You are on page 1of 18

!

!
!
!

Case!3:!3(year(old!well(child!check!(!Benjamin!
David Kwee, M.D. Morehouse School of Medicine!
Health maintenance visit of a preschooler. Models how to conduct a preschoolers visit and counsel parents
about health promotion, nutrition, dental health, and behavior issues. The differential diagnosis and treatment of
atopic dermatitis are also covered.
Final Diagnoses: Iron deficiency, dental caries, eczema

Learning!objectives!
1. Describe the key components of a toddler well-child visit, including:
The importance of identifying parent concerns in order to set priorities for the visit effectively.
The role of the physician in guiding parenting skills through affirming and validating parent's efforts and
recommending and facilitating modifications in parenting and behavior.
Nutritional assessment and recommendations for diet and feeding behaviors.
Assessment of dental health and common factors leading to childhood caries.
Methods for performing developmental assessment screening tests and developmental surveillance.
Methods for performing a physical examination tailored to the age and mood of the child.
Topics for anticipatory guidance, such as safety.
2. List key developmental milestones for children between the ages of 3 and 5 years old.
3. Identify eczema and discuss first-line therapy.
4. Discuss the common causes and work-up of anemia in an otherwise healthy
child, as well as first-line therapy of iron-deficiency anemia.

Important Review Topics for a Three-year-old's Health Maintenance Visit!!


Social!

The social environment plays a major part in how children develop.

It is necessary to understand the family context before giving advice.


To enter this arena, ask about changes and family stressors in a non-threatening way.

Nutrition
Pre-schoolers can suffer from poor nutrition. Inadequate fruit, vegetable, and iron intake is quite common.
Calcium, and vitamin D deficiencies also are common.
Children should receive vitamin D supplementation as it is very difficult to attain the recommended daily
allowance through nutritional sources or from sun exposure.
Exercise
According to the American Academy of Pediatrics (AAP) guideline "Active Healthy Living: Prevention of
Childhood Obesity through Increased Physical Activity": "Toddlers should be allowed to develop enjoyment of
outdoor physical activity and unstructured exploration under the supervision of a responsible adult caregiver.
Such activities include walking in the neighborhood, unorganized free play outdoors, and walking through a
park or zoo."
Having quality play environments is optimal at this age.
Numerous studies have demonstrated a positive effect of physical activity on prevention of obesity.
Toilet Training
Toddlers at age 3 may not have achieved full toilet "independence"--especially toddlers with intense, willful
temperaments.
Requiring assistance toileting is not a clear sign of developmental delay at this age, but may preclude attendance
at child care or preschool.
Dental
The American Association of Pediatric Dentists (AAPD) and the AAP both state that all children should be seen
within 6 months of the first tooth eruption or by one year of age. Additionally, the AAP states that all children
should be screened by 6 months to see if they are at a higher risk of developing caries. Your community,
however, may not have a pediatric dentist. Also, many general dentists feel that the first visit should be at age 3
years. This is an unresolved issue between general and pediatric dentists.
See the AAPD policy statement about "early childhood caries," the diagnostic term that has replaced "baby
bottle tooth decay" or "milk bottle caries." Also see the AAPD policy statement about "the dental
home," advocated for children at higher risk of dental caries.
Safety
Car seats are often used inappropriately; toddlers are moved too soon to booster seats.
The National Transportation Safety Board advises that toddlers older than 24 months or who have outgrown the
weight and height limits on their car seats should be in a forward-facing car seat in the car's back seat.
Older children should stay in a booster seat until they reach a height of 4' 9" (142 cm).
In the toddler years, overall safety issues become increasingly important because of the increased independence,
inquisitiveness, and motor skills of preschoolers.
Injuries are a major morbidity in the preschool years.

Assessing!development!
Early!Childhood!Developmental!Assessment!!
Developmental assessment of most preschoolers is a process of both observing the child and taking a history from
the parent.

Developmental Surveillance

A form of developmental assessment--often in the form of play activities--incorporated into the exam.
Helps to determine areas of concern, prompting further evaluation, if necessary.
Performed at every encounter with the family.
The experienced pediatrician takes a "mental snapshot" of the child's development and compares it to
predicted norms.
Evidence continues to mount that developmental surveillance alone inadequately identifies developmental
delays.

One standard, recognized source for health maintenance information for children is Bright Futures from the
American Academy of Pediatrics. This excellent, comprehensive document provides evidence-based synthesis of the
best available information on what to expect at each age. Remember, the behaviors identified for each age in Bright
Futures are what MOST kids at that particular age will do; but these are simply descriptions of expected behaviors,
not a developmental screening test.!

Developmental!Assessment!!
Pediatricians do not, in general, perform definitive developmental assessments, but do perform screening tests to
determine which children must be fully assessed.
Less than 3 years: Children of this age with suspected developmental problems should be evaluated by one or more
of the following (the choice may be determined by which specialists are available in the community):!

Early Intervention (each state is mandated to provide developmental assessments and services for those
children at risk for or determined to have developmental delays)
A developmental-behavioral pediatrician
A child psychiatrist or child psychologist
Early childhood learning specialists.

Ages 3 to 5 years: If problems are detected early, services provided by the school system for 3- to 5-year-olds can
often help these children catch up to their peers.
Reference: Hagan JF, Shaw JS, Duncan P, Eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third
Edition, American Academy of Pediatrics. 2008

Developmental!Milestones!for!38,!48,!and!58year8olds!by!Domain
3-year-old

4-year-old

Socio-emotional

Communication

Dresses self
Feeds self

Speaks in 2- to
3-word
sentences
75%
understandable

Cognitive

Knows name
and use of "cup,
ball, spoon,
crayon"

Physical

Builds tower of
6-8 cubes
Throws a ball
overhand
Rides a tricycle
Copies a circle

!
!
!

Knows gender
and age
Friendly to
other children
Plays with
toys/engages in
fantasy play

States first and


last name
Sings a song
Most speech
clearly
understandable

Names colors
Aware of
gender
Plays board
games
Draws person
with 3 parts
Copies a cross

Hops on one
foot
Balances for 2
seconds
Pours, cuts, and
mashes own
food
Brushes teeth

5-year-old

Listens and attends


Can tell difference between real and
make-believe
Shows sympathy/concern for others

Articulates well
Tells a simple story using full
sentences
Uses appropriate tenses and
pronouns
Counts to 10
Follows simple directions

As children get ready for school, the


developmental milestones shift to more
cognitive processes. Asking the parents about
school performance is as important as the
following milestones:

Draws a person with > 6 body parts


Prints some letters and numbers
Copies squares and triangles

Balances on one foot


Hops and skips
Ties a knot
Has mature pencil grasp
Undresses/dresses with minimal
assistance

First!contact!
Question)
The first priority is to establish the relationships between you and Benjamin and his mother in order to have a
productive well-child visit. How would you proceed? (There is no single right answer.)
Multiple Choice Answer:
A: O Tell Benjamin, "I understand that you are scared. This is not going to hurt you, though, so you have nothing to
fear."
B: O Ask Benjamin, "Would you like to be on your mother's lap, so that you are more comfortable?"
C: O Give a toy to Benjamin. "Benjamin, why don't you relax and play for a minute, while I talk with your mother."
D: O Tell Benjamin's mother, "Sometimes even 3-year-olds have bad behavior at the doctor. We will do the best that
we can. Fortunately, most illness in 3 year olds is found not only on physical, but with symptoms."

Answer)Comment)
At 3 years of age, some children can be cooperative at the pediatrician's office, some are wary still, and some still
need a lot of parental reassurance.
Smiling and talking with Benjamin in a pleasant, reassuring, calm voice, smiling is an outstanding strategy, rather
than just talking and interacting with his mother. Giving the pre-schooler a fun activity to do while obtaining a
medical history is effective; just giving a couple of crayons and drawing on the table exam paper can engage the
child so that he is cooperative.
Many parents are embarrassed when their children act up at the office, but reassuring that it is normal childhood
behavior will allow the parent to relax more.

!
!

Benjamin's!rash!

Eczema (Atopic Dermatitis)


Benjamin has a typical eczema eruption with thickening of his skin and inflammation. Eczema has been called "the
itch that rashes," because there is a cycle of irritation leading to scratching, leading to the rash. Educate parents that
anything leading to itching (even a child's rubbing his face on Mom's sweater) can exacerbate eczema.
Eczema and Allergies
Although eczema often occurs without a history of allergies, such a history would support an atopic diathesis and
should prompt you to ask additional questions about allergic triggers and asthma symptoms. (Benjamin's mother
says that he does not have allergies and has never had any wheezing.)
Family History
While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear
environmental (allergic) triggers.
Treatment
The basic tenets of treatment are:

Protecting skin by lubricating extensively


Using anti-inflammatories in short bursts, and
Treating associated skin infections aggressively.

Pharmacological Treatment
Prescribe topical hydrocortisone, alternating a higher concentration for severe flares with a lower concentration for
minor bouts. Often over-the-counter hydrocortisone is inadequate.
Newer anti-inflammatory topicals, including the calcineurin inhibitors, have proven effective, although safety
concerns have not been fully resolved in this class of medications.
Remember that sometimes simply prescribing antihistamines can help with the itch:

The non-sedating antihistamines approved for children, loratidine (Claritin) and cetirizine (Zyrtec), may be
effective.
Traditional antihistamines (with sedative side effects) such as diphenhydramine (Benadryl) and
hydroxyzine (Atarax or Vistaril) are often used at bedtime to decrease itch.

In developing an effective treatment plan, it is important to understand what treatment has been used already.
(Benjamin's mother tells you she has applied hydrocortisone intermittently, saying she uses it only when the rash is
"really bad.")
Differential Diagnosis
Sometimes eczema may be confused with the other common inflammatory rashes:

Psoriasis: Although psoriasis can occasionally first look like eczema, it is rare in children this young.
When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis
is usually precipitated by a strep infection.
Seborrhea: While it is unusual to have a new case of seborrheic dermatitis at age 3, this should also be part
of the differential diagnosis, especially in early infancy (e.g., cradle cap).

Problems!with!current!diet!
Question)
Considering the information Benjamin's mother has just given you, what do you believe are the most important
nutritional issues for Benjamin?

!
Answer)Comment)
The most important nutritional issues for Benjamin are:
Inadequate Nutrition
From the history, Benjamin is likely to be lacking vegetable and fruit intake. One study of preschool-aged children 2
to 3 years old found that these children consumed, on average, about 80% of the recommended fruit servings/day,
but only 30% of the recommended vegetable servings/day. Iron intake in toddlers occurs predominantly from meat,
legumes, and iron fortified cereals, of which Benjamin eats little. Iron is of crucial importance to normal
development in this age group due to its role as a CNS co-catalyst.
Milk and Juice Intake
Recent studies suggest that 100% fruit juice intake and milk may be deficient in many preschoolers diets, with
substitution of fruit drinks or other high-fructose corn syrup-sweetened beverages. For young children already at risk
of overweight or obesity, excess intake of fruit juices, especially juice drinks with sweetened high-fructose corn
syrup, can add substantial calories to a child's diet and contribute to the development of early obesity. The AAP
recommends no more than 4-6 ounces of juice per day.
Early Childhood Caries
Bathing teeth throughout the day with milk or juice from a bottle can result in early dental caries. Early childhood
caries typically have a lag time before visible decay. Thus the patterns established when a child is 1 to 3 years old
may result in caries when the child is 3 to 5 years old. Although constant use is most damaging, even routine
bedtime use of the bottle can lead to cavities. It is recommended that parents discontinue the bottle by the time the
child is 12- to 15-month-olds. In older toddlers, it becomes more difficult if the bottle has become their transition
object or "lovey."
Control Battles About Food
Benjamin is a determined child, and his mother has set up a pattern of negative interaction about eating. Because she
has allowed Benjamin control over what he eats, Mom is unlikely to be able to promote healthy food habits. Food
rewards and punishment in preschoolers may promote obesity by interfering with children's ability to regulate their
own food intake.
References:
Fox MK, Condon E, Briefel RR, Reidy KC, Deming DM. Food consumption patterns of young preschoolers: are they starting off on the right
path? J Am Diet Assoc . 2010 Dec;110(12 Suppl):S52-9.
Baker RD, Greer FR; Committee on Nutrition. American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency
anemia in infants and young children (0-3 years of age). Pediatrics. 2010 Nov;126(5):1040-50. Epub 2010 Oct 5.
Faith MS, Dennison BA, Edmunds LS, Stratton HH. Fruit juice intake predicts increased adiposity gain in children from low-income families:
weight status-by-environment interaction. Pediatrics. 2006 Nov;118(5):2066-75.
Committee on Nutrition: The Use and Misuse of Fruit Juice in Pediatrics Pediatrics. 2001 107:1210-1213.
Baughcum, A.E. Maternal feeding practices and childhood obesity. Pediatrics and Adolescent Medicine 1998; 152 (10):1010-1014.

Elements!of!the!exam!
Physical Exam of the Toddler
General Tips
Listen with your stethoscope first in case he/she starts crying. I f the exam needs to be truncated due to the child's
behavior, then you should focus on:

Neurodevelopment
Monitoring previously recognized findings
New findings identified by parents, and
Physical problems common in preschoolers for which intervention may be helpful.

Exam Area

Possible Findings

HEENT

Mouth: Caries
Ears: Middle ear effusions that may persist after earlier URI and affect hearing.

Eyes

Strabismus (see below for how to examine)

An enlarged thyroid is rare in children.


Many children have "shotty" nodes (pea or marble-sized, nontender, easily mobile lymph
nodes that are not fixed to surrounding structures) in the anterior and occasionally
posterior cervical chain. These are normal in the cervical and inguinal chains in children
and may persist for years.

Most murmurs will be functional.


New murmurs of congenital heart disease are unlikely, but signs of atrial septal defect
sometimes are appreciated better in older children.

Yield likely to be low in a healthy child.


May hear subtle wheezing in a child with a history of allergies.

Palpation for organomegaly and masses is appropriate.


While the most common mass will be stool, children this age occasionally have an
enlarged kidney or, very rarely, an abdominal tumor such as Wilms' or neuroblastoma.

Neck

Cardiac

Lungs

Abdomen

Several gait variants occur at this age. The m ost common is in-toeing due to tibial torsion with or
without femoral anteversion:
Musculoskeletal

Most spontaneously resolve by age 8 years.


Often walking will strengthen anterior leg muscles and allow correction.
Persistence has been associated with joint problems later in life.

Careful history and examination for potentially treatable causes of intoeing is appropriate. (For
most cases, reassurance and follow-up is all that is necessary, but if intoeing does not

spontaneously resolve by 4 years of age, referral to an orthopedic surgeon is warranted.)


Link to images and an explanation of tibial torsion .

Genitals

Neurologic

Hernias are sometimes seen.


This segment of the exam also provides the opportunity to teach about who can
appropriately examine the child.
Some girls show nonspecific vulval erythema due to poor hygiene once they are toilet
trained and caring for themselves in the bathroom.
Assessment of overall muscle tone, strength, and coordination is appropriate.
In general, the neuro exam at this age is more focused on assessing a child's achievement
of overall neurodevelopmental status, including gross and fine motor, along with
language and social-skills milestones.

Reference: Broderick P. Pediatric vision screening for the family physician. AFP. Sept. 1,
1998. http://www.aafp.org/afp/980901ap/broderic.html Accessed August 17, 2011.

Examining for Strabismus


Two methods of assessing presence and degree of strabismus:

The Hirschberg light reflex


The cover/uncover test

Continuing!the!Exam)
Question)
Which of the following safety issues are important to discuss with the parents of a 3-year-old?

!
Answer)Comment)
Car accidents (C), swimming pools (D), falls (E), firearms (F), poisonings (G), and fires (H) are all important
causes of injury in a child of Benjamin's age and should be reviewed with parents.
The Injury Prevention Program (TIPP) was started in 1983 by the AAP to help pediatricians prevent injuries in their
patients. "TIPP is designed to provide a systematic method for pediatricians to counsel parents and children about
adopting behaviors to prevent injuries-behaviors that are effective and capable of being accomplished by most
families." The program includes an AAP policy statement, safety surveys for parents to complete, age-appropriate
safety information for parents, and a schedule of safety counseling for pediatricians.
At age 3, a child should be put in a front-facing car seat in the back seat (A). By definition, SIDS (B) affects
children under one year of age (infants).
To view the TIPP information that should be provided to Benjamin's mother, go to this link:
http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-2-to-4-Years.aspx

A!gun!in!the!house!
Question)
What advice would you give about guns in the home?

Non-evaluated freetext
Preferably, remove the gun from the home. Put a safety lock on the gun. Keep the gun in a locked cabinet. Keep the
ammunition separate and locked.

!
Answer)Comment)
Parents may have incorrect expectations of their school-aged child's ability to reason appropriately about guns. In a
study from 2003, the authors found that 52% of parents who owned guns thought that their children were "too
smart" or "knew better," even though only 40% had given specific instructions to their children regarding guns. In
this survey only 12% of parents who owned guns locked them.
Another study from 2001 found that, when given the opportunity, boys 8-12 would handle a gun (76%) and pull the
trigger (48%). Parents' opinions about whether or not their child would handle a gun were not predictive of which
boys would handle the gun.
Even when the child is as young as Benjamin, it is important to provide parents with these brief facts.
Fortunately, you had observed Dr. Harris counsel a parent in a similar situation earlier this week. You learn from
Mrs. Jones that, because she and Benjamin live alone, she purchased the gun recently for self-protection. While you
understand the feeling that Ms. Jones has about protecting her child, this is a significant safety concern. Parents who
possess guns for protection from crime are likely unwilling to place the gun in one locked cabinet and ammunition
in another. While this recommendation may be excellent for families with hunters, you advise her that while you
understand her concern, households with preschoolers in them are at increased risk for injuries from guns and she
must balance the need for self-protection with the risk of injury to her child. You tell her that the only foolproof way
to prevent accidental injury due to the gun is to remove the gun from the house and seek additional security such as
a home alarm or "burglar bars." Benjamin's mother tells you that she was in fact somewhat worried about bringing
the gun into the home and will think about your advice.
References:
Connor SM, Wesolowski KL. They're too smart for that: Predicting what children would do in the presence of guns. Pediatrics.
2003;111(2):E109-14.
Jackman GA et al. Seeing is believing: what do boys do when they find a real gun? Pediatrics. 2001;107(6):1247-50.

!
!

Immunizations!and!lab!tests!
Question)

Which evaluations are appropriate today? (Select all that apply.)


!
Multiple!Choice!Answer:!
A:!X!Fingerstick!hemoglobin/hematocrit!
B:!O!CBC!
C:!O!Lead!level!
D:!O!Radioallergosorbent!test!(RAST)!
!
Answer)Comment)
Due to Benjamin's history of poor diet, the most appropriate evaluation today is an evaluation for possible anemia
with a fingerstick hemoglobin/hematocrit (A).

Anemia Screening

Typically, screening for anemia is done at 12 months and again at preschool or kindergarten entry.
The initial 12-month window coincides with a period in development when diet, particularly iron sources,
is often in flux.
If there are risk factors for anemia, then testing may be done at any visit.
Results of a screening hemoglobin can be known immediately.
Spun hematocrit still relies on blood volume, and hydration status can falsely affect the result.

A CBC (B) is more test than you need now. It provides information about anemia, but is more costly and
inconvenient than a hemoglobin test. Plus, it takes longer to obtain the results, possibly delaying treatment.
Lead screening (C) was already done when Benjamin was younger, and the results were normal. He does not have
any risk factors for lead poisoning:

Unlike younger children, developmentally at age 3 Benjamin is no longer mouthing objects


He does not live in at-risk housing
Nor is he an immigrant -- significant because children born in certain countries outside the U.S. are at
increased risk for lead poisoning.

If he is anemic, you may need to reassess environmental exposures.


A radioallergosorbent test (RAST) (D) is a blood test used to determine to which allergens a person is sensitized.
Although this information might help his mother avoid exposure to allergens that trigger his eczema, RAST testing
is not indicated at this time. For some younger children, food allergy can contribute to eczema, but this is less
common by the preschool years. For most children a clear allergen is never found.

Causes!of!anemia!
Question)

Of the following causes of anemia, select the most likely causes in this child:
!
Multiple!Choice!Answer:!
A:!X!IronGdeficiency!anemia!
B:!O!Alpha!thalassemia!
C:!O!G6PD!deficiency!
D:!X!Lead!poisoning!
E:!O!Chronic!illness!
F:!O!Chronic!blood!loss!
G:!O!Hemolysis!
H:!O!Decreased!marrow!production!
I:!O!Folate!deficiency!
J:!O!B6!deficiency!
!
Answer)Comment)
Given Benjamin's poor nutritional intake, the most likely cause of anemia in this otherwise healthy child is iron
deficiency (A).

Iron-Deficiency Anemia
Epidemiology
Nationally among preschoolers deficient iron stores may occur in up to 35% of low-income children (versus only
7% in other preschoolers), with up to 10% having iron-deficiency anemia.
Association with Cognitive Difficulty
With respect to the association between iron deficiency anemia and cognitive difficulties, it is unclear whether
cognitive problems result from iron deficiency, anemia itself, or concurrent environmental factors in children at risk
for iron deficiency. Given iron's role as a co-catalyst in CNS processes, it is reasonable to be concerned about iron
deficiency being a potential cause of his anemia.
Causes

Lack of iron intake is the most likely acquired cause of iron-deficiency anemia.
In rare cases, iron stores are decreased from chronic GI blood loss (e.g., food allergies and gluten
enteropathy).

Lead poisoning (D) is also on the differential diagnosis, however, as Benjamin's hemoglobin was normal at 12
months: his anemia has to be acquired. Lead poisoning would be higher on the differential diagnosis if Benjamin
lived in pre-1970s housing, lived near a busy interstate, or was a recent immigrant.
Benjamin shows no symptoms of chronic or severe illnesses (E) that cause anemia -- such as collagen vascular
disease, malignancy, or other chronic illness. These are unusual acquired causes of anemia.
In this child of northern European descent, a hemoglobinopathy (e.g., alpha thalassemia (B), G6PD deficiency (C) or
sickle cell disease) would not be high on the differential. It does need to be considered in children of Mediterranean,
Asian or African descent. (And, of course, he would have been anemic at 12 months of age and his newborn
screening hemoglobin electrophoresis would also have been abnormal, with hemoglobin "Barts" present.)
Decreased marrow production (e.g., aplastic anemia) (H), hemolytic anemias (G) and vitamin deficiencies (e.g.,
folate and B6(J)) are rare in children and present with a more severe anemia (Hgb less than 9 g/dL (90 g/L)).
In patients like Benjamin whose anemia is mild, many providers will provide a trial of iron rather than do any
further workup at this point. If the hemoglobin recovers to the normal range after a trial period, that is sufficient
evidence of iron-deficiency anemia.
References:
Eden AN. Preventing iron deficiency in toddlers: A major public health problem. Contemporary Pediatrics. 2003;20(2):57-67.
Falk H. International environmental health for the pediatrician: Case study of lead poisoning. Pediatrics. 2003;112(1):259-264

!
!

Summarizing!and!working!to!change!food!behaviors!
Counseling Parents About Children's Eating Habits
You can make long-term differences in a child's health only by working as a team with the parent. In two-parent
families, or when extended families are also caring for the child, all members must be engaged and educated about
necessary changes.
Rather than focusing on the details of the child's diet, try to leverage a few key changes involving the eating
process. To change a child's nutrition patterns:

Provide!the!parent!with!straightforward,!simple!strategies!that!can!be!implemented!sequentially.!
Provide!support!and!reassurance!that!the!child's!reactions!will!subside!if!the!parent's!approach!
remains!consistent.!
Try!to!prepare!the!parent!for!handling!future!challenges.!

The child will benefit by having a loving, predictable environment with appropriate boundaries.
And, of course, always offer availability to assist the family in developing additional strategies if needed.

!
Question)
What practical steps would you take today in addition to oral iron treatment (given as 2-4 mg/kg/day of elemental
iron divided once or twice daily)?

Non-evaluated freetext
Among the things to prescribe for Benjamin's mother are to stop giving a bottle to him, limit his eating to mealtimes,
don't bargain with him, and gradually introduce new iron-rich foods.

!
Answer)Comment)
A seasoned pediatrician would prescribe four specific steps to interrupt Benjamin's current behavior around food:

Stop the bottle now. It is helpful to actually have Benjamin and his mother jointly discard the bottle in the
trash to show him it's gone for good. Usually children stop their requests for the bottle after a few days.
(You recall that Mrs. Jones has already been able to do this once.)
Limit Benjamin's eating to 3 meals and 2 snacks, stopping the food and drink grazing. If he is thirsty,
give him water, not juice. Limiting the amount of juice a toddler drinks may improve his nutrition in
several ways. For one, when he is drinking juice or milk, his appetite for solids is blunted. He needs
adequate solids for energy and vitamins.
No bargaining or cajoling. Benjamin is to eat at time-limited meals. He needs to have his hunger
ultimately drive his choices, and only healthy options should be provided. Dessert should never be held as
an incentive for "good" eating.
Gradually change his diet content by introducing new foods he is likely to try and slowly decrease the
quantity of old favorites.

References!
1.
2.

3.
4.

5.

6.
7.
8.
9.
10.
11.
12.
13.
14.

15.
16.
17.
18.

19.
20.
21.
22.

American Academy of Pediatrics. Family Pediatrics: Report of the Task Force on the Family. Pediatrics
2003;111(6):1541-1571S.
Baker RD, Greer FR;Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and
young children (0-3 years of age). Committee on Nutrition. American Academy of Pediatrics. Pediatrics.
2010 Nov;126(5):1040-50. Epub 2010 Oct 5.
Baughcum AE. Maternal Feeding Practices and Childhood Obesity. Pediatrics and Adolescent Medicine
1998;152(10):1010-1014.
Beltran-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, Griffin SO, Hyman J, Jaramillo F,
Kingman A, Nowjack-Raymer R, Selwitz RH, Wu T; Centers for Disease Control and Prevention (CDC).
Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis--United
States, 1988-1994 and 1999-2002. MMWR Surveill Summ. 2005 Aug 26;54(3):1-43.
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm
Bright Futures, American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care.
Available at
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf.
Last accessed August 18, 2010.
Broderick P. Pediatric Vision Screening for the Family Physician. American Family Physician. Sept. 1,
1998. http://www.aafp.org/afp/980901ap/broderic.html
CDC Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR
2001;50 (RR-14).
Committee on Nutrition. The Use and Misuse of Fruit Juice in Pediatrics. Pediatrics 2001 107: 1210-1213.
Connor SM, Wesolowski KL. They're too smart for that: Predicting what children would do in the presence
of guns. Pediatrics 2003; 111 (2):E109-14.
Dawson G. et al. Preschool Outcomes of Depressed Mothers: Role of Maternal Behavior, Contextual Risk,
and Children's Brain Activity. Child Development 2003; 74(4):1158-1175.
Dennison BA, Rockwell HL, Baker SL. Fruit and vegetable intake in young children. Journal of the
American College of Nutrition. Aug 1998; 17(4):371-8.
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, February 2002. Freely
available on the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s11c01.html
Eden AN. Preventing iron deficiency in toddlers: A major public health problem. Contemporary Pediatrics
2003; 20(2):57-67.
Faith MS, Dennison BA, Edmunds LS, Stratton HH. Fruit juice intake predicts increased adiposity gain in
children from low-income families: weight status-by-environment interaction. Pediatrics. 2006
Nov;118(5):2066-75.
Fox MK, Condon E, Briefel RR, Reidy KC, Deming DM Food consumption patterns of young
preschoolers: are they starting off on the the right path?. J Am Diet Assoc. 2010 Dec;110(12 Suppl):S52-9
Falk H. International environmental health for the pediatrician: Case study of lead poisoning. Pediatrics.
2003;112(1):259-264.
Fox MK, Condon E Breifel RR, Reidy KC, Deming DM. Food Consumption Patterns of Young
Preschoolers: Are They Starting Off on the Right Path? J Am Diet Assoc. 2010;110(12 suppl);S52-9.
Georgia Dept. of Community Health. Tuberculosis (TB) Risk Assesment.
http://health.state.ga.us/pdfs/tb/CH.Risk&Inst.09.Eng.pdf
Glaser DW. "Anemia in Case Based Pediatrics For Medical Students and Residents". Department of
Pediatrics, University of Hawaii John A. Burns School of Medicine, February 2002. Freely available on the
Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s11c01.html
Green M et al. (eds) National Center for Education in Maternal and Child Health. Georgetown University.
2002.
Hughston Sport Medicine Foundation site on In-Toeing in Children:
http://www.hughston.com/hha/a_12_3_2.htm
Jackman GA et al. Seeing is believing: what do boys do when they find a real gun? Pediatrics
2001;107(6):1247-50.
Lewis M. Child and Adolescent Psychiatry. Philadelphia: Williams and Wilkins, 1996:450.

23. Sass P, Hassan G. Lower Extremity Abnormalities in Children. American Family Physician 2003; 68
(3):461-468.
24. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US children, 19891991. Pediatrics. Oct 1998;102(4 Pt 1):913-23.
25. Wasserman RC. Screening for vision problems in pediatric practice. Pediatrics in Review. Jan
1992;13(1):4-5.
Other Sources:
1.
2.
3.
4.
5.

6.
7.
8.
9.
10.
11.
12.
13.
14.

American Academy of Pediatric Dentistry's policy on early childhood caries:


http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113
American Academy of Pediatrics TIPP safety screening
report: http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-2-to-4-Years.aspx
AAD Guidelines for Atopic Dermatitis
http://www.aad.org/research/_doc/ClinicalResearch_Atopic%20Dermatitis%20Part%20I.pdf
CDC information on 13-serotype pneumococcal conjugate vaccine:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5909a2.htm
Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures
Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory
Committee.
Hirschberg Light Reflex: http://eyeontechs.com/new/?p=218
Iron in Diet: http://www.nlm.nih.gov/medlineplus/ency/article/002422.htm
Reach Out and Read program: http://www.reachoutandread.org/
Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis:
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm
The development of drawing skills in children: Bright Futures, 2002. http://www.brightfutures.org
UpToDate, the online clinical information resource. Burton D. Rose, MD, and Joseph M. Rush, MD,
founders. 2004.
Victor Lowenfeld and Betty Edwards' Web site on the development of drawing in
children: http://www.learningdesign.com/Portfolio/DrawDev/kiddrawing.html
Preventing Early Childhood Caries: http://www.thecommunityguide.org/oral/caries.html
Abnormal Cover/Uncover Test Video - http://www.mrcophth.com/