PREVENTIVE PEDIATRIC MEDICINE PART 1 – DR.
CALIGAGAN
PREVENTIVE PEDIATRIC MEDICINE PART 1
Christian T. Caligagan, M.D.
 Well care is provided in the medical home fostering strong
relationships between clinic or practice and child and family,
and assisting in the provision of appropriate surveillance,
screening, and sick care.
 In Pediatrics in general, it is difficult to handle patients
because you handle not only the patients themselves,
but also with the relatives.
 A child has regular scheduled visits that are needed to
ensure adequate nutrition, detect and immunize against
infectious diseases, and observation the child’s
development.
 You discuss nutrition, talk about vaccines, accident
prevention, anticipatory guidance, and observe the
child’s development (do developmental screening)
 Preventive care for children and adolescents offers a greater
opportunity for health cost-saving.
 “An ounce of prevention is a lot better than a pound
of cure”
 The expense that you will incur because of the
hospitalization and medical cost is more expensive
than preventing the disease from occurring
 Preventive Check-Up in Pediatrics would also mean:
 Well Baby
 Well Child
 Well Adolescent
 Health Supervision Visit
 Preventive Maintenance Check-Up
 Clinical History and Physical Examination are very
important tools of Pediatricians (also to doctors in
general)
 You still need to get the history and perform physical
examination during a well-child check-up
 Observe if the child is a victim of neglect and abuse
 Anticipatory Guidance and Counselling are also done,
as well as an opportunity to address the concerns and
questions
 In the OPD, there is a “Well-Baby/Well-Child/Well-
Adolescent Days”
 It is not mixed with sick consultations because
Preventive Check-Ups usually needs a long time
 Usually it is during Tuesday or Thursday Afternoon
 These things could be done during a sick consult but
keep in mind that some parents would not be very
interested to listen because all they want is for their
child to be treated right away
TASKS OF WELL CHILD CARE
1. Disease Detection
 Sometimes patients will be brought to us by parents
without any complaints, but after doing a thorough
history and physical examination, you may detect that
there is something wrong with the child.
2. Disease Prevention
 Through immunization, vaccination, counseling on
the different accident prevention, giving anticipatory
guidance, etc.
3. Heath Promotion
4. Anticipatory Guidance
 DISEASE DETECTION
 Accomplished both by SURVEILLANCE AND SCREENING
 Surveillance and screening are sometimes used
interchangeably
 Surveillance
─ Occurs in every encounter
 When the patient is brought to the doctor, there
is usually surveillance happening already
─ Enhanced by the opportunity for repeated visits and
observations with advancing developmental stages
 Screening
─ More formal process utilizing some form of a tool,
which has been validated which has a known sensitivity
and specificity
─ Screening can give you a more definite diagnosis
 When you are doing surveillance, all you need to do is
ask questions, take the history, and do physical
examination. But when you talk about of screening,
you do something, like request for laboratory exam.
 For example: ANEMIA
 You can detect anemia in children simply by asking
for a dietary history and history of signs and
symptoms of anemia (pallor, easy fatigability, etc.),
by doing physical examination (checking the nail
beds, palms of the hand, soles of the feet, palpebral
conjunctiva)  SURVEILLANCE
 You can definitely diagnose anemia by requesting
for CBC (hematocrit and hemoglobin tests) and
other laboratory tests  SCREENING
 DISEASE PREVENTION
 Includes PRIMARY AND SECONDARY PREVENTION
 Primary Prevention – no disease yet
─ Example: Vaccinating against Chicken Pox
 Secondary Prevention – patients with specific risk factors
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 PREVENTIVE PEDIATRIC MEDICINE PART 1 – DR. CALIGAGAN
─ Example: A patient suffering from Rheumatic Fever and
you want to prevent the further damage to the valve
resulting to Rheumatic Heart Disease
REMEMBER: Rheumatic Fever is not synonymous
with Rheumatic Heart Disease
 Both have cardiac involvement but in
Rheumatic Fever, valves may not yet be
involved
 What you do as a secondary form of prevention
to prevent Rheumatic Heart Disease from
happening is by giving patients diagnosed with
Rheumatic Fever a regular injection of
Benzathine Penicillin every 21 or 28 days
 A pediatrician needs to individualize disease prevention
strategies to the community, as well as to the specific
family and patient
 HEALTH PROMOTION and ANTICIPATORY GUIDANCE
 Health Promotion and Anticipatory Guidance are 2
activities that actually distinguish a sick consult from a
well-health consult
 It shifts the focus to wellness and to the strengths of the
family
─ For example: What is already being done well and how
can this might be improved
INFANCY AND EARLY CHILDHOOD
 Some of the things that should be dwelled upon when a
patient comes to you:
 Nutrition
 Physical Activity
 Sleep
 Safety
 Emotional, Social, and Physical Growth
 Parental Well-Being
These are common concerns of parents when they
bring in their child for consult if their child is an infant
or in the early childhood stage.
 For each well-child visit, there are topics that are specific to
individual children based on their:
 Age
 Family Situation
 Chronic Health Situation
 Parental Concern
 Family Milieu  You also need to do sub-screening for:
─ Parental Depression
─ History of Family Violence
─ Substance Abuse
─ Nutritional Inadequacy
─ Lack of Housing
All of these things have a bearing on the child.
 Answering parents’ questions is one of the most important
priority of the well-child visit
 Promoting family-centered care and partnership with
parents increases the ability to elicit parent concerns,
especially about their child’s development, learning and
behavior
 Identify developmental disorders as early as possible
MIDDLE CHILDHOOD AND ADOLESCENCE
 As the child enters school-aged years, additional
considerations emerge
 We still do the same things like checking the nutrition,
physical activities, etc., but there are other
considerations that emerge that needs to be checked
when you see older pediatric patients
 Attention to developing autonomy requires fostering a
clinician-patient relationship separate from the clinician-
child family relationship with increasing needs for privacy
and confidentiality as the child ages
 Specially to adolescents
 Before, when patients are younger, it is only the
pediatrician and the care-giver of the child. But when
you are dealing with an older child and an adolescent,
you need to have a separate session with them.
 You can already get information from them.
 There are certain issue/topics that cannot be
discussed in front of the parents like:
─ Sexuality related behavior
─ Use of alcohol and tobacco
─ Drug use
 There are 6 health behaviors that are most important in
adolescents and adults which contribute significantly to
morbidity and mortality:
1. Nutrition
 Body Image: Anorexia and Bulimia are some
concerns
 Iron Deficiency Anemia
2. Physical Activity
 Body Image: Anorexia and Bulimia are some
concerns
 Iron Deficiency Anemia
3. Sexuality Related Behavior
4. Tobacco, Alcohol, and other Drug Use
5. Behaviors that Contribute to Unintentional and
Intentional Injuries
6. Violence
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 PREVENTIVE PEDIATRIC MEDICINE PART 1 – DR. CALIGAGAN

TOPICS OF CONCERN DURING HEALTH SUPERVISION VISITS 2. Allow infants to settle on their own so that they
1. Teething accomplish a successful independent transition to sleep.
2. Sleep Problems 3. If child protests, parents should use the same consistent
3. Toilet Training approach repeatedly.
4. Temper Tantrums and Breath Holding Spells  Night Awakening
5. Discipline ─ Parents should delay response so arousal states do not
6. Media Influence on Behavior progress to complete awakening.
7. Violence ─ Use the same approach of promoting nighttime settling
8. Tobacco Use  Nightmare
9. Obesity ─ Common; vivid, scary or exciting events easily recalled
by the child upon awakening
 TEETHING  Night Terrors
─ Less common events lasting 10-15 min, during which
 Teething in general can lead to intermittent, localized time the child is not easily aroused and may appear
discomfort. frightened and agitated.
─ On awakening the next morning, have amnesia
 Most infants have their 1st tooth erupt at age 6-8 months
 Emphasize a calm and soothing approach to facilitate the
 May have mild symptoms of gingival swelling and
child’s return to sleep.
sensitivity

 It could cause irritability to some but the localized  Sleeping pattern during the 1st year of life is so erratic
discomfort is brought about by gingival swelling and  Basic Principles of Sleep Hygiene (For Children):
sensitivity.  Must have a set bedtime and bedtime routine
 Bedtime and wake-up time should be the same on
 Lack of association with: school and non-school night
─ Fever  Make the hour before bed shared quiet time
─ Through the use of bedtime stories and lullabies
 If patients would have fever during tooth  Don’t send your child to bed hungry
eruption, it would just be low-grade. But most of  Avoid products containing caffeine for at least
the time fever is absent. several hours before bedtime
 Make sure the child spends time outside everyday
─ Drooling
 Keep your child’s bedroom quiet and dark
 There could be excessive salivation.  Keep your child’s bedroom at a comfortable
temperature
─ Diarrhea  Don’t use your child’s bedroom for time-out
punishment
 It is usually not related to diarrhea.  Keep the television set out of your child’s bedroom
 Some problems encountered during sleep:
─ Mood Disturbances
 Insomnia – repeated difficulty in initiating or
─ Sleep Disturbances
maintaining sleep
─ Rashes
 Obstructive Sleep Apnea (OSA)
Majority of patients who are having their first tooth  Parasomnias – episodic nocturnal behaviors which
eruption do not have apparent difficulties. often involve cognitive disorientation, autonomic
No fever, no diarrhea -- Only gingival swelling and and skeletal muscle disturbance
sensitivity/pain ─ Partial Arousal Parasomnias happening during
the Non-Rapid Eye Movement (NREM) Phase of
Sleep
 SLEEP PROBLEMS  Sleep Walking and Sleep Terrors
 Educate parents about: o Usually they have amnesia of the events that
─ Separation anxiety, which develops in the latter half of happened  When they are awaken from
the 1st year of life sleep and you ask them what happened or
─ Normal sleep requirements to help them understand a what they dreamt about, they could not
child’s need for naps, sleep schedules and bedtimes. recall anything
 To help child settle at night: o Parents notice that when their children are
1. Establish a regular bedtime routine starting with a quiet usually scared and have no idea what had
interaction like reading a bedtime story. hap

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 PREVENTIVE PEDIATRIC MEDICINE PART 1 – DR. CALIGAGAN
happened when they have already awaken
 Confusional Arousal
─ Nightmares – associated with the Rapid Eye
Movement (REM) Phase of Sleep
 Could be vivid, scary, or exciting events that
could be easily recalled by the child upon
waking up
 TOILET TRAINING
 Average age of successful toilet training: (1960’s) 27-28
months; (1990’s) 35-39 months
 Early training (<2 years old) should be discouraged due to
its association with chronic stool retention and encopresis
(fecal soiling)
 Key factor: READINESS OF THE CHILD
 Positive reinforcement and regular toilet times
 Give calm and understanding support
 NOCTURNAL ENURESIS
─ Occurrence of involuntary voiding at night at 5 years old
 At 2-4 years old, the child is developmental ready to
begin toilet training but the ideal age for toilet
training is between 35-39 months (around 3 years
old)
 Girls typically acquire bladder control before boys
 Bowel control in general is usually achieved first
before bladder control
 TEMPER TANTRUMS AND BREATH-HOLDING SPELLS
 Child’s expression of anger in outburst of rage
 Normal part of a child’s development
 TYPE OF TEMPER TANTRUMS:
1. Frustration or Fatigue-Related
─ Give support, sleep or food
─ Positive remarks
2. Attention-Seeking or Demanding
─ Ignore them and allow them to regain composure
over time.
3. Refusal (related to bedtimes and school)
─ Parents should be clear in their request for the child
to comply and must allow opportunity for compliance
─ Should be approached with firmness and consistency
─ If above fails, move the child physically to bed or to
the car
4. Disruptive
─ Physical removal followed by a time-out (1 min/yr of
age)
─ TIME-OUT – removal of positive reinforcement for
unacceptable behavior. This technique requires
consistency and patience.
5. Potentially Harmful or Rage-like
─ Best intervention is holding the child to calm and
allow him or her to relax in the parent’s arms
 Although temper tantrums are a normal part of childhood
and parenting, it is important to assess the family and
determine if there are contributing factors such as
parental depression or family violence that may require
other referrals and interventions.
 Both are common during the 1st year of life
 Age-typical expression of frustrations or anger, or
probably by hunger (for the very small kids)
 Parents are best advised to attempt to avert defiance
by giving the child choices, but once the child has
begun a tantrum, a child can be given a time-out.
 Time-Out is the removal of positive reinforcement for
an unacceptable behavior
 Calculated as 1 minute/year of age
 DISCIPLINE
 Parents have a tendency to apply discipline strategies
similar to those use by their parents
 Inquire about methods of discipline and offer practical
advice and alternatives
 A positive, supportive and loving parent-child relationship
 Instruct to maintain a positive atmosphere within their
home
 Advise parents to provide clear expectations about
desired behavior
 Cornerstone for effective discipline include:
─ Consistency of parental behavior
─ Open communication within families
─ Mutual respect
 Referral for counseling is the most important priority if
there is marital discord, drug or alcohol abuse
 Verbal reprimand may become abusive when reprimands
do not address undesired behavior but rather, assault the
character of the child
 PUNISHMENT – involves issuing a negative stimulus or
verbal reprimand, or inflicting physical pain, to reduce or
eliminate an undesired behavior.
─ Physical punishment may be harsh and abusive.
─ Pediatrician must remain emphatic, flexible and
committed to their relationship with the families
 The use of corporal punishment is not an effective
means of behavioral control
 Corporal Punishment = bodily harm
─ Spanking
─ “Sinturon”
─ “Luhod sa monggo”
 As children habituate to repeated spanking, parents
have to spank even harder to get the desired
response, increasing the risk of serious injury
 Punishment can be give and it involves issuing a
negative stimulus or verbal reprimand, or inflicting
physical pain, to reduce or eliminate an undesired
behavior
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 PREVENTIVE PEDIATRIC MEDICINE PART 1 – DR. CALIGAGAN

behavior ischemic heart disease and low birth weight can promote
 Punishment in contrast to Time-Out  Punishment smoking cessation
= you give something/you render something
(spank, shouting, etc.)  OBESITY
 Verbal reprimand can be done but is not  Childhood obesity is an epidemic in the US
recommended  Type II diabetes mellitus incidence is increased
 Sufficiently harsh punishment may inhibit undesired
 Increased risk for cardiovascular diseases, bone
behaviors, but a great psychological cost
problems, and emotional problems.
 Other Discipline Strategies:
1. Countdown
2. Clear communication of rules UNMET NEEDS AND FUTURE CHALLENGES IN PREVENTIVE
 The cornerstone of effective discipline in children PEDIATRICS
would be based on:  The FUTURE:
─ Mutual Respect = mutual respect between the 1. New immunizations
parent and the child 2. Improved screening tests to provide early diagnosis of
─ Consistency of parental behavior diseases.
─ Open communication within families 3. Unique genetic information to individualize preventive
3. Frequent approval and therapeutic strategies.
4. Enhanced treatments that minimize the impact of chronic
conditions on the health of the children.
 MEDIA INFLUENCE ON BEHAVIOR
 Growing evidence that demonstrates the impact of media,
particularly TELEVISION, on the health of the children
 There are untoward effects in terms of violence and
aggressive behaviors, substance abuse, sexual activity,
body image, school performance, and obesity
 This influence is related to content and total viewing time
 One to two hours/day

 In the US, children under 2 years old are not allowed

to watch the television, but if ever they are allowed
to do so, they are only allowed 1-2hrs/day.

 VIOLENCE
 Permeates the lives of children
 Homicide, suicide, child abuse, domestic violence, access
to firearms, substance abuse, school shootings, gang
participation, media violence, date rape, bullying and
terrorist acts are examples of the daily infiltration of
violence into the lives of children

 TOBACCO USE
 Eighty (80%) of people who smoke had their first cigarette
before 18 years of age

 The earlier that you started smoking, the more

established smoker you are.

 CIGARETTE SMOKING – is the most preventable cause of

mortality and morbidity in US today
 Parental disapproval of smoking may prevent adolescents
from becoming established smokers
 Giving of brief educational messages that effectively
explain the relationship of smoking to lung cancer,

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