Preventive health checks for toddlers

This Update is by Karen Booth, RN, Emerg Nursing Cert, Dip App ScN, BHSc, registered nurse/nurse manager at Leichhardt General Practice, Sydney, vice-president of the Australian Practice Nurses Association and registered immunisation provider. The author has no disclosures. Any reference to products throughout this review does not constitute endorsement.

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Introduction 

THE early years of life are not only an important time of physical growth and brain development but also an important time for learning healthy behaviours, and for developing skills that will build a healthy lifestyle into adulthood. 

The RACGP Red Book recommends child health surveillance be conducted at two, three and four years of age. This should include surveillance of growth, hearing, vision and language development and anticipate emerging behavioural and emotional problems.1

By implementing health screening programs in pre-school children it is hoped health issues such as delayed development, illness and lifestyle risk factors can be detected early before they cause significant problems. 

While the four-year-old check is comprehensive, it can also be time-consuming in a busy general practice. It can be conducted by a practice nurse or a GP, and detailed information appears at www.health.gov.au/internet/main/publishing.nsf/Content/Healthy_Kids_Check.

Before you begin 

It is important to note that while the Healthy Kids Check is a health assessment often carried out by practice nurses, many components of this check are screening tools and not considered diagnostic tests. Problems identified during the check will be referred for formal investigation by a specialist health provider in the identified area, e.g. an orthoptist or audiologist. 

Any preventive health service requires a holistic approach. The following points should be discussed within the practice:

• The appointment should be scheduled with adequate time to allow for assessment and documentation, 30 minutes being the minimum, and 45 minutes if the child is to be immunised.

• A normal health assessment does not require follow-up with the GP. 

• Any problems identified during the check will require a separate appointment with the GP.

• For those practices without an accredited nurse immuniser, the GP should factor in time during the health check to approve the vaccinations and prevent delays.

• Parents need to be reminded to complete the Parents’ Evaluation of Developmental Status (PEDS) tool in the child’s personal health record before the appointment. This should be included in the initial contact call or invitation letter, and the clerical staff can remind parents when booking appointments.

• Appointments should be clustered into a clinic format, as it makes for a more efficient flow and use of resources.

A child may be quite apprehensive if they are aware that they will be “getting a needle”. In practice, it is sometimes better to immunise the child at a different time. 

The Federal Health Department has templates for the Healthy Kids Check. To streamline the documentation, these templates can be downloaded into clinical software and set up to auto-fill much of the clinical information and measurements collected. It is possible to set up the Healthy Kids Check forms so that the assessor can tick normal responses/findings items. Then free text is only required for abnormal findings. This saves a significant amount of time during the assessment. A signed printout of the form may then be given to the parent.

The Assessment: 

Engage and Make it Fun

An essential part of the assessment is taking note of the child’s past medical history and presentations and updating the records where needed. It is also essential to document any allergies or to record “nil known”. 

Additionally, it is important to take a family history of hearing, eye and developmental problems as well as other relevant family health issues, e.g. asthma, and to ask the parents if they have any concerns about any of these aspects of their child’s health.

Ears 

The prevalence of permanent hearing impairment in children is relatively low – from 1% in three-year-olds to 2% in children aged 9-16 years. In addition, at any given time, 5%-7% of young children have a temporary 25 dB hearing loss associated with otitis media with effusion.2

Is there a family history of childhood hearing problems? Has the child had a history of recurrent ear infections? During the hearing check, you can whisper a secret to the child and get them to repeat it to the parents. The whisper test has shown to have a sensitivity ranging from 80%-96%, with specificity ranging from 90-98 per cent.2

On inspection, eardrums should be translucent pale grey. Many children will have ear wax obscuring their canals and this is normal. The most important issues in the hearing check are parental concern or recurrent ear infections and referral for formal testing as appropriate. 

Eyes 

Children’s eyes continue to develop until approximately eight years of age.3 According to the Australian Institute of Health and Welfare (2008), the prevalence of eye disorders among children in Australia is not known with certainty. This is mainly because many eye disorders, mostly refractive errors, go undiagnosed.4

Long or short-sightedness was the most commonly reported problem, with one in 20 children wearing glasses to correct their vision. Approximately 1% of children were affected by astigmatism – where light rays cannot be focused clearly on a point on the retina, leading to blurred vision.4

Data relating to eye health among Indigenous children is relatively limited. A study of Indigenous children in Western Australia in 2001-02 found about 8% of Indigenous children aged 4–17 years had abnormal vision in both eyes, and nearly 5% were prescribed glasses or contact lenses.5

Previous research has found that Indigenous people generally have high levels of visual acuity and a low prevalence of refractive error, suggesting Aboriginal and Torres Strait Islander children have less myopia and astigmatism than non-Indigenous children.5When performing the eye screening test, check the point of light reflection is symmetrical in both eyes. When following the toy across the visual field, look for evidence of drift or flicking. 

Any abnormal response may indicate eye muscle weakness and the need for referral for more formal testing. 

BMI

Height and weight can be charted on the centile graph. BMI is used to estimate the total amount of body fat and gives a clearer picture of whether the individual is underweight, normal or overweight. It is calculated by dividing the weight in kilograms by your height in metres squared (m2).6,7

The healthy weight range for adults of a BMI of 20-25 is not a suitable measure for children. A child is at risk of being overweight if the BMI is above the 85th centile.

Teeth

Lift the Lip is a mandatory element of the Healthy Kids Check. There are many good resources, easily accessed online, to instruct health professionals in the process of this oral examination. 

It is the perfect time to discuss oral care for children, e.g. developing healthy oral hygiene habits, avoiding sugary drinks and juices, and quenching thirst with water. This is also a good time to suggest early preventive health visits to the dentist. 

Again it is also advisable to have details of local community dental programs for those children who already have tooth problems and where the cost of visiting the dentist privately may be a deterrent.

Toileting habits

Questioning toileting habits is more than just asking whether the child can manage on their own. Constipation is very common in children and may indicate an inadequate fluid or fibre intake.

Constipation can be compounded by lack of exercise or urge avoidance/delay. Children need to develop good bowel habits to avoid constipation and its associated problems, e.g. tummy pain or fissure caused by hard stools.

Bedwetting (nocturnal enuresis) is a common problem. About 5% of 10-year-olds, 1% of 15-year-olds and one-fifth of five year olds wet the bed.8 Mostly, at this age parents need reassurance their children will eventually grow out of this problem. In some children, the development of antidiuretic hormone is slower than in others. If the bedwetting is still occurring after age seven, the family can return to see their GP or nurse to discuss other options.8

Development

Fine and gross motor skills assessment can also be incorporated into play as well as parent questioning. Health advice can be given as you progress through the diet and healthy habit check list.

For the promotion of a healthy active lifestyle, it is recommended children participate in:

- At least 60 minutes (and up to several hours) of moderate to vigorous physical activity every day

- Activity can be achieved through active free play, structured programs or both

- No more than two hours per day of sedentary screen time. 

(Source: RACGP Guidelines for Preventive Activities in General Practice [The Red Book] 7th Edition, 2009)

Parents and health professionals need to remember that children develop and mature at different rates. Our key concern is that they are meeting their developmental milestones.

At four, children should be easily understood and using well-formed sentences. They will enjoy engaging with other children both in active outdoor pursuits as well as more creative ‘pretend’ games and role playing and listening to stories. It would be expected that four year olds feel sympathy for others and can share their toys and take turns, at least some of the time.9

On completion, the nurse will discuss the findings with the parents and make recommendations to the GP for further assessment of any identified problems. The parents are able to take away a printed copy of the assessment and the child is rewarded with the Get Set 4 Life – Habits for Healthy Kids booklet.

Conclusion

There have been some concerns expressed by health groups in relation to overlap of some of the health check programs. As members of the primary care health team, we need to be aware that not every preschooler will go to see their GP or practice nurse for immunisation or screening, nor return to their early childhood centre to complete all health checks.

Although there may be some overlap, it is more likely that these programs complement the services of the other and refer for flow-on services.

Equipment that makes examinations child’s play

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• Eye chart using shapes (Tip: make sure the child knows the name of the shape before reading the chart. I use a pirate patch as part of the game.)
• Small toy for child to follow/watch when checking eye movements
• Small torch
• Auroscope and paediatric ear speculums
• Gloves
• Variety of small beads in small container, pen for drawing.\

Source: The Get Set 4 Life – Habits for Healthy Kids booklet