central Non-central unequal
should be investigated corneal reflex corneal reflex
LEA at least 20/32 LEA at least 20/32 or >1
1. GI symptoms – diarrhea, colic, vomiting, bleeding (0.63) or Snellen line difference between
2. Skin rash 20/40 eyes or Snellen <20/40
3. Nasal symptoms – rhinorrhea, stuffiness, sneezing,
itchiness * Logarithmic Visual Acuity Chart
4. Coughing with or without wheezing ** Snellen Chart

A. General Procedures Immunization

1. Screening for inborn errors of metabolism • Every visit should be an opportunity to update and
2. Screening for hearing impairment complete a child’s immunization
3. Screening for eye/visual defects
4. Immunization
5. Iron supplementation
6. Vitamin A supplementation
7. Mantoux Test
8. Deworming

rainwater@mymelody.com || 1st semester, AY 2011-2012

Iron Supplementation B. Procedures for patients at risk
Targets Preparation Dose 1. Complete blood count
LBW Drops: 15mg elemental 0.3 mL OD from 2-6 2. Urinalysis
iron/0.6 mL mos when 3. Work-up for sexually active adolescents
complementary
foods are given Complete Blood Count
Infants Drops: 15mg elemental 0.6 ml OD for 3 • PSHBT: should be done at least once between 6-24
(6-11 mos) iron/0.6 mL months mos; 2-6 years; 10-19 years
Children Syrup: 30mg elemental 1 tsp OD x 3 mos OR
• SAMPI: should be done at each stage of adolescence
(1-5 y/o) iron/5 mL 30 mg weekly x 6
mos w/ supervised • Those at risk:
administration o Poor nutritional history
Girls Tablet: 60mg elemental One tablet OD o Active menstruating female adolescents
(10-19 y/o) iron w/400 mcg folic acid and fad dieters

Vitamin A Supplementation Urinalysis

Targets Preparation Dose • Should be done for all patients with signs and
Infants 100,000 IU 1 dose only (usually symptoms suggestive of a possible renal disease
(6-11 mos) given at 9 mos regardless of age
during measles
• SAMPI recommends screening urinalysis on first
immunization)
Children 200,000 IU 1 capsule q 6 mos adolescent visit
(12-71 mos)
Work-up for Sexually Active Adolescents
Screening for Tuberculosis (Mantoux Test) • For sexually active females
• Recommended at least once for asymptomatic o Annual vaginal wet mount and PAP smear
children between 1 and 14 years old • For sexually active males
• Recommended anytime for symptomatic children o Annual serological test for syphilis
• Uses 5 TTU PPD and read at 48-72 hours • For sexually active male and female annual non-
• Regardless of BCG status, an induration of ≥5mm is culture test for gonorrhea and Chlamydia
considered positive in the presence of any or all of
the ff:
o Hx of close contact with a known or
suspected case of TB
o Clinical findings suggestive of TB
o Chest X-ray suggestive of TB
o Immunocompromised condition
• In the absence of the above, an induration of ≥10mm
is considered positive

Deworming
• For all children aged 12 months to 14 years
• Schedule: single dose every 6 months
• Dose: Albendazole
12-24 mos – 200 mg
≥ 24 mos – 400 mg
Mebendazole
≥ 12 mos – 500 mg
• Must not be done in children with:
o Severe malnutrition
o High fever
o Profuse diarrhea
o Abdominal pain

rainwater@mymelody.com || 1st semester, AY 2011-2012

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subarachnoid hemorrhage
Anticipatory Guidance Two-month visit
• Never shake baby, don’t leave baby alone, safe ride
1. First Dental Visit (not in front seat), clean appropriate toys
• The first dental visit is recommended at the time of
eruption of first tooth and no later than 12 months of Four month visit
age • Proper use of car safety seat, don’t use soft toys,
childproof home, use safety locks, don’t use baby
Dental Care walkers, check sources of lead
Age Group Fluoride Frequency/ Amount
concentration (PPM) day Six month visit
6 mos – Tooth cleaning with Twice • Keep in high chair/ play pen, avoid burns, avoid choke
2 years small smear of foods
regular toothpaste
2 – 6 years Twice Half a pea 9 Months to 9 Years of Age
6 years Pea size • Age appropriate toys
and above
• Car safety
Dental Care: other anticipatory measures • Childproof home
• Guidance on oral hygiene and infant diet • Caution near water, pools and tubs
• Cleansing the infant’s teeth as they erupt either with • Pedestrian safety
washcloth or soft brush will help reduce bacterial • Supervise play
colonization • Stranger precautions
• Use of dental floss is important to reduce • Child sexual abuse prevention
interproximal caries
10 to 19 year visit
2. Nutrition Counseling • Use of protective sports gear, anticipate errors in
• Counseling regarding breastfeeding started during judgment, increased risk-taking, teach non-violent
the prenatal period must be continued during well- conflict resolution techniques, discuss tobacco,
child visits alcohol and drugs
• Giving of foods that are too sweet (sweetened
Prevention of Child Maltreatment
beverages, candies), too salty (chips, curls), and too
oily (gravies, dressings) should be avoided Child Maltreatment (WHO)
• Media food advertising may influence children’s “All forms of physical and/or emotional ill-treatment, sexual
choices toward higher-fat or higher-energy foods abuse, neglect or negligent treatment or commercial or other
exploitation, resulting in actual or potential harm to the child’s
3. Physical Activity
heath, survival, development or dignity in the context of a
• A physically active lifestyle will be carried into
relationship or responsibility, trust and power”
adulthood and reduce health problems related to
inactivity Risk Factors
• Age-appropriate physical activities for 60 minutes • Individual factors in parent and caregiver in the child
daily or on most days of the week • Relationship factors
• Discourage children from prolonged periods of Community factors

add
•
sedentary activity for periods >2hrs/day • Societal factors

4. Injury and Poisoning Prevention Protective Factors

The following are policy statements of the PPS, Inc. • Good parenting
• Child safety in private motor vehicles • Strong attachment between parents and children
• Child safety in public motor vehicles • Positive non-physical disciplinary techniques
• Child pedestrian injury prevention
• Child helmet use Republic Act 761- (Anti-Child Abuse Law)
• Drowning prevention “The head of any public or private hospital, medical clinical and
• Burn injury prevention similar institution, as well as the attending physician and nurse,
• Household product poisoning shall report, either orally or in writing, to DSWD the examination
• Medicinal poisoning and/or treatment of a child who appears to have suffered abuse
• Watusi poisoning within 48 hours from the knowledge of the same.”

Newborn visit 5. Counseling on Exposure to Lead and Other Toxicants

• Hand washing, minimize exposure to others, SIDS • Lead is an ubiquitous environmental toxicant that can
precaution, safe and smoke-free environment attack many different organ systems, the most
studied of which is cognition.
First week visit
• Avoid prolonged exposure to sun, monitor
temperature, sleeping arrangements add smoker
• Avoid drinking hot liquids when holding baby
exposureto tobacco
One month visit
• Safe crib, keep small and sharp objects and plastic
bags away from crib, test temperature of bath water

rainwater@mymelody.com || 1st semester, AY 2011-2012

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