Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 17

Seven- to Ten-Year Visit(School Age)

Elizabeth Godfrey Terry

Appendicitis, 541

Myopia, 367.1

 

Asthma, 493.9

Night terrors, 307.46

 

Attention deficit hyperactivity disorder, 314.01

Nightmares, 307.47

 

Osgood-Schlatter's disease, 732.4

Puberty, V21.1

 

Breast enlargement, 611.79

Ringworm, 110.9

 

Chickenpox, 052

Rubella, 056.9

 

Cystic fi brosis, 277

Scabies, 133

 

Emotional disturbances, 313.3

School phobia, 300.23

 

Encopresis, 787.6

Scoliosis, 737.3

 

Enuresis, 788.3

Separation anxiety, 309.21

 

Epiphyseal separations, 732.9

Sexual abuse, 995.83

 

Eruption of a tooth, 520.6

Sickle cell anemia, 282.6

 

Heart disease, 429.9

Sleep apnea, 780.57

 

Heart murmurs, 785.2

Sleep disturbances, 780.5

 

Impetigo, 684

Sleepwalking, 307.46

 

Learning disorders, 315.2

Substance abuse, 305.9

 

Legg-Perthes disease, 732.1

Urinary tract infections, 599

 

Measles, 055.9

Voice change, 784.49

 

Menstruation, 626.9

Wet dreams, 608.89

 

Mumps, 072.9

   

I. OVERALL IMPRESSION

A. Early school agers are in routine of being in school, learning; now gaining skills to get along with many different personalities.

II. NUTRITION

A. Caloric and nutrient needs.

1. Three full meals and 1-2 snacks a day.

2. Consumes 1600-2400 calories/day; needs vary depending upon amount of activity and development. Or: female 1200-1600 calories (4-8 years 1200 calories; 9-13 years 1600 calories); male 1400-1800 calories (4-8 years 1400 calories; 9-13 years 1800 calories). Calorie estimates based on a sedentary lifestyle. Increased physical activity will require additional calories: by 0 to 200 kcal/day if moderately physically active and by 200 to 400 kcal/day if very physically active.

3. Refer to My Plate for serving size, food group recommendations (see Appendix E).

4. Whole grains preferred over refined-grain products; at least half the grains should be whole grains.

5. Sweetened beverages and naturally sweet beverages, such as fruit juice, should be limited to 8 to 12 oz/day.

6. Need at least 800-1200 mg of calcium/day.

7. Introduce and offer fish regularly, especially oily fish such as salmon, broiled or baked, and sardines. Avoid fish high in mercury content. Remove skin from poultry prior to serving. Offer more meat alternatives, such as legumes (beans) or tofu.

8. Serve fresh, frozen, or canned vegetables and fruits at every meal.

B. Willing to try variety of foods from major food groups.

C. Appetite varies according to growth, activity.

D. May have big appetite during growth spurt and then cut back.

E. Good internal cues regarding appetite. Parents choose types of food and beverages served and child chooses how much to eat.

F. Beginning steps toward obesity may start if child is not allowed to listen to internal cues.

G. 19.6% of children ages 6-11 are obese. Excess caloric intake and physical inactivity strongly associated with obesity.

H. Consider daily children's multivitamin if child is not consuming enough servings to get essential nutrients.

III. ELIMINATION

A. Enuresis occurs in 10% of 7-year-olds and 5% of 10-year-olds.

1. Children with this condition should receive complete exam to rule out underlying conditions such as urinary tract infections.

2. Children with sleep apnea at greater risk for enuresis.

B. Encopresis affects 1.5% of young school children.

IV. SLEEP

A. Need 10-11 hours/night.

B. Encourage and emphasize need for regular and consistent sleep schedule and bedtime routine.

C. Make bedrooms conducive to sleep—keep TV and computers out of bedroom.

D. Occasional nightmares or sleep disturbances such as night terrors, sleep walking.

E. May have fear of dark or of being alone (separation anxiety).

F. Emotional disturbances such as stress, anxiety, leading to insomnia.

G. Difficult bedtime behavior may develop.

H. Snoring, daytime sleepiness may be symptoms of sleep apnea.

V. GROWTH AND DEVELOPMENT

A. Musculoskeletal.

1. Calculate and plot BMI once a year. BMI between 85th and 95th percentile for age and sex is considered at risk for overweight. Close supervision by healthcare provider may be considered.

2. Development not as rapid.

3. As body size increases, body fat relatively stable, giving slimmer appearance than preschool years.

4. Average height increase: a little over 2 in./year.

5. The closer to puberty, greater the chances for increased growth.

6. Tends to be an increased growth rate between 6 and 8 years of age that may be accompanied by appearance of small amount of pubic hair.

7. If unusually short/tall for age, may need to consider possibility of growth disorder.

8. Appetite tends to vary due to growth fluctuations, but child should not be losing weight.

9. Orthopedic problems of this age group:

a. Fractures, sprains, strains.

b. Epiphyseal separations, dislocations.

c. Scoliosis.

d. Avascular necrosing lesions of epiphysis.

• Legg-Calve-Perthes disease.

• Osgood-Schlatter disease.

10. Motor skills improve in strength, balance, coordination.

B. Skin.

1. Hair may become a little darker, skin becomes more adult like.

2. Scabies, impetigo, ringworm can be problems at this age.

C. Teeth.

1. Should be able to brush teeth by themselves, may still require some assistance.

2. Brush with fluoride toothpaste after each meal but at least twice a day; floss once a day.

3. Water supply should contain adequate fluoride, if not, consider fluoride supplement (see Appendix B).

4. Eruption of permanent teeth occurs in order in which primary teeth are lost.

5. Dental visits twice a year for exams, cleanings.

6. Sealants as recommended.

7. Problems with dental decay can peak during these years as well as periodontal diseases, often due to poor hygiene.

D. Eyes: visual acuity of 20/20 although about age 8 may begin to have myopia with no overt signs except school difficulty.

1. Evaluate regularly for visual acuity and ocular alignment (approximately every 1-2 years) at primary healthcare visits. Screening examinations should be done at routine school checks or after the appearance of symptoms. Screening emphasis should be directed to high-risk children, such as those with positive family history. Any child who does not pass screening test should have an ophthalmological examination.

2. Children with presumed or diagnosed learning disabilities should undergo a comprehensive pediatric medical eye examination to identify and treat any undiagnosed vision impairment. Referrals should be made for appropriate medical, psychological, and educational evaluation and treatment of the learning disability.

E. Ears: problems decrease due to further development of eustachian tubes and nasopharynx, although ear infections can still be frequent in younger school ager.

1. Consider hearing screening if history of frequent ear infections or concerns about speech development.

F. Throat: tonsillar tissue continues to enlarge, reaching its peak from 8-12 years when it levels off, begins to recess.

G. Immune system: continues to mature; allergic conditions more common.

H. Hematopoietic system: abnormal hemoglobin/hematocrit levels should not be attributed to dietary intake. Etiology should be established for any hemoglobin below 11.5 g.

I. Heart.

1. Murmurs are often heard in these years.

2. Any doubt of etiology requires referral to pediatric cardiologist.

3. Circulation.

a. Average pulse rate:

• Age 8: 78.

• Age 10: 74.

b. Average blood pressure:

• Age 8: 105/60.

• Age 10: 111/66.

c. Cholesterol screening for children with a family history of high cholesterol or heart disease, whose family history is unknown, or who have other factors for heart disease including obesity, high blood pressure, or diabetes. Screening should take place after age 2 but no later than age 10.

J. Respiration rate.

1. Age 8: 22 breaths/minute.

2. Age 10: 20 breaths/minute.

K. Gastrointestinal system.

1. Liver function is mature but still growing in size.

2. Appendix: open lumen and increased size increases risk of blockage, inflammatory reaction (appendicitis).

L. Genitourinary system.

1. Urinary tract infections can be common, especially in girls; often asymptomatic at this age.

M. Nervous system: essentially mature by age 10.

1. Begins puberty.

a. Girls.

• Breast budding can begin as early as age 8; others not until 13, with the average being around age 10.

• Puberty before age 8: girl should be evaluated for precocious puberty (twice as frequent in females as in males).

• Peak growth period (height, weight, muscle mass, etc.) occurs 1 year after puberty has begun.

• Menstruation usually begins 2 years after onset of puberty, on average just before age 13.

b. Boys.

• Peak growth period occurs about 2 years after onset of puberty.

• Begin puberty about 1 year later than girls.

• First sign of puberty in boys is enlargement of testes, thinning and reddening of scrotum. This occurs on average at age 11, but may occur anytime between 9 and 14 years of age.

• Puberty before 9: boy should be evaluated for precocious puberty.

2. Secondary sex characteristics.

a. Girls.

• Breast enlargement: 8-13 years.

• Axillary hair: 11-13 years.

• Pubic hair: 10-12 years.

• Menarche: 10-16 years.

b. Boys.

• Genitalia enlargement: 9-13 years.

• Axillary hair: 12-14 years.

• Facial hair: 11-14 years.

• Pubic hair: 12-15 years.

N. Language.

1. Although better able to express emotions and ideas, may talk in abstract terms without fully comprehending meaning of such speech.

2. Learning to communicate clearly with friends.

VI. SOCIAL DEVELOPMENT

A. Needs to master balance of feelings in dealing with successes, failures.

1. Self-concept (body self, social self, cognitive self) affects child's ability to be successful.

B. Successful accomplishments are of high priority for child in order to build positive self-image. Should feel successful with most day-to-day skills, activities, and chores.

C. Making friends is one of most important mid-childhood tasks.

1. Average number of friends: about five.

2. Sibling friendships may replace outside friends or need for them.

3. Selects friends of similar temperament, interests.

4. Often focus on “best friend” relationship, which can be more satisfying than large group.

D. Increasingly seeks peer for companionship.

E. Cliques may begin to form.

F. Parents and teachers are important significant others and will influence behavior, self-concept.

1. Encourage parents to share unscheduled spontaneous time with their child; time to be together, to listen, and to talk.

G. School issues.

1. School phobia.

2. Learning disorders.

3. Attention deficit hyperactivity disorder.

4. Bullying.

5. After school care and activities.

6. Dealing with fears, disappointments, and stress.

7. Parent-teacher communication.

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. Influenza vaccine.

1. Annual trivalent seasonal influenza immunization is recommended for all children 6 months of age and older.

2. Especially recommended for children with high-risk conditions such as asthma, diabetes, or neurological disorders.

3. Live-attenuated influenza vaccine is acceptable alternative to inactivated influenza vaccine for healthy persons 2-49 years of age.

4. Children 9 years of age and older need only 1 dose.

5. Children < 9 years need a minimum of 2 doses of 2009 pandemic H1N1 vaccine. If H1N1 not received during last year's flu season, 2 doses of seasonal influenza vaccine needed this year.

6. Children < 9 years who have never received the seasonal flu vaccine before will need 2 doses.

7. Children younger than 9 years who received seasonal flu vaccine before the 2009-2010 flu season need only 1 dose this year if they received at least 1 dose of the H1N1 vaccine last year. They need 2 doses this year if they did not receive at least 1 dose of the H1N1 vaccine last year.

8. Children < 9 years who received seasonal flu vaccine last year for the first time but only received 1 dose should receive 2 doses this year.

9. Children younger than 9 years who received a flu vaccine last year, but for whom it is unclear whether it was a seasonal flu vaccine or the H1N1 flu vaccine, should receive 2 doses this year.

10. Children who need 2 doses should receive the second dose at least 4 weeks after the first dose.

B. Varicella vaccine.

1. Children ages 7 through 18 years without evidence of immunity should receive 2 doses if not previously vaccinated or the second dose if only 1 dose has been administered.

2. For children ages 7 through 12 years, minimum interval between doses is 3 months–but accepted as valid if the second dose was given at least 28 days after the first dose.

C. Measles, mumps, rubella (MMR): Children not previously vaccinated should receive 2 doses or the second dose for those who have received only 1 dose, with at least 28 days between doses.

D. Hepatitis A vaccine: recommended for children over 23 months of age who live in areas where vaccination programs target older children or who are at an increased risk for infection or for whom protection is desired; can begin vaccine at any visit with the 2 doses being given at least 6 months apart.

E. Hepatitis B vaccine: The 3-dose series should be given to those not previously vaccinated.

F. Pneumococcal vaccine (PPSV): To be given to children with certain underlying medical conditions, including a cochlear implant. A single revaccination should be given after 5 years to children with functional or anatomic asplenia or an immunocompromising condition.

G. Meningococcal conjugate vaccine (MCV4).

1. Recommended for children ages 2 through 10 years with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk.

2. Recommended for children previously vaccinated with MCV4 or MPSV4 who remain at increased risk after 3 years (if first dose administered at age 2 through 6 years) or after 5 years (if first dose administered at age 7 years or older).

H. Human papillomavirus vaccine (HPV): May be given in a 3-dose series to males ages 9 through 18 years to reduce their likelihood of acquiring genital warts.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A. Nutrition.

1. Offer nutrient-dense foods that include a wide variety of fruits, vegetables, whole grains, and nonfat or low-fat dairy foods.

2. Stress importance of parents being good role models. Child who sees parent enjoying a wide variety of nutritious foods is more likely to want them.

3. Encourage a healthy breakfast daily.

4. Encourage reading food labels when shopping especially noting calories from fat, type of fat, sodium, cholesterol, vitamins, minerals, and serving size. Child can help to read the labels.

5. Encourage family meals at home. Children who eat meals with family at home have a better quality diet.

6. Offer healthy ways of eating when eating out is necessary and remind parents to be mindful of portion sizes.

7. Encourage parents to closely supervise but involve child in family food preparation. Children are more likely to eat foods that they help prepare.

8. Encourage family use of USDA's Food Guide for Kids

9. Child may need multivitamin if not eating enough to get essential nutrients if an erratic eater or on a highly selective diet. Most healthy children eating well-balanced diet do not require supplementation.

10. Some children may still be picky eaters at this age so may have to slightly adjust portions or food groups in order ensure adequate intake; may eat more at snack times than at regular meals.

11. Healthy snacks 1-2 times a day can include:

a. Fresh, canned, frozen vegetables or fruits. Keep cut-up veggies such as celery sticks, cucumber slices, or broccoli in the refrigerator. Try frozen grapes or bananas for fun treat.

b. Cold skim or 1% milk with whole-grain sugar-free cereal, peanut butter sandwich, or crackers with hummus.

c. Fruit smoothie made with fresh fruit, skim milk, ice, and a dash of vanilla or cinnamon.

d. Non fat or low-fat yogurt or cheese.

e. Air-popped or unbuttered popcorn.

f. Baked tortillas or pretzels with salsa.

g. Chocolate skim milk made at home to control the amount of sugar.

h. Low-fat frozen yogurt, fruit juice bars (without added sugar).

12. Encourage healthy eating behaviors including no snacking in front of TV. Parents should model these behaviors.

B. Sleep.

1. Stay consistent in routine activities such as daily mealtimes, playtimes, bedtime, wake-up time.

2. Avoid caffeine/other stimulants; limit food, drink before bedtime.

3. An hour or so before bedtime, begin a relaxing routine such as warm bath then a story in quiet bedroom.

4. Bed should only be used for sleeping, not for watching TV or homework. TVs and computers should be kept out of bedrooms.

5. Children who are overtired/have interrupted sleep may be more likely to have sleep disturbances such as night terrors.

C. Growth and development.

1. Musculoskeletal.

a. Need an hour or more of a variety of age-appropriate daily physical activities including team/individual sports, family activities, free play, walking, bicycling, chores, walking up and down stairs. Parents should model, prioritize, and promote regular physical activity.

b. Limit total amount of screen time (TV, computer) to < 2 hours a day.

c. As they approach puberty, children tend to put on a little more weight, which is normal.

d. Increases in BMI percentiles should be discussed with parents but in nonjudgmental, blame-free manner.

e. Because fractures are common in this age group, children should wear appropriate protective sports gear but also consume adequate calcium to decrease risk of fractures.

2. Skin.

a. 30 minutes before going outside, on both sunny and cloudy days, thickly apply broad-spectrum UVA-UVB sunscreen with SPF 15+ to all exposed areas of body, especially ears, nose, face, neck, shoulders, hands, and feet.

b. Suggest using sunscreen or sunblock with zinc oxide or titanium dioxide for areas that easily burn.

c. Reapply sunscreen every 2 hours and after swimming or sweating heavily, regardless of whether sunscreen is waterproof.

d. Use cool, comfortable clothing, especially clothes with a tight weave, to cover the body and protect from the sun.

e. Wear a wide-brimmed hat to shield head, face, ears, and neck.

f. Encourage sun avoidance between 10 a.m. and 4 p.m. when UV rays are the strongest. Seek shelter, shade, or umbrellas when out during those times. Remind that UV rays reflect and bounce back from sand, water, concrete, and snow so even in shade sun protection is needed.

3. Teeth.

a. Dental visits twice a year for exams, cleaning.

b. Brush teeth at least twice a day with tartar-control, fluoride toothpaste; floss once a day.

c. Still may need some help with brushing.

d. Verify water source for adequate fluoride.

e. Care of baby teeth as important as permanent teeth. Early loss of baby teeth due to caries or accidents can lead to spacing issues with premature rupture of permanent teeth resulting in orthodontic issues.

f. Discuss importance of wearing mouth guards, helmets while playing sports.

4. Eyes.

a. Wear sunglasses with 100% UVA-UVB protection whenever outside, in car.

b. All youth in organized sports should be encouraged to wear appropriate eye protection and especially when engaged in high-risk sports and activities such as basketball, baseball/softball, lacrosse, hockey, paintball, BB gun, or when around yard debris. Mandatory protective eyewear for athletes who are functionally one-eyed and for athletes whose ophthalmologists recommend eye protection after eye surgery or trauma.

c. Warn about dangers of fireworks to eyes; enjoy fireworks displays put on by professionals.

5. Puberty.

a. Encourage honest, age-appropriate discussions about sex with child using accurate terminology and listening carefully to child's questions so parent only gives as much information as child requires.

b. Concerns of girls about puberty:

• Menstruation.

• Breast development.

c. Concerns of boys about puberty:

• Voice change.

• Wet dreams.

• Involuntary erections.

• Breast enlargement.

• One testicle lower than other.

6. Cognitive and social development.

a. Very sensitive to views of others.

b. Appreciate having rules.

c. Begin to have strong internal gauge of right and wrong.

d. Friendship and teamwork are important parts of this stage of development.

e. Eager for more independence but frustrated by what they cannot accomplish since they are still in the process of mastering skills. Important to have sense of achievement, accomplishment to build strong self-esteem.

f. Encourage an appropriately challenging academic schedule and a balance of extracurricular activities. This is determined by child's unique needs, skills, and temperament.

g. Encourage exploration of activities and interests in a balanced way without the pressure of having to excel in everything.

h. Encourage parents to promote child activities that are fun, increase self-confidence, and involve friends.

D. Safety.

1. Auto.

a. Children should be properly secured at all times while traveling in car.

b. Children should ride in booster seats until the vehicle safety belts fit correctly, when they are 4 ft 9 in. tall. This may not be until they are 8 to 12 years of age. Can move to safety belt when child can place his/her back firmly against vehicle seat back cushion with knees bent over vehicle seat cushion. Lap belt must fit low and tight across upper thighs. Belt should rest over shoulder and across chest.

c. Shoulder belt should never be placed under arm or behind child's back.

d. Children younger than 12 years should never ride in front seat.

e. Keep all doors locked while in motion.

f. Never leave young children alone in car.

g. Children should not ride in truck beds or any other area of vehicle that does not have seat and seat belt.

h. Children lack judgment, coordination, reflexes to drive other motorized vehicles such as mopeds, snowmobiles, mini-bikes, ATVs.

2. Bicycle safety. Children who ride bikes should:

a. Wear helmets at all times. Helmets should meet safety standards of the Consumer Product Safety Commission (CPSC; www.cpsc.gov). Helmets should fit properly; parents may want to bring them in to check for proper fit. Parents should wear helmets as well to serve as a good role model.

b. Know basic road rules such as obey all traffic signs/lights, stop and look both ways at intersecting points such as driveways/streets, ride in single file or on bike paths, ride in same direction as traffic.

c. Should not wear loose-fitting clothing, strings, ties that could get caught in bike chain or parts.

d. Wear shoes with laces tied.

e. Should not wear earphones while riding.

3. Skateboard safety: children should always wear helmet and never ride near traffic.

4. Water safety.

a. Never allow child to swim alone or play unsupervised in or by water—even for a moment.

b. Child should learn to swim and take lessons from qualified instructor.

c. Backyard swimming pools should be enclosed with high, locked fence on all sides. Fences should be at least 4 ft high on all sides.

d. Diving should not be allowed until underwater depth has been determined and checked for hazards.

e. No swimming near boats, fisherman, unsupervised open water.

f. Children should always wear a life jacket when in a boat.

g. Parents should know how to perform CPR.

5. Fire and burn accidents.

a. Install smoke detectors, on all floors and particularly in or near sleeping areas.

b. Keep fire extinguishers in kitchen, other areas where fire could start.

c. Have family fire plan in place; practice regular fire drills.

d. Discourage playing with matches, etc.

e. To avoid scalding burns from water, heaters should never be set > 120°F (48.9°C).

6. Home alone: most children are not old enough until age 11 or 12. Child should be learning safety, security, emergency guidelines (calling parent, neighbor, 911) in preparation for emergencies or for when the time comes that the child is old enough to be left alone for short times such as after school.

7. Gun safety: guns, ammunition need to be stored and locked separately. Child needs to know to stay away from and alert parent should he encounter a gun at a friend's house or elsewhere.

8. Bullying: children of this age can sometimes be the target of bullies. Child needs to know strategies for dealing with bullying. Strong friendships should be encouraged to avoid being bullied.

9. Sexual abuse.

a. Most sexual abuse occurs between the ages of 8 and 12.

b. In 80% of these cases, abuser is known to child.

c. Reinforce “good touch/bad touch” concepts and awareness of possible scenarios that may occur. Promote abuse-prevention programs at school and encourage parents to listen carefully to child who might have a concern, particularly of a sexual nature.

10. Substance abuse.

a. Begins with experimentation and casual use, often under peer pressure.

b. Problem drinking often begins in grade school.

c. Prevention of substance abuse needs to begin before adolescence.

d. Secondhand smoke is a serious health hazard for children. Increases risk of developing asthma, bronchitis, middle-ear disease, pneumonia, wheezing and coughing spells, behavioral/cognitive problems.

e. Children whose parents smoke are more than twice as likely to smoke themselves than are children of nonsmokers.

11. Media.

a. In addition to < 2 hours of screen time per day and keeping TVs and computers out of bedrooms, remind parents about the importance of careful selection, watching together, and discussing programs their children watch.

b. Encourage parents to be knowledgeable about online and social media.

c. Keep computers in a central area of the house where computer activities can be monitored. Parents may want to consider purchasing online programs that allow them to monitor computer activity.

d. Encourage parents to talk often with their children about online and social media safety and responsibility.

e. Encourage parents to set a good example by limiting their own viewing time and engaging in other healthy activities.

BIBLIOGRAPHY

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American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology. Policy statement: Vision Screening for Infants and Children. Revised and approved, March 2007: http://www.aao.org/one_passthru.cfm?link=URL&target=http://one.aao.org/asset.axd?id=2efe6879-b631-4878-b878-18bc1679114c. Accessed June 4, 2011.

American Academy of Pediatrics and American Academy of Ophthalmology. Joint Statement: Protective Eyewear for Young Athletes. Revised and approved October and November 2003: http://www.aao.org/about/policy/upload/Protective-Eyewear-for-Young-Athletes.pdf.Accessed June 4, 2011.

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