Pediatric Primary Care Case Studies (24 page)

The military has an Operation Homefront program (accessed at
http://www.operationhomefront.net
) that is an excellent resource that provides emergency assistance and morale to troops, to the families they leave behind, and to wounded warriors when they return home. The Department of Defense has a Web site called Military Homefront dedicated to providing information to help troops and their families and service providers (
http://www.militaryhomefront.dod.mil
). Civilian healthcare providers may find this Web site beneficial when caring for military families.

When do you want to see this patient back again?

This patient should be scheduled to come back in a week to be rechecked. However, if Lauren develops any symptomatology (as identified in the educational plan), she will need to be seen earlier.

Key Points from the Case

1. Treatment of jaundice depends on the cause of the jaundice. In Lauren’s case, it was physiological jaundice. She needs to be kept hydrated and the jaundice should resolve in 10–14 days.

2. Breastfeeding every 2 to 3 hours, nursing 8 to 12 times in a 24-hour period, is expected during the first few days of life. By 1 week of age, the newborn should be breastfeeding every 2 to 3 hours with longer stretches up to 4 hours for sleeping.

3. The role of the provider is to help the new family deal with specific issues, health issues, and the needs of the mother and baby. It is a supportive role as the family makes adjustments to the new family member. Education and anticipatory guidance can help alleviate unnecessary anxiety.

4. Military families have special needs as parents that need to be addressed.

REFERENCES

American Academy of Pediatrics, Committee on Fetus and Newborn. (2004). Hospital stay for healthy term newborns.
Pediatrics, 113
, 1434–1436.

Budzik, C. (2008). Providing well child care for military families: What every provider needs to consider.
Pediatric Annals, 37
(3), 185–188.

De Almeida, M. F. B., & Draque, C. M. (2007). Neonatal jaundice and breastfeeding.
Nurse Research, 8
(7), 282–288.

Gibbs, D. A., Martine, S. L., Kupper, L. L., & Johnson, R. E. (2007). Child maltreatment in enlisted soldiers’ families during combat-related deployment.
Journal of the American Medical Association, 298
, 528–535.

Giles, S. (2005). Army dependents: Childhood illness and health provision.
Community Practitioner, 78
(6), 213–217.

Hagan, J. E., Shaw, J. S., & Duncan, P. (Eds.). (2008).
Bright futures guidelines for health supervision of infants, children, and adolescents
(3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Johnson, L. H., Bhutani, V. K., & Brown, A. K. (2002). System-based approach to management of neonatal jaundice and prevention of kernicterus.
Journal of Pediatrics, 40
(4), 396–403.

Lamberg, L. (2004). When military parents are sent to war, children left behind need ample support.
Journal of the American Medical Association, 292
(13), 1541–1542.

Chapter 7

The Overweight Preschooler

Margaret A. Brady

Childhood overweight is an increasing health problem that the primary healthcare provider (PCP) often faces on a daily basis when seeing pediatric patients. Rarely do parents of young children bring their child to the PCP for either sick or well child visits with expressed concerns of overweight. Typically, parents think in terms of “baby fat” that will magically disappear as the child grows or believe that comorbidities linked to obesity are issues seen only during adulthood. Because childhood overweight often becomes a chronic problem, the PCP must be vigilant in identifying risk factors and in assessing weight, nutrition, and physical activity issues when caring for children. The PCP must also remember that nutrition and weight are likely culturally bound. Therefore, a family-centered approach is needed because the child typically is not the only obese member of the family unit.

Educational Objectives

1.   Describe how genetic inheritance and environmental factors impact the development of obesity in young children.

2.   Explain the diagnostic criteria used to determine whether a child is at risk for overweight or obesity.

3.   Describe the common clinical manifestations and comorbidities associated with pediatric obesity.

4.   Apply physical activity and nutrition management guidelines for prevention of overweight and obesity to a toddler who is at the 85th percentile for BMI.

5.   Integrate knowledge of culture, development, nutrition, physical activity, and behavioral approaches to develop a treatment plan for the toddler who is obese.

   Case Presentation and Discussion

Maria Smith is a 3-year-old girl who is brought in by her mother, Margarita Smith, for her 3-year-old health supervision examination. Mrs. Smith says that the family just moved from out of state and that Maria and her younger 22-month-old brother, Bobby, are now going to be receiving care at your clinic. Mrs. Smith says that Maria has been a healthy child and she has no real concerns at this time except that Maria needs to see a dentist
because she has lots of cavities. Mrs. Smith pauses and then says, “Maria’s preschool teacher says Maria needs to go on a diet because she is too fat.” You acknowledge that it is important for Maria to see a dentist and that her growth and development are important issues that you will be discussing with Mrs. Smith as part of this health supervision visit.

The Health Supervision Visit and Areas of Concern Identified by the Mother

The Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
(Hagan, Shaw, & Duncan, 2008) outlines 10 themes that should be promoted when children are seen for health supervision visits: the promotion of family support, child development, mental health, healthy weight, healthy nutrition, physical activity, oral health, healthy sexual development and sexuality, safety and injury prevention, and community relationships and resources.

Mrs. Smith has already identified issues related to oral health and healthy weight. You decide that you need some introductory family background and then will investigate these oral health and healthy weight issues next because they are the concerns she has listed as her priority items.

What questions should you ask Mrs. Smith about family support and mental health issues?

You begin by asking general questions about the family and learn the following. Mrs. Smith is married to Maria’s father, who was recently discharged from the Army and now works as an auto mechanic. She proudly tells you that they bought their first home and are happy to have two healthy children, Maria and her 22-month-old brother, Bobby. The maternal grandmother, grandfather, and 18-year-old uncle live around the corner from them. The grandparents watch the children 2 days a week while Mrs. Smith works at a fast food restaurant during the day. Money is tight but they are doing OK and are happy to now have health insurance through Mr. Smith’s job. Mrs. Smith smiles and tells you that her husband is very loving with the children and loves to read to them before bedtime. The children and Mr. Smith like to go to the local park on the weekends so Maria and Bobby can play on the swings with the other neighborhood children. Mrs. Smith is Hispanic and Mr. Smith is African American. Mrs. Smith said that she and her husband are happy in their marriage. While they were dating, it was a tense situation for both families at first because of their different ethnicities, but their respective families now like each other.

During the visit, you note that Mrs. Smith communicates in a loving manner with the children and gives them appropriate choices. When either one of them misbehaves (e.g., when Maria reached for a tongue blade), her response was appropriate.

Developmental Surveillance and Promotion of Safety and Injury Prevention

Your clinic routinely uses a developmental screening checklist for all health supervision examinations. The list was developed from
Bright Futures
materials.

Maria does well in all areas (social-emotional, communicative, cognitive, and physical development), and Mrs. Smith is pleased. She reports that Maria is toilet trained for bladder and bowel during the day and wet her bed only once this past month. Maria has been attending Head Start for the past 6 weeks and “is doing well” socializing with the other children.

After asking Mrs. Smith questions about car safety seats, pedestrian safety, fall risks, and guns, you are comfortable that both Maria and her brother are well supervised and the appropriate safety precautions have been implemented to prevent unintentional injuries in the home and car environment.

Oral Health

Maria has not yet seen a dentist despite obvious caries in her frontal incisors. Mrs. Smith says that she was told by her last primary care provider that the cavities were from drinking too many bottles of milk. She says, “I was so tired with two babies that I let Maria have a bottle of milk to carry around the house. I feel badly now because that is why she has all those cavities. I know that I need to take her to the dentist.” Upon further questioning, you are told that Mrs. Smith took the bottle away from Maria at 22 months of age and that she often had 50 ounces of whole milk a day when she was a toddler. She has not had a bottle for the past 10 months and drinks 24 ounces of whole milk a day from a cup and only with her meals and snacks. Mrs. Smith brushes Maria’s teeth with a soft toothbrush and toothpaste twice a day, “but it is a struggle.” Maria drinks tap water daily; their water has the recommended amount of fluoride.

Healthful Nutrition, Physical Activity, and Healthy Weight

Culture and food are often interconnected, so you start off by asking questions about Maria’s typical eating pattern—number of meals, snacks, portion sizes, and food preferences.

You are told that Maria eats three meals and two snacks daily. Maria likes cheese but isn’t good about eating vegetables. She also likes apples and strawberries. She prefers the “kids’ meals” from the fast food restaurant that mom works in and eats them four times a week. The Smiths enjoy a family meal on Saturdays and Sundays at either the maternal or paternal grandparents’ home, having either Mexican food or “soul” food depending on the relative they are visiting. Maria’s favorite vegetable is a “french fry”; she has sodas about three times a week as a treat and has about 12 ounces of juice a day. The grandparents like to give Maria and Bobby candy treats on the weekends, but Mrs. Smith doesn’t give them candy otherwise.

You ask about the physical activities Maria likes to do. Mrs. Smith says, “Maria loves to draw her pictures,” and she prefers interacting with other children by sitting down as she “isn’t a runner.” You also ask Maria what she likes to do best with the other children at preschool or home. She says, “I like to color and play with my dolls.” You ask Maria how fast she can run, what her favorite games are, and whether she likes to play inside or outside. She replies, “I can’t run as fast as the other kids. I like to stay inside with teacher and watch videos. I like
The Little Mermaid.”
When asked how long Maria watches videos, TV, or participates in other screen time activities on a daily basis, Mrs. Smith says, “about 3 hours, but more like 5 hours when grandma is babysitting.”