12 Month Well Child Care



12 Month Well Child Care

AAP Board Content Specifications:

• Evaluate the motor developmental progress/status of an infant at 12 months of age, including recognition of abnormalities

• Evaluate the cognitive and behavioral developmental progress/status of an infant at 12 months of age

• Vaccinations:

o Know the indications, contraindications, limitations, and schedule for MMR & Varicella, live & inactivated influenza vaccinations

o Plan appropriate administration of MMR during outbreak

o Understand the effects of immunity if MMR is administered before 12 months

o Advise pregnant women regarding receipt of MMR vaccine

o Know indications & schedule for Hep A vaccine

o Understand the changing antigen composition of influenza vaccination & importance of administration to children with chronic illnesses

AAP priorities to assess for this visit:

• Family support

• Establishing routines

• Feeding & appetite changes

• Establishing a dental home

• Safety

Questions:

1) What are some questions to ask the parents at this visit? What interactions should you observe?

2) What are some developmental milestones a 1 year old should have achieved?

3) What is an appropriate diet? What further recommendations should you give at this appointment?

4) What parts of the physical exam are important? Screening tests that should be done at this visit?

5) What oral health topics should be addressed at this visit?

6) What safety topics should be addressed at this visit?

7) What anticipatory guidance is important at this age?

1) Family Functioning:

Parental questions:

• How are the family and the baby?

• Any changes since our last visit?

• Where are you living? Does anyone else care for your child other than you?

• What major changes/stresses have occurred in your family since your last visit?

Parent-Child interaction observations:

• How does the parent interact with the toddler (anxiously, calmly, inattentively)?

• Do parents stimulate the baby with language and play?

• Is baby free to safely explore environment with watchful parents and check back with the parents both visually and physically?

• When the physician gives the child a book, does the child take the book to share with parents?

• How does the parent react when the doctor praises the child? How does the parent react to being praised?

• Does the parent seem positive when speaking about and directly to the child?

2) Developmental Milestones:

• Social-Emotional: plays interactive games, imitates activities, hands you a book when he wants to hear a story, waves “bye-bye”, shows distress when separated from parent

• Communicative: points to desired objects, imitates vocalizations and sounds, speaks 1-2 words, mama & dada specifically, jabbers with inflections of normal speech

• Cognitive: follows simple commands (please give me the block), looks for block if dropped or hidden, can point to known persons when requested (Where is ____?)

• Physical Development: bangs 2 blocks together & may start to stack 2, stands alone, may start to take a few steps alone, has fine pincer grasp

3) Diet:

• Toddlers eat 3 meals and 2-3 snacks a day.

• Introduce cow milk now- Whole milk vs 2%/1%

• Offer liquids in a sippy cup and a spoon for eating.

• Toddlers tend to graze & their appetites vary.

• Offer nutritious foods consistently and their hunger will regulate to ensure sufficient amount of intake over time.

|Growth & Caloric Requirements |

| | | | | | |

|Age |Daily weight |Monthly weight |Monthly |Monthly |Recommended |

|  |gain |gain |Lt |HC |Kcal/kg/day |

|  |g/day |lb/month |cm/month |(cm/mo) |Kcal/kg/day |

|0-3 months |25-35 |2 lb |2.6-3.5 |2 |115 |

|3-6 months |15-21 |1.25 lb |1.6-2.5 |1 |110 |

|6-12 months |10-13 |1 lb |1.2-1.7 |0.5 |100 |

|1-3 yrs |4-10 |13 oz |0.7-1.1 |0.27-0.15 |100 |

|4-6 yrs |5-8 |8 oz |0.5-0.8 | | |

|7-10 yrs |5-12 |6 oz |5-6 cm/yr | | |

|11-18 yrs |varies |  |M: 1.5-6cm/6 mo |  |  |

|  |  |  |F: 1.5-5cm/6 mo |  |  |

|Catch Up |Infant: 60-90 | | | | |

|(FTT) |Child: 30 | | | | |

4) Physical Exam: A complete exam should be done, but here are some important components for this age

• Plot Wt, Ht. and HC; weight for length

• Eyes: red reflex, corneal light reflex, watch for eso/exotropia, cover/uncover test

• Mouth: examine teeth for demineralization (white spots), caries, plaque and staining

• GU: male (testes fully descended); females (labial adhesions)

• Neuro: check tone, strength, symmetry of movements, observe gait

Screening Tests:

• Hbg or Hct to screen for anemia

• Lead to screen for lead poisoning

• Selective screening: blood pressure, vision, hearing, TB

Vaccinations:

• Typically given MMR, Varicella, Hep A +/- Flu (in season) in our clinics, may vary in private practices

5) Oral health topics:

• The American Academy of Pediatric Dentistry, American Dental Association, and the American Association of Public Health Denistry recommend that infants be scheduled for an initial oral exam within 6 months of the eruption of the first primary tooth but no later than 12 months (see attached Oral health Guidelines 2008)

• The AAP recommends that every child have a dental home established by 12-18 months if they have low caries risk, but those with moderate-high risk should have a dental home established by 6-12 months.

• Clean teeth twice daily with water and a soft cloth or toothbrush.

• If he/she is still using a bottle, offer only water in the bottle.

6) Safety Topics:

• Avoid small, hard foods like peanuts or popcorn, on which your child can choke, and cut any firm, round food (e.g., hot dogs, raw carrots, or grapes) into thin slices.

• Childproof home: secure furniture so that child can’t pull them over; cover outlets, gates on stairs; keep sharp objects out of child’s reach; no dangling electrical, telephone, blind, or drapery cords.

• Make sure televisions, furniture, and other heavy items are secure so they can’t pull them down on themselves.

• Lock away medications & all cleaning, automotive, laundry, and lawn products.

• Keep poisons, household cleaners, chemicals, and medicines locked up. The number for Poison Control is 1-800-222-1222

• Drowning Prevention: “touch supervision” whenever young children are in or around water. Do not let siblings supervise toddlers in water. Empty buckets, tubs, or small pools immediately after use.

• Some children climb out of the crib at this age. Be sure mattress is on lowest rung.

• No guns in the home. If necessary should be stored unloaded & locked with ammunition locked separately from gun.

7) Anticipatory Guidance:

• Model good behavior. Babies learn more by example than by words, yelling, or spanking

• Use descriptions of the desired behavior (e.g., “Please sit” rather than “Don’t Stand”)

• Redirecting and distracting the toddler is an excellent way to reduce unwanted behaviors. For hitting, biting, kicking a brief 1 minute “time out” is appropriate. Remember all caregivers need to be consistent with discipline.

• Share your views about your child’s diet, discipline, and safety standards with all caregivers. (babysitters, grandparents, ect)

• Establish a nightly bedtime routine that begins with quiet time & ends with child soothing themselves in their crib.

• Toddlers should continue to have 1 nap during the day.

• Toddler should stay rear-facing car safety seat (likely convertible seat) until 2 years. The back seat in is the safest place for children to ride & parents should review their car manufacturer details about the possible backseat locations for the car seat.

References:

1. American Academy of Pediatrics, Bright Futures 3rd edition. 2008: 385-394.

2. Behrman, RE et al. Nelson Textbook of Pediatrics 16th edition. Philadelphia: WB Saunders Company, 2000.

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