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198 Cards in this Set
- Front
- Back
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what are the 4 major components of the teeth?
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enamel-outer layer
dentin-inner layer (most of tooth) pulp-contains neurovascular structures root- secures tooth in socket to bone |
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when in fetal development does initiation or growth of teeth occur?
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6 weeks
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when in fetal development does calcification of teeth occur?
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3 or 4 months, permanent teeth begin to develop now
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what is malocclusion?
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misalignment of the bite
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what is primary dentition?
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The period of primary dentition begins with the eruption of the first tooth between 4-12 months of age. The first tooth to appear is usually mandibular central incisor. The incisors erupt first (central and lateral); then the first molars, the cuspids, and the second molars. Maxillary teeth generally erupt 1 to 2 months after their mandibular counterparts. The 20 primary teeth should all be in place by 36 months of age. Late eruption in kids who are otherwise growing and developing normally is not a cause for concern.
The space in the jaws occupied by the primary teeth is essentially the same space that will be available for its successors. Premature loss of primary teeth can cause this space to close leading to crowding of the permanent teeth. As the jaw grows bigger and longer, the new space that formed behind the existing teeth is taken up by the additional permanent molars that erupt behind the primary teeth. |
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what is mixed dentition?
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Mixed dentition occurs during the transition form primary teeth to permanent teeth. It begins at about 6 years of age with the exfoliation of the primary teeth, usually the central incisors, followed by the eruption of the first permanent molars. This stage usually lasts until the last primary tooth is shed – usually about 12 years of age.
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what is permanent dentition?
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This stage begins with the exfoliation of the last primary tooth. The permanent teeth number 32 (including the third molars or wisdom teeth). Each of the four quadrants of the mouth contains two incisors, one cuspid, two premolars (bicuspids) and three molars. Adolescents should be evaluated to see if their jaws have enough room for the eruption of the third molars. If not, the teeth should be extracted before eruption.
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what to include in dental history?
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Pattern of tooth eruption
Fluoride content of the water and the amount of water consumed Fluoride supplementation orally and topically Use of tooth brush, toothpaste and floss Dental visits Traumatic oral injuries Family history malocclusions, periodontal disease Need for antibiotic prophylaxis with dental work (cardiac defects) Other age related history factors: Infants and toddlers up to age 3: bottle-feeding and breastfeeding past the age of 12 months. Use of pacifier, nipple, bottle, cup. Preschoolers age 3-5 years: oral habits—finger sucking, pacifier use School-age and adolescents: oral habits, orthodontic corrections, activities and sports participation |
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what are some effects of dental caries?
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The caries can lead to difficulty eating, speech dysfluency, low self-esteem and both chronic and acute pain, missed school.
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who gets caries?
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Children who are from poorer areas and members of certain ethnic groups experience disproportionately higher prevalence and severity of dental caries and they frequently have less access to care. When looking by ethnicity, A/PI and NA have the most caries followed by Hispanics, AA, and caucasian In new haven, it is estimated that 20% of kids have 80% of dental caries. The younger the child’s age when caries begins, the greater the risk for future decay. If you can spot cavities with your naked eye they are already very bad.
Children from poorer areas experience more dental caries and more severe. 20 percent of kids have 80 percent of caries. The younger the child’s age when caries begins, the greater the risk for future decay. |
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what are causes of caries?
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Infectious disease transmissible and caused by colonization with S.mutans
Usually transmitted from mother to child After S.mutans, caries is a dietary disease Reducing dietary support for S.mutans (refined carbs) can control rate of caries along with brushing and fluoride Second hand smoke increases risk Second Hand smoke increases caries risk independent of age, SES, and frequency of dental visits |
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when does AAP recommend first dental visit?
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The AAPD recommends that all children have their first dental visit by age 12 months or six months after the first tooth erupts whichever comes first. (First visit by first birthday). However, in reality, most kids do not go until they are at least three years old. By that time oral health may already be compromised. We are the only source of dental care for the first 3 years of children’s lives. For this reason, we have to be aware ways to prevent caries in the primary teeth until the kids first dental visits. The early interventions by NPs gives parents a chance to be properly educated about oral hygiene, prevention of dental injuries and prevention of nursing caries.
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how can NPs encourage dental health?
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Preventive dental care includes: brushing, flossing, fluorides, oral habits, orthodontics, parental involvement, proper diet, sealants and sports safety.
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what nutrition is needed for dental health?
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Vitamins A,C, D
Calcium, Fluoride Low sugar diet-- including starches No bottles in bed |
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toothbrushing guidlelines
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Regular brushing and flossing along with dental visits provide the mainstays for oral hygiene. Disrupting and removing as much plaque as possible through oral hygiene practices is the simplest approach to plaque control. Brushing at least once daily removes plaque. If the teeth are brushed only once a day, it is preferable to brush at night to remove the build-up that occurred throughout the day. Also not as much saliva is produced at night to wash away some of the bacteria that attaches itself to teeth. During infancy, parents can wipe the baby’s gums and teeth with a damp washcloth after feedings. A soft toothbrush moistened with only water may be used after several teeth have appeared. Toothpaste can be introduced around age 4 years when children can spit the toothpaste out. Children younger than this often swallow the toothpaste. A pea-sized amount should be used to minimize fluoride ingestion.
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when should flossing be initiated?
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Flossing should be initiated when children are between the ages 2-3 years of age. It’s not usually indicated before then because tooth – to –tooth contact is minimal. Flossing removes plaque in between teeth in spaces that are inaccessible to the toothbrush.
Parents should brush and floss the children’s teeth until about age six when they have developed the motor skills to continue on their own. They should still be supervised. |
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what has been the primary factor in reducing the prevalence of dental caries among children in the US
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fluoride
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how do we get our fluoride?
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Fluoride may be provided both systemically and topically. Fluoridation of the water is an effective way to provide systemic fluoride. It is recommended that systemic fluoride begin at about 6 months of age. Only fluoride ingested during the tooth forming years has the systemic effect of enhancing late resistance to caries. The optimal concentration of fluoride in the local water supply varies in accordance with the climate ( the rationale being that people in temperate climates drink more fluids than people in colder climates).
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how to know if someone needs fluoride?
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It is really not sufficient to ask if families live in a fluoridated community. You need to know the source of their drinking and cooking water. Some people may drink only bottled water but use tap water to cook which still supplies some fluoride systemically. Children may also drink fluoridated water at their day care centers. Reports also suggest that commercial distributors of bottled water use multiple water sources with varying levels of fluoride in their water which makes assessment of children’s actual fluoride exposure difficult. Fluoride supplementation is only recommended when you can show that a child’s fluoride intake is less than optimal. The fluoride level in local tap water can be obtained from the local health department. Because fluoride absorption is reduced to 60% to 70% when it is given with formula or milk, it is recommended that fluoride supplements be given on an empty stomach.
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what happens with too much fluoride?
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Excessive fluoride ingestion may lead to fluorosis, particularly in the permanent teeth. Fluorosis occurs when too much fluoride deposits in the enamel of teeth causing discoloration. The most sensitive age for developing fluorosis is 18-30 months.
Although acute fluoride toxicity is rare, ingestion of large amounts can be potentially fatal. To avoid accidental overdoses, no more than 120mg of supplemental fluoride should be prescribed at one time. |
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Topical fluoride
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Topical fluoride is also very important. Almost all toothpaste manufactured in the US provides topical fluoride. Topical fluoride reaches the teeth directly in the mouth. Topical fluoride is most effective when delivered at very low doses many times throughout the day through water, foods containing fluorides, and fluoridated toothpaste. Fluoride rinses are available over the counter. Another common form of topical fluoride is professionally applied fluoride which renews the high levels of fluoride in superficial enamel.
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Eruption cyst
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cyst on the gums that precedes the eruption of a tooth. It’s circular, bluish and swollen. Usually up to 1 cm and located on the gumline over an erupting tooth. It ruptures spontaneously and the tooth erupts. Acetaminophen and cold packs can be used for comfort. If it appears infected, referral to a dentist is necessary for excision.
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Sealants
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Dental caries in the permanent teeth usually originate in the pits and grooves normally found on the biting aspects of the back teeth because these areas trap food and are hard to clean with a toothbrush. The enamel layer is often thinner on these areas than on other areas of teeth and fluoride is less effective than on other more exposed areas of the tooth.
Dental Sealants are plastic coatings applied to teeth to prevent dental caries by creating a physical barrier against bacterial plaque and food retention. Sealants are usually applied only to permanent teeth but can be applied to primary teeth is the child is at high- risk for caries |
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Natal teeth or neonatal teeth.
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Natal teeth are present at birth. Neonatal teeth erupt within the first thirty days of life. They occur in 1 of every 2,000 births. There is a 15-20% familial occurrence. They should be referred to a dentist and if loose, extracted.
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Teething
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inflammation and sensitivity that can be present as teeth erupt. Lots of symptoms have been associated with teething. Last year, the results of a prospective study on teething was published. 125 children were followed for eight months to record symptoms associated with teething. They were recruited at the 4 month visit and followed until 12 months. Symptoms were only significant 4 days before tooth emergence, the day of, or 3 days after. Symptoms that were associated with teething include increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite for solid foods and mild temperature elevation.
Things that were not significantly associated with teething were congestion, loose stools, increased frequency of stools, decreased appetite for liquids, cough, rashes other than on the face, vomiting, and fever > 102 degrees. |
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Early Childhood Caries
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Caries and nursing bottle syndrome—other names are early childhood caries (ECC). Associated with severe dental decay, usually of multiple maxillary primary teeth. These caries are the result of repeated and prolonged contact with milk, juice, formula from a bottle or prolonged breastfeeding episodes. In April, 1999 results from a lab study were published that showed that when breast milk is combined with another carbohydrate source, the combination produces caries at a rate faster than that of sugar alone. However, they still note that breast milk alone did not damage tooth enamel. Also, infants who are strictly breastfed are more resistant to tooth decay than those who are fed sugar rich foods together with infant formulas.
If ECC is noted, Referral to a dentist is needed and extraction under general anesthesia may be necessary. ECC is completely preventable Encourage parents to avoid putting babies to bed with juice or milk filled bottle or using the breast as a pacifier. Only water. Parents should be encouraged to start using a cup at 6 months of age and wean children from the bottle at age 1 year. Parents may need guidance on other ways to calm their babies. |
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Symptoms that were associated with teething
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increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite for solid foods and mild temperature elevation.
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Symptoms that were not significantly associated with teething
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congestion, loose stools, increased frequency of stools, decreased appetite for liquids, cough, rashes other than on the face, vomiting, and fever > 102 degrees.
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Gingivitis
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inflammation of the gums. Eruption gingivitis occurs temporarily with the emergence of a tooth. Marginal gingivitis occurs with poor dental hygiene. Gingivitis is the most prevalent lesion of the oral soft tissues in young children affecting about 80 % of children. It is managed by improved brushing and flossing, professional dental cleaning every 6 months, and saline mouth rinses as necessary.
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Tooth Trauma and tx
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avulsion (tooth knocked completely out of the mouth)
intrusion – tooth pushed back into the gums and fracture of the anterior, upper teeth. Management: avulsed teeth If primary – do not reimplant; if permanent – find tooth and rinse and insert tooth into socket if possible. If not, keep tooth moist in milk, saliva, or saline – avoid tap water. The chance for successful reimplantation is zero if the tooth is left out of the mouth for more than 90 minutes. Intruded teeth – primary teeth: usually return to original position in 6-8 weeks, refer to dentist to make sure permanent teeth are not affected; for permanent teeth refer to dentist for surgical re-positioning. Fractured teeth: refer to dentist. |
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Finger sucking
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Prolonged and excessive digit sucking can produce malformations in the developing teeth and bones. Get rid of pacifiers by age three. Positive reinforcement should be given for not sucking fingers and distraction can be used by parents at times when sucking ois likely to occur. A dentist can apply an appliance to teeth is sucking continues past the age of 5 years
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Tongue thrusting
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Some children maintain the infantile habit of thrusting their tongue through their anterior teeth instead of placing the tongue on the roof of the mouth to swallow. This can produce a space between the upper and lower front teeth. If this habit persists past age 7, refer to dentist.
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What to look for in dental assessment when suspectful of Child Abuse
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Intraoral lacerations or tears; perioral bruising. If child abuse is suspected report findings to child protective services and consult dentist for assessment and treatment
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who should not use fluoridated toothpaste?
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children under 2.5 years unless high-risk
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at what age is fluoride supplementation recommended?
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over 6 years, but only in children where water supply does not provide enough fluoride
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excess fluoride prevention in infants/children
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breast milk
ready to use formula purified or other low-fluoride water |
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methamphetamine decay pattern
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decay on buccal smooth surface of teeth and interproximal surfaces of anterior teeth
18-34 yo, more men than women |
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what is legal blindness?
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20/200
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pupils of newborn
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small and do not dilate well
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newborn eyesight
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farsighted (hyperopic)
20/400 eye misalignment common responds to changes in illumination and fixates n points of contrast |
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eyes at 1-3 months
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tears with crying
at 2.5 months can follow object through 180 degrees |
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eyes at 6 months
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20/100
nerve fibers develop in response to light fundus approximates adult eye eye alignment and coordination achieved color vision near adult |
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eyes at 1 year
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full EOMs
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eyes at 4 years
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can read 20/50
therefore books are large print |
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eyes at age 7
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neurons and connections stop development
ambyopia no longer treatable can read 20/20 |
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eyes at age 11-13
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becomes less hyperopic (farsighted) and more myopic (nearsighted)
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Strabismus
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An eye turn where the patient only uses on eye at a time.
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Amblyopia
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The lack of a single focused image not allowing for full eye neuron development, also called lazy eye.
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neonatal conjunctivitis
Neisseria gonorrhea |
a. Incubation - 3 to 5 days
b. Very pussy - careful on opening eyes for exam as pus may squirt out c. Injection and edema d. Gram negative diplococci e. Corneal ulceration, perforation and visual impairment are possible complications f. Inoculation occurs as baby passes through maternal infected birth canal g. Prophylaxis - 1% Silver Nitrate, 1% Tetracycline, .5% Erythomycin |
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neonatal conjunctivitis
Chlamydial Infection |
a. Incubation - 2 weeks
b. Inoculation from infected maternal birth canal (50% of the neonates exposed in the canal get Chlamydia) c. Unilateral infection with pus is common d. Treatment - systemic Erythromycin |
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neonatal conjunctivitis
Other Bacterial Conjunctivitis |
a. S. Aureus, Hemophilia, S. Pneumoniae, Enterococci
b. Typically treated with topical antibiotics c. Culture may help choose drug of choice |
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neonatal conjunctivitis
Viral conjunctivitis |
Most commonly Herpes Simplex
a. Incubation 3 days to 2 weeks b. Inoculation from infected birth canal c. Corneal ulceration, scarring and vision loss may be complications d. Topical Viroptic and systemic Acyclovir therapy should be initiated e. Referral is indicated |
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Congenital Glaucoma
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1. Buphthalmos (enlarged cornea) is the hallmark
2. Normally aqueous fluid is made and drained constantly; in glaucoma drainage, tubules are blocked, fluid builds us in eye, pressure pushes on the optic nerve creating cupping and damaging nerves that go to side vision 3. Referral is indicated |
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Other causes of red conjunctiva at birth
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1. Corneal abrasions - usually self limited
2. Subconjunctival hemorrhages self-limited 3. Birth trauma |
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Nystagmus
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at birth check for(involuntary rhythmic eye movements) with a penlight
a. Usually indicates bilateral vision loss in the first year of life b. May indicate complete color vision loss (monochromism), albinism or blindness c. Referral is indicated. |
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Retinopathy of Prematurity
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a. A Vaso Proliferative Retinopathy (non-inflammatory damage to the retina of the eye. Most commonly it is a problem with the blood supply that is the cause for this condition.)
b. In 1950s - premature infants given 02 were found to have ROP c. In 1960s - studies show that oxygen below 40% decreased incidence of ROP d. Currently infants at risk are below 1500 gm birth weight or children with respiratory distress syndrome e. Retinal vasculature proliferates leads to scar tissue retinal detachment and vision loss f. Referral is indicated |
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Cataract
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a. An opacification of the lens
b. Causes: genetically inherited metabolic disease, trauma, inflammatory process or infection c. Seen as an opacity in the retinal reflex d. Causes leukokoria (white pupil) e. Painless loss of vision f. Uncorrectable with glasses g. Treatment - surgical removal of lens - correction of power loss is needed (i.e, contacts, glasses or intra-ocular implant) h. Referral is indicated |
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Retinoblastoma
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a. Intra-ocular malignancy
b. Genetic component c. 50% of children with retinoblastoma have a white fundus reflex d. Most common intra-ocular malignancy e. Prognosis for life directly related to extension of tumor f. Referral as soon as possible is indicated. |
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hirschberg test
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alignment of light reflex in blth eyes
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optokinetic drum test
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will illicit nystagmus
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lacrimal drainage
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should be present by 6 months
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when should snellen be attempted?
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3-5 years
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for 2-5 yo, when is vision referral indicated?
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20/50 or when there is 2 or more line difference in acuity
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refractive error
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error in focusing of light by the eye and a frequent reson for reduced visual acuity
may result in difficult with snellen |
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myopia
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near sightedness
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hyperopia
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far sightedness
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presbyopia
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blurry near vision
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astigmatism
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distortion
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Colomba
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A congenital defect that may be first detected around 2-5 yo with fundal exam
1. The incomplete closure of the fetal (choroid) fissure 2. May present as white area of retina 3. May have keyhole pupil 4. Vision may be affected if retinal macula is affected |
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in child over 5, when is referall for eyesight needed?
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20/30 or two line difference in acuity
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Amblyopia
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(lazy eye- poor or indistinct vision in an eye that is otherwise physically normal- developmental problem of the brain, not an organic problem of the eye- the part of the brain corresponding to the visual system from the affected eye is not stimulated properly, and develops abnormally = Rx- eye patch) must be treated by age 7 to be effective
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when is visual field test affected?
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in glaucoma, retinal disease, and brain tumor
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Outline guidelines for referral of a child who “fails” vision screening.
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• A referral is indicated if vision is less than 20/50 or there are 2 lines difference in acuity
• If child fails first screening, a second rescreening using the same procedure should be performed (unless a mechanical vision tester was used). In that case, a second rescreening should be completed using the Snellen Chart screening procedure. • If child fails, rescreening, notify parents and send a written referral for a professional eye examination. |
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Treatment of Amblyopia
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• Amblyopia is the most common cause of monocular visual impairment in children and young and middle-aged adults, and opinions vary on the appropriate treatment regimens.
• Atropine and patching are effective treatments for moderate amblyopia in children in the age range of 3 to <7 years old and that the initial choice of treatment regimen can be made by the eye care provider and the parents. • When patching is prescribed, 2 hours of daily patching is as effective for moderate amblyopia as prescribing 6 hours of daily patching. For severe amblyopia, prescribing 6 hours of daily patching is just as effective in improving visual acuity as prescribing more intensive patching regimes. It must be kept in mind that these results refer to the intensity of patching that was prescribed and not to the actual amount of patching that occurred. Additional work, however, is needed to determine whether these regimens can attain maximum improvement in visual acuity that is sustained when treatment is discontinued. |
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Bacterial Conjunctivitis
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Visual Acuity: normal
Redness: overall Pain: no Pupil: normal Discharge: yes, yellow Itch: no Preauricular Node: no |
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viral conjunctivitis
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Visual Acuity: may be reduced
Redness: overall Pain: minor Pupil: normal Discharge: yes teary Itch: no Preauricular Node: YES |
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allergic conjunctivitis
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Visual Acuity: normal
Redness: overall Pain: no Pupil: normal Discharge: yes, mucous Itch: YES Preauricular Node: no |
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iritis
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Visual Acuity: slightly reduced
Redness: circumlimbial flush Pain: yes, PHOTOPHOBIA Pupil: SMALLER Discharge: No Itch: No Preauricular Node: No |
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angle closure glaucoma
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Visual Acuity: reduced
Redness: overall Pain: yes Pupil: OVOID FIXED Discharge: no Itch: no Preauricular Node: no |
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esotropia
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eye turns in
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exotropia
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eye turns out
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hypertropia
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eye turns up
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Rapid Eye Movement (REM)
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o Active dream stage
o Nerve impulse to muscles blocked o Irregular breathing and heart rate o Ends with brief awakening o Occurs in cycles o REM sleep stages decrease with age o Newborn enter sleep cycle in REM |
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Non-Rapid Eye Movement (Non-REM)
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occurs in 4 stages
o Stage I: Drowsiness, light sleep o Stage II: Deeper sleep but easily aroused. 50% of mature sleep. Some dreams. o Stage III: Deeper sleep, body relaxed, shallow breathing. Occurs earlier in night, 15-20% of mature sleep. Develops in infants at 3-4 months o Stage IV: Deep sleep. EEG pattern changed; If awakened person is confused Transition from stage IV to waking responsible for sleep walking and night terrors |
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SLEEP: Newborn
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16-20 hours
(sleep 2.5-4 hrs at a time) Half of sleep is daytime sleep REM sleep with frequent arousal. Circadian rhythm not established |
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SLEEP: 3-4 months
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15 hours
More organized into day time wakefulness and nighttime sleeping Non-REM sleep occurs. Able to sleep longer at night. Can fall back to sleep once aroused at end of REM. Circadian rhythm present |
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SLEEP:6-12 months
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14-15 hours
2 naps Need for feeding at night less acute. Can sleep for 12 hours. Separation anxiety starts. |
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SLEEP:Toddler
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11-12 hours at night
Gives up morning nap but continues afternoon nap Separation anxiety continues. Rituals important |
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SLEEP:Preschool
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11-12 hours at night
Some stop afternoon nap. Fears of “monsters” develop |
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SLEEP:School-Age
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10-11 hours at night
NO NAP Early school a problem. Sleep problems learned behavior or sign of stress |
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SLEEP:Adolescents
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9 hours at night
NO NAP Irregular sleep schedule. Most don’t get enough regular sleep. |
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SIDS prevention
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• AAP recommendation in 2005—Infants should be placed only on back (side not as safe) for unsupervised sleep to decrease incidence of SIDS
o Co-sleeping may be hazardous and should be discouraged (AAP, 2005) o Infant encouraged to share bedroom but not bed o Use of pacifier during sleep shown to decrease SIDS o No soft surfaces and loose bedding o Hazard of maternal smoking o Hazard of overheating o Hazards of preterm birth and low birth weight |
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who should be referred for a T&A?
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child over 10 with 3+ or 4+ tonsils and hx of disordered sleep breathing
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Health consequences of SDB
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Neurobehavioral morbidity--ADHD, daytime sleepiness, Externalizing, hyperactive behaviors
Increased Health care needs decreased Cognitive function increased Asthma and allergies |
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decreased sleep associated with
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increased levels of ghrelin (an appetite stimulant)
decreased levels of leptin (an appetite suppressant) increased fatigue leads to decreased exercise The more time that is spent asleep, the less time there is to eat |
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ELIMINATION: Infants
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60 cc
reflexively empties 20X / day |
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ELIMINATION: Toddlers
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300 cc
Can hold urine for 2 hours. Voids 7-12X / day. |
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ELIMINATION: Preschoolers
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98%+ will have bladder control by 4 years of age during day
Voids 7-12X / day. |
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ELIMINATION: School-Age
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Same capacity as adults (650-1500mL)
5-6 x/day 1-3x or less and 8-12x or more is a problem |
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Primary Enuresis:
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Continued involuntary leakage of urine (has never been toilet trained)
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Secondary Enuresis:
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Had bladder control for at least 3 months but not currently
o Diurnal (daytime) o Nocturnal (night time) |
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Primary nocturnal enuresis common:
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o 7%-20% of 5 year olds, 10% of 6 year olds, 3% of 10 year olds
o 95% functional, not organic o More common in boys o Family pattern |
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Secondary enuresis
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requires further evaluation
o UTI, diabetes, constipation, sickle cell, chronic renal failure o psychosocial stressors, abuse |
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treatment for non-organic enuresis
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• “Tincture of Time”—enuresis will improve with age and increased function
• Decrease fluid intake (before bedtime) • Scheduled toileting—peeing before bedtime, waking up to pee at night • Bladder control training • Enuresis alarms • Behavior modification--Do not punish—ask parents about their emotions/frustrations regarding enuresis to get a sense of how they are handling/approaching situation; May strip the bed • Motivational therapy—reinforce POSITIVE behavior • Drug therapy-- Desmopressin acetate (DDAVP)—should only be used as a short-term treatment for non-organic enuresis; for children with secondary enuresis, drug therapy prevents diagnosis and treatment of primary cause |
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Breast fed stools
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yellow, seedy, 1-8X/day or only 2-4 times /week
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Formula fed stools
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brown / green / soft / formed 1-4X/day
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child readiness for toilet training
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One study suggests boys are ready a few months later than girls
Walks well (coordination of muscles, able to get to the toilet) Able to sit and play Able to dress & undress self partially (getting clothes off to pee/poop) Wants to put toys “where they belong” (cooperation, following rules, not negativistic) Likes to imitate (and therefore will try using toilet like others do) Not in period of negativism Takes pride in doing things BM formed at regular time each day Able to remain dry for 2 hours at a time (this develops in toddler years) Has words for urine and stool (“I have to go peepee” or “I have a poopy”) |
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parent readiness for toilet training
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Has appropriate expectations of child
Has time to work with child on new task Can accept “accidents” as inevitable Understands and able to use positive reinforcement vs negative reinforcement |
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complicating factors for toilet training
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Starting too early
Not appropriate time, i.e., new baby, illness Child’s difficult temperament--Less adaptable, Less persistent, Negative mood, Lower in approach Parent / Child conflict Children with special health care needs--Developmental delay (Downs), Motor delay, cerebral palsy), Neurological dysfunction (spina bifida) |
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authoritarian parenting
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harsh, unrepsonsive, lack of warmth
rigid, strict parents use power assertive methods of control |
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authoritative parenting
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warm, responsive
parents set limits use of verbal explanations expect appropriately mature behavior from children |
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permissive parenting
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lax, inconsistent discipline
encourage children to express impulses freely indulgent |
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uninvolved/neglectful parenting
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indifferent, passive, neglectful
parents focus on own needs rather than children's needs |
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traditional parenting
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blending of styles along traditional gender role parenting
cultural traditions |
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overparenting
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intense focus on all activities of child
push for child to excel child center of attention, lack of awareness of needs of others |
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child outcomes: authoritarian parent
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conflicted, irritable, aggressive
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child outcomes: authoritative parenting
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energetic, friendly, cheerful
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child outcomes: permissive parent
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implusive, aggressive
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child outcomes: uninvolved parent
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neglected child
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child outcomes: overparenting parent
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self-centered, lack of independence/self-direction
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discipline for infancy
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Structured daily routines
Respond flexibly to needs Create safe spaces Distract / remove from potential hazards or problem activities |
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appropriate expectations for infancy
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Infants are not “bad”, “mean”
Can you “spoil” an infant? |
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discipline for toddlers
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Toddlers
Positive reinforcement for desired behavior Introduce verbal communication Firm “no”, consistently Remove from the event with simple verbal response Brief time-out for settling down Distraction / redirecting Safety first, pick your battles |
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appropriate expectations for toddlers
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Need for continued supervision
Temper tantrums common, ignore. Time-in for good behavior Problems when tired, hungry, over-stimulate |
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discipline for preschoolers
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Positive reinforcement for desired behavior
Use of more rules & routines (reassuring) Consequences associated with rules Verbal re-direction (greater vocabulary) Physical re-direction Role-modeling |
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appropriate expectations for preschoolers
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Magical thinking
Begin to understand feelings of others Time-in and time-out effective Still need to monitor for safety |
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discipline for school-age children
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Positive reinforcement
Rules more internalized Increased responsibility & self-control Consequences need to fit the action Explanations, consistency Modeling of parents and peers influential |
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appropriate expectations for school-age children
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Play by the rules
Respectful of others Learn from previous experiences Environmental influences greater Grounding and withholding privileges appropriate |
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Time-out
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Must occur immediately after behavior
Remove child from situation Placed in neutral, boring, safe, non-frightening place Child must be ignored during time-out and gain control 1 minute per year of age or until they gain control. Return to positive activity Most effective 18 months to 5-6 years |
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Ages and Stages Questionnaire (ASQ)
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4 mos through 6 yrs.
Totals compared to single cutoff--> delay or not High risk ( biologic or environmental) 4-6th grade reading level |
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ASQ-Social/Emotional (ASQ-SE)
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Behavioral/mental health problems
Needs interview |
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Parents’ Evaluations of Developmental Status (PEDS)
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Birth through 8 years; focuses on concerns, not milestones
10 questions--> risk levels--> refer, re-screen, education, reassure, monitor closely. As successful with higher and lower SES parents But 5th grade reading level |
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Pediatric Symptom Checklist
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4-16 yrs : Academic and psychosocial dysfunction
Identifies attentional, internalizing, externalizing or academic issues Parent and child forms Available …Bright Futures |
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Modified CHAT (M-CHAT)
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AUTISM SCREEN
Parent only questionnaire From 16-48 months ≥ 3 items refer ≥ 2 critical items refer AAP at 18 months Available … Bright Futures |
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Denver II
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1 mo to 6 years
Performance-based and parental report Range of success for each item Main criticism -- low sensitivity in predicting future development and school readiness. |
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Bayley Infant Neurodevelopmental Screener (BINS)
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3 mos to 24 mos
More limited age range Good for high risk populations |
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Bayley Scales of Infant Development
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1 month to 42 mos
mental Index Language, problem-solving, perceptual Psychomotor Index Fine and gross Frequently used research tool; good S & S Trained examiner |
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Pediatric Extended Examination at Three (PEET)
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Neurodevelopmental evaluation
Fine and gross motor, memory, language, perception sequencing, attention Extensive manual to use Helpful for “complicated” children. |
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What is global developmental delay?
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Subset of developmental delay
Significant delays ≥ 2 domains Motor Language Personal-social Adaptive Used with children < 5 years |
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what is mental retardation?
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Intellectual or cognitive disability
Lifelong Diagnosed when standardized measures of IQ valid (>5 years) American Association of Mental Retardation: Intelligence Adaptive behavior Manifests before 18 years |
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fragile X behavior manifestations
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Delayed motor/language
Tantrums Hyperactivity Gaze aversion, shyness Anxiety Hand biting/hand flapping Perseveration with words and activities |
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expressive language
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ability to produce meaningful words and sentences
cooing? babbling? speaking? |
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receptive language
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ability to understand what is being said
can child follow simple directions and commands? |
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phonetics
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position and movement of ips, tongue, vocal tracts and folds in producing speech
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symantecs
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aspects of meaning, as expressed in language or other systems of signs
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syntax
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rules that govern ssentence structure and grammar
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normal vocab at 2
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200-500 words
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phonolgical disorders
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follows a pattern
place/manner/voice fricatives into stops |
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articulation disorders
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no pattern
can't say "r" etc |
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dysfluency
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stuttering at 3+ years
caught up on start syllables |
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expressive language disorders
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less than 100 words at age 5
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who's at risk for speech and language delays?
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autism, cleft lip/palate, hx hearing loss, DS, CP
hx of ear infection positive fam hx, males, perinatal risk factors |
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who should have a hearing test?
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speech-language delay, hx of OM, risk factors for hearing loss (JCIH), fam hx of hearing loss, prematurity, trauma, parental concern
JCIH NICU admit over 5 days, ECMO, assisted ventilation, ototoxic drugs, loop diuretics, hyperbilirubinemia with exchange, in utero infection, craniofacial anomalies, head trauma, chemo |
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usher syndrome
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risk of progressive hearing loss
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when to test hearing in school age children?
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on first entry into school
every year from K-3 7th grade 11th grade entry into special ed grade repetition entering new school system w/ no record of testing test at 20-50 dB from 500-4000 Hz |
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developmental impact of hearing loss on: language
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incidental learning
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developmental impact of hearing loss on: cognition
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verbal v. performance measures
less cognitive flexibility lower levels of language skills |
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developmental impact of hearing loss on: academic achievment
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reading levels poorer than math levels
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developmental impact of hearing loss on: social emotional skills
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opportunities for interaction
social exchanges are language mediated less mature, impulsive, aggressive behavior |
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types of audiometric testing
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behavioral
immitance otoacoustic emission testing brainstem evoked response test |
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methods of behavioral hearing testing
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standard hand-raising technique
conditioned play audiometry visual reinforcement audiometry |
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conductive hearing loss
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BC symbols withing normal while AC shows some degree of hearing loss
at least a difference of 10 dB usually due to fluid or impacted cerumen |
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sensorineural hearing loss
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AC and BC threshholds match within 10dB of one another
permanent-- meningitis, ototoxic drugs, premature, hyperbilirubinemia |
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mixed hearing loss
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both AC and BC threshholds show a loss with BC better than AC
difference >10dB unusual in children |
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Speech Awareness Threshhold
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softest level of speech a patient can DETECT 50% of time
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Speech Reception Threshhold
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softest level of speech a patient can IDENTIFY 50% of the time
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PB%
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speech recognition
accuracy with which a person can repeat single syllable words |
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tympanometry
|
test of middle ear function
records compliance of the TM as varying degrees of air pressure are introduced into the ear canal |
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otoacoustic emissions
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sounds produced either spontaneously or evoked by the cochlea, specifically the other hair cells
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speech and language: 6-8 months
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Vocalizations show increasing variety in pitch and tone
Imitation of specific speech sounds oArticulate single-sound units Vowels, consonants, blends [ah, ba, da, ga, ch] oGradually progress to double-consonant sounds Vocalize using 3+ syllables Respond to verbal cues Play at making noises when alone Developmental Milestones: oCoos and gurgles with inflection oResponds to simple phrases oTurns to localize sound in any plane oResponds to own name |
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speech and language milestones:18-25 months
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Developmental Milestones
oPoints to body parts when asked oHas expressive vocab of 10-50 words o50% of speech intelligible to strangers |
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speech and language milestones: 12-18 months
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Developmental Milestones
oPoints to unexpected sound or familiar objects when asked oFollows simple direction without cues oImitates some sounds, first words by 12 to 15 months old |
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speech and language milestones: Birth to 1 month
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Able to give clear signals of disress
oCrying, arching, gagging Able to habituate to sound and light oSelf-calming behaviors Sucking, moving hand to mough, grasping clothing |
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speech and language milestones:
1-3 months |
By talking to infant during caregiving activities, parents encourage early language development
Start to make cooing and babbling sounds Developmental milestones o Startles to loud noise o Awakens to sounds o Blinks or widens eyes to noises |
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speech and language milestones: 4-5 months
|
Babbling, using vowel sounds, cooing and laughing
Experiment with variations in tone and pitch o Low-pitched chuckles o Deeper laughs Begin to laugh out loud Responses to sounds become more localized o Search for sound or bell Developmental milestones o Quiets to parent’s voice o Stops activity to listen to new sound o Looks for source of sound o Reciprocates vocally and initiates sounds |
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speech and language milestones: 9-12 months
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Receptive language skills improve
Participate in games o Pat-a-cake, peek-a-bo Momentarily stop activity when hear “no” o Do not truly understand what “no” means Enjoy songs and rhymes o May participate in “singing” along Expressive language has expanded to total of 3 or 4 words Can name a picture in a book, visually look for an object when named, follow simple one-step requests |
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environmental factors leading to obesity/lacj of exercise
|
built environment
community standards |
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environmental factors leading to endocrine disorders
|
percholate, DDT, DDE
reporductive problems due to endocrine-disrupting chemicals |
|
|
environmental factors leading to cancer
|
pesticides, radon, solvents, synthetic chemicals, ETS, UV light
cancer risk unknwon due to long latency |
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|
environmental toxins
|
air quality, water quality, food quality and safety
|
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|
ozone
|
respiratory tract irritant
EPA standard is <0.075 but health risks may be lower increased ozone assoc with increased asthma ED visits |
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|
particulate matter
|
solid or liquid particples suspnded in air
two sizes small particles reach lower airways increased levels assoc with increased mortalilty, asthma, and bronchitis |
|
|
sulfur dioxide
|
formed from burning coal and oil and industrial processes
increased levels assoc with increased respiratory and CV disease |
|
|
nitrous dioxide
|
major component of acid rain and increased ozone and smog
increased levels assoc with increased resp illness and allergic response |
|
|
carbon monoxide
|
colorless, odorless gas
95% from car emmissions displaces oxygen in blood |
|
|
air pollution and infant mortality
|
increased deaths with increased particulate matter and carbon dioxide in air prior to death
increased risk of SIDS |
|
|
AQI
|
air quality index
orange-- 101-150 (unsafe for sensitive individuals) red-- 151-199 (unsafe for all) |
|
|
minimal erythemal dose
|
depends on skin type and thickness, amount of melanin ability to produce melanin after exposure, intensity of radiation
|
|
|
basal cell carcinoma and squamous cell carcinoma
|
most common malignancies in adults
usually not fatal unless untreated or immunocompromised related to cumulative sun exposure |
|
|
melanoma
|
most common fatal skin cancer
occurs in teens and young adults metastic melanoma has a grave prognosis early detection is important children do get melanoma!! A-asymmetry B-border C-color D-diameter E-evolving |
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|
UV index
|
0-2 minimal
10+ very high |
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|
SPF
|
sun protection factor
ratio of time to sunburn with suncreen as compared to time to sunburn without sunscreen SPF15 allows one to stay out 15x longer |
|
|
indoor air pollutants assoc with asthma
|
ETS, dust mites, cockroaches, animal allergens, mold and mildew, nitrogen dioxide
|
|
|
ETS and kids
|
environmental tobacco smoke
increased SIDS, acute resp. infec, ear prolbems, more severe asthma, greater risks with general anaesthesia, injury from fire, become smokers themselves |
|
|
interventions for ETS
|
advise parents to quit
|
|
|
cleaning mold and mildew
|
area larger than 3x3 should be professionally cleaned
smaller areas should be cleaned with 1:10 chlorine solution |
|
|
NO2
|
byprduct of fuel burning appliances
odorless gas that irritates eyes, nose, throat, lungs and causes SOB long term exposure can lead to chronic bronchitis outdoor NO2 precursor to groundlevel production of ozone |
|
|
sx of CO poison
|
headache, NV, dizziness, sore throat, confusion
more common in winter months |
