1. Monitoring of children’s health Prof.Dr. Emel Gür İ.Ü Cerrahpaşa Tıp Fakültesi Çocuk Sağlığı ve Hastalıkları ABD Sosyal Pediatri Bilim Dalı

2. Examination Maintance Improvement of health To prevent diseases and disabilities Early diagnosis and treatment To prevent deaths of babies and children Support to families for healthy raising of children Aim

3. Prevention of diseases Follow up of growth and development Appropriate feeding according to age Immunisation Support to families Health education Consultancy Family planning Early diagnosis and treatment History Physical examination Lab. tests Activities

4. Steps in monitoring of childrens health Follow up Meeting and history Examination of growth and development Detailed physical examination Screening Immunisation Health trainning and counseling Mother’s questions Determination of the next appointment

5. Monitoring of the growth Aim; to follow up the health, to detect health problems in its early stage, to prevent malnutrition At each examination weight, height and head circumference sholud be correctly measured, standart growth curve should be evaluated and it sholud be interpreted in the right way Parents should participate actively in the examination of growth

6. Periods in the monitoring of babies and children AGE GROUPS PERIODS OF MONITORING FİRST 48 H ONCE 15. DAY ONCE 41. DAY ONCE 2 - 12 MONTHS 2, 3, 4, 6, 9, 12. MONTH 1 – 3 YEARS WITH THE PERIOD OF 6 MONTHS ≥4 YEARS WITH THE PERIOD OF 1 YEAR Bebek ve Çocuk İzlem Protokolü. T.C Sağlık Bakanlığı AÇSAP Genel Müdürlüğü. Genelge 2008/45.

11. Growth curves for Turkish children

12. Weight curves for Turkish children

13. Marked curves of children’s weight good dangerous attentioncatch up of growth

14. Monitoring and support of development (Guide for monitoring of chidren’s development) Is there any worry about child’s development, hearing, talking, understanding, use of hands and body movements? Can your child explain what he wants? What is your child understanding? What is he doing with his hands and fingers, what is the way he is making his body movements? What is the way he communicates with the family members and foreigners? Can you give us information about the way he is playing games?

15. Screening of development Screening of developmental problems is useful for monitoring of risk infants Denver II is a reliable screening test for the children at their first 6 years of life Development, personal and social inteligence,fine and rough motor skills and language are examined by Denver II test

16. Screening of Early Childhood Strabismus Vision problems Hearing problems Interruption of growth Child abuse Teeth problems Cornea reflex Allen, Snellen tables OAET Measurement of growth and weight History, inspection, physical examination Physical examination

17. Screening of newborn Hypothyroidism Phenylketonuria Hydrocephalus Cleft palate Congenital heart deseases Hernies Undescended testis Hypospadias Serum T4/TSH Guthrie Measurement of head circumference Physical examination

18. Screening Routine screening History Inspection Physical examination Laboratory tests Sensorial tests Additional screening (family history, ethnicity etc..)

19. Screening of school-age children Scoliosis Parasitosis Behaviorial disorders Physical examination Stool smear History, examination

20. Screening of Newborn

21. Newborn Screening Programs Phenylketonuria screening program, which has been implemented in 22 cities by support of the Turkish Republic ministery of health since 1987, was carried out by Istanbul University Faculty of Medicine, Hacettepe University Faculty of Medicine, Cumhuriyet University Faculty of Medicine, Dokuzeylül University Faculty of Medicine in 74 cities. General newborn screening programs in Turkey; 1993 Phenylketonuria 2007 Congenital hypothyroidism 2008 Biotinidase deficiency Since 2006 Newborn metabolic screening tests are being analysed at Ankara central laboratory and İstanbul Hıfzıssıhha Institute.

22. Time of taking blood sample for newborn screening tests Blood should be taken in the first 48-72 h, after first enteral feeding (appsolutely before child is being discharged) For the PKY ve biotinidase screening at least 48 h enteral feeding (75 kcal/kg/day) Blood sample taken in the first 24 h can give a false negative result for PKY and biotinidase; for hypotiroidism it can give a false positive result Total parenteral nutrition can lead to falce negative results If the blood sample was taken too early or before feeding, it should be repeated in 1-2 weeks

23. Taking blood sample for newborn screening Heel should keep warm (max. 42 C, heated by wet towel for 3 min) and under the level of hearth It should be cleaned by 70% isopropyl alcohol and left to dry Plantar face of the heel is punctured at its media or lateral side by steril lancet (at depth of 2.0-2.4 mm)

24. Use of Guthrie cards at newborn screening The first drop of blood is cleaned by gauze, later drops make contacts with Guthrie cards an by this way 5 marked areas are fullfilled (heel should not be squeezed, carton should not be suppressed ) Front and rear side of the card’s marked section should be filled out completely. However, blood should be absorbed at only one side. Blood sample should be dried at horizontal position at room temperature at least 3 hours. There should not be any contact at card’s marked section before and after taking blood sample.

25. Right blood sample Unequal spread of blood Blood clots at sample Wrong filled circles Poor saturation

26. Recording and delivery of Guthrie card ID, address, name of hospital, number of sample, date of birth date of blood sampling, prematurity, transfusion, time and way of feeding should be written on Guthrie card. Card should be covered in an envelope and immediately delivered to City Health Council, Center of Public Health (Fatih Grup Başkanlığı ) and Refik Saydam Hıfzısıha center. Screening status should absolutely be recorded at file of the baby.

27. Screening of Phenylketonuria Screening of Phenylketonuria Frequency 1/10 000 (Turkey: 1/4 500) Each year 250-300 patient, from 20-25 persons one is carrier Caracterized by sever motor-mental retardation Detected by fluorescent immunoassay (FIA) In the case of positive result test should be repeated (FIA, enzyme, paper chromatography, HPLC, Tandem mass spectrometry) Ozalp I, Coşkun T, Tokatli A, Kalkanoğlu HS, Dursun A, Tokol S, Köksal G, Ozgüc M, Köse R. Newborn PKU screening in Turkey: at present and organization for future. Turk J Pediatr. 2001;43 (2):97-101.

28. FLOW CHART FOR PHENYLKETONURİA BLOOD SAMPLE İNAPPROPRİATE BLOOD SAMPLE APPROPRİATE BLOOD SAMPLE REPEATED BLOOD SAMPLE SCREENING LAB. FA LEVEL ( FIA METHOD) ≤2 mg/dl2.1 – 3.9 mg/dl ≥4 mg/dl REPETEAD BLOOD SAMPLE ≤ 2 mg/dl ≥ 2.1 mg/dl DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISM HPLC method FA>120µmol/L and FA/tirozin>2 follow; FA>360 µmol/L treatment.i 3 day 72 h 3.-5.day NORMAL Access to lab 3-5 day 72 h Access to lab. 2-3 day

29. Biotinidase deficiency General frequency 1:60 000 Turkey 1:11 763 (117 case/year) Convulsion, hypotonia, ataxia, vision, and hearing loss, skin rash, mental retardation, acidosis, coma, death Screening is performed by colorimeric test If biotinidase deficiency is +, the spectrophotometric test is performed Baykal T, Huner G, Sarbat G, et al. Incidence of biotinidase deficiency in Turkish newborns. Acta Paediatr, 1998;87(10):110-3. Tanzer F, Sancaklar M, Büyükkayhan D. Neonatal screening for biotidinase deficiency: results of a 1-year pilot study in four cities in central Anatolia. J Pediatr Endocrinol Metab. 2009;22(12):1113-6.

30. FLOW CHART FOR BİOTİNİDASE DEFFİCİENCY BLOOD SAMPLE 3.-5. DAY UNAPPROPRİAE BLOOD SAMPLE APPROPRİATE BLOOD SAMPLE REPETEAD BLOOD SAMPLE SCREENİNG LAB. (colorimetric method) ENZYME ACTİVİTY (+) REPETEAED BLOOD SAMPLE ENZYME ACTİVİTY ↓ or (-) DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISM Spectrophotometric method <3.5U/L (enzyme activity as %) Enzyme activity <%30 partial, <%10 total enzyme defficiency ENZYME ACTİVİTY (+) ENZYME ACTİVİTY ↓ or (-) Access to lab. 2-3 day 72 h Access to lab. 3-5 day 72 h

31. Hypothyroidism Frequency of 1/3500-4000 (World), Turkey : 1/2700 Severe growth retardation and mental retardation Heel blod sample for screening: TSH and T4 level TSH; primary and compensated hypothyroidism is recognized, central hypothyroidism is skipped (low false positivity) T4; primary, secondary, tertiary hypothyroidism, TBG deficiency, hipertiroksinemi, slow rise in level is diagnostic for con. hypothyroidism (compensated hypothyroidism could be skipped) Yordam N, Calikoğlu AS, Hatun S, Kandemir N, Oğuz H, Tezic T, Ozalp I. Screening for congenital hypothyroidism in Turkey. Eur J Pediatr.1995;154(8):614-6. Update of newborn screening and therapy and congenital hypothyroidism. Pediatrics 2006;117(6):2290-303. Lafranchi SH. Newborn screening strategies for congenital hypothyroidism: an update. J Inherit Metab Dis. 2010 Mar 2. [Epub ahead of print]

32. FLOW CHART FOR CONGENİTAL HYPOTİROİDİSM BLOOD SAMPLE INAPPROPRİATE BLOOD SAMPLE APPROPRİATE BLOOD SAMPLE REPEATED BLOOD SAMPLE SCREENING LAB. TSH level <15 mlU/L 15-50 mlU/L>50 mlU/L REPEATED BLOOD SAMPLE <15 mlU/L NORMAL ≥15 mlU/L APPROPRIATE LAB. Serum T4 10mlU/L CONSULTATION OF SPECIALIST DEPARTMENT FOR PEDIATRIC ENDOCRINOLOGY Access to lab. 2-3 day 72 h 3.-5.day Access to lab. 3-5 day 72 h

33. Developmental dysplasia of the hip DDH frequency 1.49% Should be screened at all newborns by physical examination It should be repeated at each examination till child start to walk Ortoloni and Barlow test are reliable at first 3 months Restricted abduction at hip is the most reliable after 3 months of age Ultrasound is helpfull before 4 months of age, X ray is helpfull for diagnosis after 6 months of age Children with positive signs should be refered to ortopedist For risk infats ultrasound is suggested at the period of 4-6 weeks (breech birth, musculo-skeletal deformities, positive family history etc.)

35. Examination of the hip joint Examination of the hip joint Barlow maneuver Subluxation, unstable hip Ortoloni maneuver Dislocated hip

36. Examination of the hip joint Restricted hip abduction (<60º)

37. Prevention of developmental hip displasia Keeping hip at abduction and slightly flexion, keeping knee at flexion is the most appropriate position for the normal development of the hip joint Swaddle and supine positions are not recommended (side position is also risky) Keeping legs with upside down position increase the risk Baby diapers bond should be wide ; clothes should not be narrow Appropriate carriage (baby sling)

38. Iron defficiency anemia Frequency of 40% among toddlers in our country For term babies at 4-6 months, for preterm babies at 2-3 months of age iron storage is becoming sufficient. İf iron defficiency lasts more then 3 months, it can lead to serious problems of development In countries with frequency of more than 10%, for term healthy babies it is recommended to check up Hb/Hct at the age of 6-12 months In our country iron is given profilactic (1mg/kg) to all term born children (breastfeeding and feeding with cow milk), starting at the age of 4 months and continuing for 1 year. Among preterm born children profilaxy starts at the age of 2 months. Control Hb should be taken at the age of 9 months Hb< 11 g/dl : treatment with iron and after 1 month control. Treatment should be continued at least for 3 months. Hb controlu should be made at adolescence

39. Urinary tract infections Frequency: females 3%, males 1.1% The main reason for the chronic renal insufficiency at underdeveloped and developing countries Diagnosis and treatment on time is very important Screening should be performed in the age of 5 year and in adolescency Screening should be performed at fresh sample of urine by stick test In the case of positive result, mycroscopic examination should be made Detail examination of urine and urine culture should be taken at those with symptoms of infection

40. Screening for congenital heart diseases The half of the congenital heart diseases could be detected at the first newborn physical examination The early diagnosis makes prevention of heart failure, hypoxemia, infective endocarditis It should be examined at all newborns by history and physical examination Cardiovascular system should be carefully examined at each examination Femoral artery pulse palpation, auscultation of heart are very important screening methodes EKO screening is recommended for all babies at risk at 16. GH

41. Hypertension Frequency at children: 1-3% Important for the heart, brain, kidney, eye complications For healthy children tansion should started to be measured at the age of 3 years, and later on it should be measured at each examination Measurement should be made at sitting position Cuff height should be 80-100% of the mid-upper arm circumference or two thirds of the length of the upper arm Hypertension; blood pressure above 95 percentile according to patients age and sex

42. Measurement of the arteria pressure Resting for 3-5 min. before measurement Measurement should be made at sitting position (for infants supine position) Cuff should be put at supported right upper arm Cuff should be placed at two thirds of the length of the upper arm, it should surround complitely circumference of the arm Cuff should be placed 2 cm above the fossa cubitalis A stethoscope should be placed on palpable brachial artery pulsations

43. Measurement of the arteria pressure Cuff should be inflated 20-20 mm above sistolic blood pressure and should be deflated with the speed of 2-3 mmHg/sec. Sistolic blood pressure: point of the 1. korotkoff sound Diastolic blood pressure: point of 5. korotkoff sound disappears If the BP is high: it should be measured on the other arm and the other leg and measurement should be repeated 1 week later

44. Examination of the blood pressure measurement At least three measurements of blood pressure According to sex and age; BP<90p= Normal: no need for folow up TA=90-95p.=borderline. No symptoms: follow up. TA=90-95p with symptoms: evaluation (urine, hemogram, urine culture, elektrolyts, urea,creatinine, uric acid, renal ultrasound, EKG ) TA>95 p =HT: advanced evaluation at hospital

45. Hyperlipidemia Atherosclerotic changes begins at childhood age. Annual risk evaluations should be done at all children after age of two Histories such as coronary artery and cerebrovascular deseases or any sudden death caused by cardiological reasons before age of 55 at family should be interpreted. T. cholesterol level>240 status of mother or father. Histories such as obesity, hypertension, diabetes or smoking at child. Cholesterol and lipid levels should be checked at children with risk factors. Lipoprotein analysis should be done at children with t. cholesterol level>200 mg/dl. Diet programs should be carried out once in each 5 years if LDL 130 mg/dl.

46. Hearing Screenings The frequency of hearing loss is %1-3 at normal babies, %2-4 at babies remained in intensive care. Age of application to a health care institution is 3.8 years in our country. A serious two-sided hearing loss influences speech and cognitive development negatively Aim is to determine the hearing loss before third month. Initiation of treatment before sixth month has a significant effect at language development. Newborn and infants should be screened with histories and physical examinations in a subjective way ; subjektif, childrens at pre-school period (3-4-5 years) should be screened with hearing tests in an objective way. It is recommended that hearing tests should be done intermittently till the end of the period of adolescence.

47. Hearing screenings at healthy infants * Newborn : Auropalpebral reflex, recoil,moro reflex * First Month : recoil,interruptions at feeding * 3-4 months : Begins to turn head toward the sound source * 4-7 months : Turns head completely toward the sound source * 9-13 months: Finds directly source and direction of the sound *21-24 months :Replies with short sentences against to the people who warns orally.

48. Children with risk factors for hearing loss Sensorineural hearing loss history at family Birth weight <1500 g Low apgar score (1.min<5, 5.min<7) Intrauterine infection, bacterial meningitis Ventilation more than 5 days. Hyperbilirubinemia requiring blood exchange Use of ototoxic drugs AOM with effusion lasting along 3 months Syndromes accompanying with hearing loss. If otoacoustic emission test (OAE ) and brainstem evoked potentials (ABR)should be carried out at risky children, hearing loss can be reduced at %20 percentage, this should be carried out for all children at first 48 hours.

49. OAE should be carried out at all babies in first 48 hours after birth. OAE test reflects the sound energy originated at cells in the inner ear ; and measured by microphones at outer ear. If OAE test fails, repeating after two months, If repeating fails too, then auditory brainstem responses ( ABR ) test should be carried out. Audiometric hearing test should be done to all children in pre-school age (4 years old) Objective Hearing Screening

50. Screening of vision Strabismus 2-6%, refraction disorders 20%, amblyopia 2-4% Amblyopia; loss of visual acuity ≥ 2/10 or difference between eyes ≥2/10 In the first 3 months permanent strabismus, after 3. month of age permanent and temporary strabismus is patological and it is the most common reason for amblyopia If strabismus was not treated in the first 6 years it leads to amblyopia, after 12 years of age amblyopia could not be treated.

51. Screening of vision * 0-3 months red reflex cornea reflex inspection * 6-12months red reflex cornea reflex inspection *3 and 5 years visual acuity red reflex cornea reflex inspection * Abnormal assymetric constutional disorder *Abnormal assymetric constutional disorder * Reduced abnormal assymetric constutional disorder

52. Screening of vision Newborn; response of the baby to mother’s face 2-3 months; focus on objects 4-5 months:attention to toys and enviroment 6. month: following moving objects VEP, optokinetic nystagmus 3-4-5 years; test for visual acuity Visual acuity should be periodically examined until the end of adolescence

53. Red Reflex Ophthalmoscopic examination for red reflex among newborns *red reflex examination should be repeated in a few months *white reflection; retinoblastoma, retrolental fibroplasia, lens opacities, congenital cataract,(TORCH)

54. Corneal reflex (Hirschberg testi )

55. Health education Good communication (non-verbal and verbal communication) To focus attention, to show empathy Avoidance of authoritarian attitudes Talking with precise and clear language First praising right behaviors, then correcting mistakes Suggestions should be appropriate to families level Suggestions should be appropriate to child’s age İt should be checked out if suggestions are understandible Practical applications Written educational materials(brochure etc.)

56. First evaluation (7-15. day) Benefits of breatfeeding Breastfeeding counseling Umbilical cord care, bath, clothes Cleanning the skin, prevention of diaper rash Causes of crying, frequency of urine and defecation Importance of hand-washing, the hazards of smoking Bed for baby, sleeping position, rhythm of sleeping (15-18 h) Disandvantages of swaddling and teat At 15 day of life D vit. (400 ıU/day) for 1 year Baby should not be left alone with children under 10 years oldwith

57. 2-4. months evaluation Relations between baby and parents or siblings Importance of play and talk with baby Growth and development, breastfeeding and problems Vaccines, the importance and reactions sleeping ( at least 16 h per day, 2-3 times a day) Baby care, crying causes Defecation (consistency is more important than number) Risk for aspiration Family planning (1.5- 2 months control)

58. 6-9. month evaluation Harmony in the family Examination of growth and development continuation of breastfeeding Vaccines, the importance and reactions Care and hygiene sleeping (12-14 h, at least 2 times a day) Importance of playing with baby Additional feeding, eating using a spoon and glass Fall from a height, hot water, sockets, water-filled containers Care of milk teeth

59. 1 year evaluation Introduction to family table (3 main meals, 2 snacks) Encourage self-feeding sleeping (at least once at daylights) Brushing teeth with a soft brush without toothpaste Measures to be taken to prevent accidents Setting rules and discipline, praise and reward constraint Wish for independence should not be supressed but should be supervised There could be a lack of appetite, no need for force

60. 2-3 year evaluation Importance of introducing a child to a family table Balanced nutrition Loss of appetite Adequate consumption of milk Accidents discipline (prize, penalty) Time for sleeping (once a day) Teeth care, visiting dentist Playing games under control Toilet habits

61. 4-5. year evaluation Balanced feeding, importance of conversations at family table Friends, playing games (under control) Answering questions about sexuality Dental care(brushing teeth with fluoride toothpaste for children), visiting dentist sleeping (sleeping at daylight not necessary) Support for pre-school education Name, surname, address and telephone number should be taught Child should be worned regarding foreigners Household and responsibility Traffic rules

62. 6-11 year Sleeping patterns (going to bed at 20.00-21.00 o’clock, totally 9-10 hours of sleeping) Balanced feeding, prevention of snack between meals, importance of breakfast tooth brushing (twice a day), visiting dentist Answers to questions about sexuality School adjustment, learning problems TV, computer games (1 hour per day) Education regarding child abuse preventing accidents Habits of reading books

63. 12- 21 year evaluation Healthy communication Respect for private life TV, computer games, internet usage should be supervised Smoking, substance use, sleeping (8-10 h), regular exercişse(at least 3 times a week)) Balanced feedşng (3 meals) Brushing teeth, visiting dentist (twice a year) No weapons at home, preventions of accidents Questions and issues related to sexuality, encourage the education and development of new skills

64. In our country; 0-1 years old 60% 1-5 years old 70% children benefit from “monitoring of children’s health “

65. Recommendations “Monitoring of children’s health “ outpatient departments should be increased; Those departments should be integrated to general child outpatient departments; “Monitoring of children’s health “ service including health education and education of parents; It should be understood as ‘ missed opportunities’