The Infant
Case 2.2 Health Maintenance
32 The Infant
His mother works as a housekeeper, and his father works in construction. The family has a pet bird.
There are no smokers in the home.
Family m edical h istory: Juancarlos ’ s mother has asthma and seasonal allergies. His 33 - year - old father is healthy and has no history of chronic medical conditions. Juancarlos ’ s maternal grandmother died at age 55 years from a myocardial infarction. His maternal grandfather has a history of Type 2 diabetes mellitus and obesity. His paternal grandparents are both deceased; both died in a motor vehicle accident several years ago.
Juancarlos is not currently taking any over - the - counter, prescription, or herbal medications. He has no known allergies to food, medications, or the environment. He is up to date on required immunizations.
OBJECTIVE
Juancarlos ’ s vital signs were taken in the offi ce today. His weight is 6.0 kg, and his length is 64 cm.
Juancarlos ’ s temperature is within the normal range at 37 ° C (temporal). When observing his general appearance, he is alert, active, and playful. He appears well hydrated and well nourished.
Skin: His skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There was no dia- phoresis noted. Juancarlos has good skin turgor on examination.
HEENT : Juancarlos ’ s head is normocephalic. His anterior fontanel is open and fl at (0.5 cm × 0.5 cm).
Red refl exes are present bilaterally and pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal; tympanic membranes are gray bilaterally with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membrane.
Both nostrils are patent. There is no nasal discharge; and there is no nasal fl aring. Juancarlos ’ mucous membranes are noted to be moist when examining his oropharynx. He has 2 teeth present without evidence of caries. There are no lesions present in the oral cavity.
Neck: Supple and able to move in all directions without resistance. There is no cervical lymphadenopathy.
Respiratory: Respiratory rate is 22 breaths per minute and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformi- ties of the thoracic cage are noted.
Cardiovascular: Heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2 + bilaterally.
Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evi- dence of hepatosplenomegaly.
Genitourinary: Genitourinary examination reveals normal male genitalia. Juancarlos is uncircum- cised, and his testes are descended bilaterally.
Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities. His extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
Which laboratory or diagnostic imaging tests should be ordered as part of a 9 - month, well - child visit?
___CBC
___Lead screening test
Health Maintenance 33
___Liver function tests ___Cholesterol level
___Baseline chest radiograph
What is the most likely differential diagnosis and why?
___Iron defi ciency anemia ___Constipation
___Other
What is your plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: According to the American Academy of Pediatrics ( AAP ) Recommendations for Pre- ventive Pediatric Health Care guidelines, there are no recommended laboratory tests or diagnostic imaging tests for the 9 - month, well - child visit. However, based on Juancarlos ’ history of receiving a low - iron formula, the health care provider may consider obtaining a hemoglobin test to screen for iron - defi ciency anemia. If the hemoglobin is abnormally low, then the health care provider can obtain a full complete blood count to confi rm the diagnosis of iron defi ciency anemia. The AAP guidelines recommend that children at risk for lead poisoning (those children living at or below the poverty line who live in older housing) receive a risk - assessment screening for lead poisoning at 9 months of age.
What is the most likely differential diagnosis and why?
Iron defi ciency anemia and constipation:
Based on the history provided by Juancarlos ’ mother, diagnoses to consider would be iron defi ciency anemia and constipation.
What is your plan of treatment, referral, and follow - up care?
The plan of treatment would be to discuss nutrition, anticipatory guidance and safety. For the 9 - month visit, the health care provider should discuss safety issues such as car safety (having the child in a rear - facing car seat) and water safety (water temperature < 120 degrees; never leaving the baby in the bathtub alone; keeping the toilet lid and the bathroom door closed; empty mop buckets after each use). In addition, the health care provider should discuss fi rearm safety, the prevention of burns, and the need for working smoke and carbon monoxide detectors.
The health care provider should discuss anticipatory guidance topics such as introducing the cup and beginning to wean Juancarlos off the bottle; reading to him each night; and discouraging televi- sion watching and encouraging more interactive activities that promote proper brain development, such as talking, playing, singing, and reading together.
Nutrition topics such as the need for iron - fortifi ed formula, not low - iron formula, to prevent iron defi ciency anemia should be discussed. Nutritional suggestions should be given to prevent constipa- tion associated with iron intake such as pureed prunes or prune juice.
The family may be referred to the WIC ( Women, Infants, and Children ) program for assistance with obtaining formula and iron - fortifi ed infant cereals. The WIC program has nutritionists on staff that will be able to provide Juancarlos ’ s family with nutritional education.
Juancarlos should follow up for a well - child visit at 1 year of age or sooner as needed for signs and symptoms of illness.
34 The Infant
Does this patient ’ s psychosocial history affect how you might treat this case?
The language difference between the health care provider and the patient ’ s family may be a potential barrier to receiving effective health care — even with the use of a certifi ed medical interpreter. Because of this barrier, the health care provider may need to spend extra time when working with this family.
What if the patient lived in a rural setting?
It may be diffi cult to obtain appropriate medical translator services for families living in rural settings.
This may prompt health care providers to use family members for interpretation, which could com- promise patient confi dentiality. Telephone translator services are available for use for practices without in - person translators. Also, obtaining supplemental nutrition services such as WIC may be diffi cult because of lack of access to nearby WIC distribution centers.
Are there any demographic characteristics that might affect this case?
Besides being of Hispanic ethnicity and not speaking English, age is a demographic factor that might affect this case. At 9 months of age, Juancarlos likely has no maternal iron stores; and since he is consuming low - iron formula and not taking multivitamins, he is at risk for iron defi ciency anemia.
Are there any standardized guidelines that you should use to assess or treat this case?
The American Academy of Pediatrics has issued several clinical practice guidelines that may assist health care providers during well - child visits. For more information, refer to the resources below and their web links.
REFERENCES AND RESOURCES
American Academy of Pediatrics . ( 2010 ). Recommendations for preventive pediatric health care. http://practice.
aap.org/content.aspx?aid=1599
American Academy of Pediatrics . ( 2010 ).Recommended childhood and adolescent immunization schedules — United States. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;125/1/195
Baker , R. D. , Greer , F. R. , & Committee on Nutrition American Academy of Pediatrics ( 2010 ). Diagnosis and prevention of iron defi ciency and iron - defi ciency anemia in infants and young children (0 – 3 years of age) . Pediatrics , 126 , 1040 – 1050 .
Centers for Disease Control and Prevention . ( 2009 ). Lead prevention tips. http://www.cdc.gov/nceh/lead/tips.
htm
Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition ( 2006 ). Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition . Journal of Pediatric Gastroenterology and Nutrition , 43 , e1 – e13 .
Food and Nutrition Program . ( 2010 ). Women, Infants, and Children. http://www.fns.usda.gov/wic/
Magar , N. A. , Dabova - Missova , S. , & Gjerdingen , D. K. ( 2006 ). Effectiveness of targeted anticipatory guidance during well - child visits: A pilot trial . Journal of the American Board of Family Medicine: JABFM , 19 , 450 – 458 . Schempf , A. H. , Minkovitz , C. S. , Strobino , D. M. , & Guyer , B. ( 2007 ). Parental satisfaction with early pediatric
care and immunization of young children: The mediating role of age - appropriate well - child care utilization . Archives of Pediatrics & Adolescent Medicine , 161 , 50 – 56 .