child health sub network guideline€¦ · 4.1 prior to assessing the infant / child’s nutrition,...

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Child Health Sub Network Guideline

Assessing infant / child nutrition, growth and

development within the Queensland Health, primary

health care setting

Document ID Version no. 2.0 Approval date 12/09/2017

Executive sponsor Chairperson QCYCN Effective date 12/09/2017

Author/custodian Chairperson QCYCN Child health Subnetwork Review date 12/09/2020

Supercedes Version 1.0

Applicable to Child and Youth Health Nurses, Registered Nurses, Midwives and Aboriginal and Torres

Strait Islander Advanced Health Workers

Authorisation Queensland Child and Youth Clinical Network

Queensland Child and Youth Clinical Network

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Refer to online version, destroy printed copies after use.

Assessing infant / child nutrition, growth and development within the primary health care setting - Guideline

Published by the State of Queensland (Queensland Health), July 2017

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of

this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Queensland Health) 2017

You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland

(Queensland Health).

For more information contact:

Clinical Access and Redesign Unit, Health Services and Clinical Innovation Division, Department of Health,

GPO Box 48, Brisbane, QLD 4001, Email: Statewide_Child_&[email protected]

An electronic version of this document is available at https://www.childrens.health.qld.gov.au/chq/health-

professionals/qcyc-network/

Disclaimer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information. This guideline is intended as a guide and provided for information purposes only. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise. Clinical material offered in this guideline does not replace or remove clinical judgement or the professional duty of care necessary for each individual client. Clinicians and health care workers must work within their individual scope of practice, adhering to legislative requirements and the Code of Conduct. Clinical care provided in accordance with this guideline should be provided within the context of locally available resources and clinical expertise.

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Content

Abbreviations……………………………………………………………………………………………………....4

1. Purpose............................................................................................................................................…......5

2. Scope.........................................................................................................................................................5

3. Related documents....................................................................................................................................5

4. Assessing infant/child nutrition, growth, and development within the primary health care setting............5

5. Nutritional assessment..............................................................................................................................6

6. Growth and physical assessment .............................................................................................................6

7. Developmental assessment......................................................................................................................7

8. Consultation..............................................................................................................................................9

10. Definitions and Terms.............................................................................................................................10

11. References and suggested reading........................................................................................................11

12. Level of Evidence....................................................................................................................................14

13. Guideline revision and approval history..................................................................................................14

14. Keywords and accreditation references..................................................................................................14

Appendix 1 – Assessing nutrition from birth to 5 years of age......................................................................15

Appendix 1 – Growth and physical assessment from birth to 5 years of age................................................17

Appendix 1 – Additional information for rural and remote populations and Aboriginal & Torres Strait

Islander Children..................................................................................................................18

Appendix 1 – Development...........................................................................................................................19

Appendix 2 – Nutrition...................................................................................................................................21

Appendix 2 – Growth.....................................................................................................................................22

Appendix 2 – Physical assessment...............................................................................................................24

Appendix 2 – Development............................................................................................................................26

Appendix 2 – Additional information for rural and remote populations and Aboriginal & Torres Strait

Islander Children...................................................................................................................27

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Abbreviations

AMS Aboriginal Medical Service ASQ-3 Ages and Stages Questionnaire (3rd edition)

CCHW Centre for Children’s Health and Wellbeing CDS Child Development Service CHQ Children’s Health Queensland

CHS Child Health Service CHSN Child Health Sub Network

CLR Corneal light reflex CNC Clinical Nurse Consultant

CQ Central Queensland CYCHS Child and Youth Community Health Service CYMHS Child and Youth Mental Health Service

EBM Expressed Breast Milk GCHHS Gold Coast Hospital and Health Service

HHS Hospital and Health Service NSQHS National Safety and Quality Health Service Standards NUM Nurse Unit Manager

PEDS Parents’ Evaluation of Developmental Status PHR Personal Health Record

QCYCN Queensland Child and Youth Clinical Network QCPIMH Queensland Centre for Perinatal and Infant Mental

Health RFDS Royal Flying Doctor Service

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1. Purpose

This Guideline has been developed to promote and facilitate a standard approach for assessing nutrition,

growth and development within the primary health care setting, for infants and children aged between 0-5

years. The assessment ages are in line with the well child health checks in the Personal Health Record1

2. Scope

This Guideline has been developed for use by all Queensland Health Child Health Nurses, Registered

Nurses, Midwives, School Based Youth Health Nurses, and Aboriginal and Torres Strait Islander Health

Workers, practicing within the Primary Health Care setting.

3. Related documents

This Guideline is to be read in conjunction with the following related documents, and applied in the context

of locally available resources, clinical expertise, and relevant legislation, policies, procedures, guidelines

and nursing standards:

• Child and Youth Health Practice Manual https://www.childrens.health.qld.gov.au/chq/health-

professionals/qcyc-network/2

• Queensland Health Developmental Screening https://www.childrens.health.qld.gov.au/chq/health-


• Child Health Sub Network Breastfeeding Position Statement

https://www.childrens.health.qld.gov.au/chq/health-professionals/qcyc-network/

4. When assessing infant/child nutrition, growth and development within the primary health care setting, consider the following practice points:

4.1 Prior to assessing the infant / child’s nutrition, growth and development review all relevant history

from the client’s medical record. Ensure all available growth data is plotted accurately on the

recommended growth chart for age and gender (See Appendix 2 p.22)

4.2 Provide an environment that ensures family privacy and confidentiality.

4.3 Ensure that the appropriate cultural and linguist supports are provided for the family e.g. Interpreter,

Aboriginal and Torres Strait Islander health liaison / health worker or cultural translator as needed by

the client.

4.4 Use appropriate communication strategies to support optimal assessment and to support family

centred, safe clinical care 2, 6. Examples of these are the AIDET and SBAR frameworks available

from

http://qheps.health.qld.gov.au/childrenshealth/html/nursing/nursing-aidetsbar.htm

4.5 Engage with the family using a partnership approach, to develop a therapeutic relationship, followed

by a strength based approach to build parenting capacity and confidence.2,3

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4.6 Undertake a comprehensive family health and psychosocial history that will support the ongoing

planning of care.2, 4-6

4.7 Elicit and explore parental concerns utilising a family partnership approach.3,40

4.8 Undertake and document clinical observations of the maternal, paternal and infant interactions.

4.9 Use appropriate evidence-based client education information and resources to provide anticipatory

guidance and health education, to support informed decision making. In addition, when providing

anticipatory guidance and health education information it is important to consider the individual

health literacy requirements of the parent/carer7.

4.10 Document all assessment findings and care planning: subjective and objective information, actions,

interventions and outcomes.

4.11 Explain the outcome of the assessment/screen with the parent/carer, including any necessary

referrals or follow-up required. Ensure that the family has understood the follow up required and the

rationale.

4.12 Recognise when there is a need for escalation, or if there is uncertainty regarding any aspect of the

assessment or findings, and seek clinical advice.

4.13 Develop an individualised plan of care in collaboration with the family to meet their level of need2,5,6

4.14 When further assessment is indicated arrange for referral/s as per the Child and Youth Health

Practice Manual2 and local HHS referral recommendations and pathways.

5. Nutritional Assessment

5.1 Nutritional assessment requires a holistic approach, inclusive of physical, social, cultural, emotional

and environmental factors2.

5.2 Support, protect and promote breastfeeding through undertaking a comprehensive assessment of

breastfeeding and lactation2.

5.3 Assess nutritional intake (quality & quantity) at each child health check and opportunistically.

5.4 When there are any concerns regarding the infant/child’s growth, either poor growth or high rates of

growth, explore possible reasons for this with the parent/carer.

5.5 Discuss the child and family’s eating practices with the parent/carer8.

5.6 Provide anticipatory guidance, education and health promotion regarding healthy eating practices

and the recommended dietary guidelines at each child health check and opportunistically8.

Refer to Appendix 1& 2 for additional nutritional assessment information and resources

6. Growth and Physical Assessment

6.1 Utilise a systematic body systems approach – head to toe then front to back, when performing a

physical examination9, 10,11

Refer to Appendix 1& 2 for an overview of the head to toe physical assessment and resources

6.2 Conduct the physical assessment in partnership with the parent/carer, providing an explanation

regarding the process and the findings.

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6.3 Follow the local HHS Infection control policies and procedures and the Australian Guidelines for

Prevention and Control of Infection in Healthcare12

NOTE: The importance of hand hygiene in reducing the risk of infection13

6.4 Perform growth measurements: weight, length / height and head circumference (HC), and plot data

on the growth chart at the regular Child Health Checks recommended in the PHR1 at 0-4 weeks, 6-8

weeks, 4, 6, 12 months, 2 ½ - 3 ½ years and 4-5 years. These recommendations are for otherwise

healthy children.

Refer to Appendix 1 & 2 – Growth

6.5 During the assessment take the opportunity to provide the parent/carer with developmentally

appropriate anticipatory guidance2

• Promote the value of parent/carer and infant attachment14

• Observe and discuss infant cues and behaviour with the parent/carer

• Demonstrate developmentally appropriate skills, such as tummy time

• Promote infant safety and injury prevention, such as safe sleeping practices

6.6 During the assessment, role model positive interaction with the infant/child and observe interactions

between the parent/carer and infant/child:

• Talk to the infant/child

• Explain to the infant/child what is happening

• Document clinical observations

6.7 Perform additional assessment / screening as indicated for infants and children living in rural and

remote Queensland populations, per the Chronic Conditions Manual – Section 2: Child Health

Checks21.

Refer to appendix 1 & 2 - additional information for infants and children who are living in rural and

remote populations.

6.8 Document assessment findings and plot growth measurements on the appropriate growth chart, in

infants / child’s medical record, and their PHR.

6.9 When atypical growth is identified arrange for referral or follow-up review as appropriate2

7. Developmental Assessment

7.1 The early years from birth to the commencement of school provide a foundation for lifelong health

and well-being. These years are a period of significant vulnerability for a child’s development,

growth, health and general well-being, all of which are influenced via a multifaceted interplay of

biological, psycho-social, and environmental factors16,17. Regular child health developmental

surveillance, and developmental screening, undertaken in the early years offers an opportunity to

identify and intervene early for those children with developmental delay17.

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7.2 Knowledge of typical infant/child development is required to undertake developmental assessment

and screening. Refer to the development sections in appendices 1 & 2 for further information

regarding typical infant/child development.

7.3 Developmental screening should be undertaken in conjunction with developmental surveillance.18

Developmental assessment involves: 2,18,19

• Parent/carer report of current development

• Obtaining developmental history

• Exploring parental/carer concerns

• Clinical observation of the infant/child

• Promoting development (evidence-based advice, information, and education). The

experiences and interactions children are exposed to in the early years provide the

scaffolding upon which to build and nurture their development17.

• Clearly documenting in the child’s medical record all developmental assessment findings,

together with specific advice, information and education provided to the parent/carer.

7.4 Universal well child health developmental checks are undertaken at ages as per the PHR. When

undertaking a developmental assessment, use the developmental assessment profile form

recommended for use in your HHS. The developmental profile form provides a template to document

assessment findings and other relevant information; nutrition, feeding, growth and physical

assessment, parent/infant interaction, child development, anticipatory guidance, information and

education provided to the parent/carer. An example of a developmental profile template used within

Children’s Health Queensland (CHQ) HHS is available from

http://qheps.health.qld.gov.au/childrenshealth/resources/html/cf-pcp.htm

7.5 PEDS and the ASQ-3 are the developmental screening tools recommended for use in the community

child health practice setting17.

The PEDS screening tool is the primary developmental screening tool used at the 6, 12, 18 months,

2 ½ - 3 ½ year, and 4-5-year universal well-child health check1. If child development concerns are

identified through the PEDS developmental screen, an additional secondary screen may be

indicated17. The ASQ-3 is the recommended secondary developmental screening tool17.

Developmental screening tools are intended to support clinical decision making, however clinical

judgement is paramount in all clinical decision making20. If a clinical decision is made to override the

recommended PEDS pathway, the reason for not following the pathway must be clearly documented

in the child’s medical record.

All Child Health clinicians utilising the PEDS and ASQ-3 developmental screening tools must be

appropriately trained in their use17.

ALERT

Clinical judgement is paramount in all clinical decision making

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7.6 When further assessment is indicated, consider consultation and arrange for appropriate referral/s

as per the Child and Youth Health Practice Manual2 and local HHS referral recommendations and

pathways.

8. Consultation

Key stakeholders who reviewed this version:

CHSN Guideline Review Workgroup members:

Tracey Button, CNC, CHQHHS CYCHS CHS

Gwen Kemp, Team Leader, Child Youth and Family Health, Cairns

Helen Cook-Bland, CNC, Child Youth and Family Health, Women’s and Children’s Service, Darling Downs

HHS

Jacqui Willcox, Senior Paediatric Dietitian, GCHHS

Jennifer Deacon, Consultant Paediatrician, GCHHS

Kellie Hill, Clinical Nurse Maternal and Child Health Services, Division of Women and Children, CQHHS

Leonie Trembath, Clinical Nurse/Senior Project officer, CCHW, CHQHHS

Libby Morton, Program Manager, QCPIMH, CYMHS, CHQHHS

Rebecca Bradshaw, Clinical Nurse, GCHHS

The Guideline: Assessing infant / child nutrition, growth and development within the primary health care

setting, was circulated for feedback through the Queensland Child and Youth Clinical Network-Child Health

Sub Network for feedback.

Guideline feedback provided by:

Kirby Murtha, Community Nutritionist, Apunipima Cape York Health Council

Claire Reilly, Paediatric Dietician, Dietetics and Food Services Department, Lady Cilento Children’s

Hospital

Colleen Allman, CN, CHS, CHQHHS

Karen Berry, Nursing Director, CHS, CHQHHS

Karin Klepper, Advanced Physiotherapist, CDS, CHQHHS

Norma Ryan, CNC, CHQHHS

Robyn Penny, CNC Liaison, CHS, CHQHHS

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10. Definition of Terms

Definitions of key terms are provided below.

Term Definition Source

Screening ‘Screening is the presumptive

identification of unrecognised

disease or defect by the

application of tests, examinations

or other procedures which can be

applied rapidly. Screening tests

sort out apparently well persons

who probably have a disease

from those who probably do not.

A screening test is not intended

to be diagnostic. Persons with

positive or suspicious findings

must be referred to their

physicians for diagnosis and

necessary treatment’ (US

Commission on Chronic Illness

cited in Child Development Sub

Network, Statewide Child and

Youth Clinical Network).

Child Development Sub Network, Statewide Child and

Youth Clinical Network. Primary care and child

development information paper. Brisbane: Clinical

Access and Redesign Unit (CARU); 2012.

Child Health

Surveillance

‘Child health surveillance is the

systematic and ongoing

collection, analysis, and

interpretation of indices of child

health, growth, and development

to identify, investigate and, where

appropriate, correct deviations

from predetermined norms’

(Stone cited in Child

Development Sub Network,

Statewide Child and Youth

Clinical Network).

Child Development Sub Network, Statewide Child and

Youth Clinical Network. Primary care and child

development information paper. Brisbane: Clinical

Access and Redesign Unit (CARU); 2012.

Developmental delay “a lag in the acquisition of a skill

or milestone otherwise expected

of a child at a particular age. This

lag may be within a single

domain, or may be across many

areas of development (global

developmental delay)” Child

Development (2013)

Queensland Child and Youth Clinical Network - Child

Health Sub Network. Queensland Health Child

Development Screening (PEDS & ASQ3) –

Implementation Guide. Brisbane: Queensland Health;

2015. Available from:

https://www.childrens.health.qld.gov.au/chq/health-


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Anticipatory

Guidance

Anticipatory guidance is given by the health care provider to assist parents or guardians in the understanding of the expected growth and development of their children. Anticipatory guidance, specific to the age of the child, includes information about the benefits of healthy lifestyles and practices that promote injury and disease prevention.

https://www.atsdr.cdc.gov/emes/training/page19.html

11. References and suggested reading

1. Queensland Government. Personal Health Record (PHR) [Internet]. Brisbane QLD: Children's Health Queensland; 2016. Available from: http://www.childrens.health.qld.gov.au/community-health/personal-health-record/.

2. Statewide Child and Youth Clinical Network - Child Health Sub-Network. Child and Youth Health

Practice Manual. Brisbane, QLD: Queensland Health Children's Health Queensland Hospital and Health Service; 2014. Available from: https://www.childrens.health.qld.gov.au/chq/health-professionals/qcyc-network/

3. Day C, Ellies M, Harris L. Family partnership model: Relective practice handbook. London: South

London and Maudsley NHS Foundation Trust; 2015. 4. Children's Health Queensland Hospital and Health Service. Family Health Assessment: A guide for

child health nurses and other child health clinicians. Brisbane: Queensland Health; 2012.

Available from: http://qheps.health.qld.gov.au/ccyfhs/html/resources.htm

5. Australian College of Children & Young People's Nurses. Standards of Practice for Children and

Young People's Nurses. Australia: ACCYPN; 2016. Available from: http://www.accypn.org.au/

6. Nursing and Midwifery Board of Australia. Registered nurse standards for practice. Melbourne:

Australian Health Practitioner Regulation Agency; 2016. Available from:

http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-

standards.aspx

7. Australian Commission on Safety and Quality in Health Care. Health literacy: Taking action to

improve safety and quality. Sydney: ACSQHC; 2014. Available from:

https://www.safetyandquality.gov.au/

8. National Health and Medical Research Council. Infant feeding guidelines: information for health

workers. Australia: NHMRC; 2014. Available from: https://www.nhmrc.gov.au/guidelines-

publications/n56

9. Hockenbery MJ, Wilson D. Wong's Nursing Care of Infants and Children. 9th ed. Missouri: Mosby

Elsevier; 2011.

10. Engel J. Pocket Guide to Pediatric Assessment. 5th ed. Missouri: Mosby Elsevier; 2006.

11. Queensland Clinical Guidelines. Guideline: routine newborn assessment. Brisbane:

Queensland Health; 2014. Available from: https://www.health.qld.gov.au/qcg/html/publications.asp

12. National Health and Medical Research Council. Australian Guidelines for the Prevention and

Control of Infection in Healthcare. Australian Government; 2010. Available from:

https://www.nhmrc.gov.au/guidelines-publications/cd33

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13. Children's Health Queensland Hospital and Health Service (CHQHHS). Standard and

Transmission Based Precautions [QHEPS]. Brisbane QLD: CHQHHS; 2016. Available from:

http://qheps.health.qld.gov.au/childrenshealth/resources/html/alpha-list.htm

14. Queensland Centre for Perinatal and Infant Mental Health (QCPIMH). Perinatal and Infant

Mental Health [Internet]. Brisbane QLD: CHQHHS; 2017 [updated 2017 February 28].

Available from: https://www.childrens.health.qld.gov.au/chq/our-services/mental-health-

services/babies-and-parents/qcpimh/

15. Fox S, Southwell A, Stafford N, Goodhue R, Jackson D. Better systems, better chances: A review of

research and practice for prevention and early intervention. Canberra Australia: Australian

Research Alliance for Children & Youth; 2015. ISBN: 978-1-921352-95-9

16. D'Aprano A, Silburn S, Johnston V, Bailie R, Mensah F, Oberklaid F, et al. Challenges in

monitoring the development of young children in remote Aboriginal health services: clinical

audit findings and recommendations for improving practice. Rural and remote health.

2016;16(3):3852. (Level of Evidence 4b)

17. Queensland Child and Youth Clinical Network - Child Health Sub Network. Queensland Health

Child Development Screening (PEDS & ASQ3) – Implementation Guide. Brisbane: Queensland

Health; 2015. Available from: https://www.childrens.health.qld.gov.au/chq/health-


18. Department of Health and Ageing. National framework for universal child and family health

services. Sydney NSW: Australian Government; 2011. 68 p.

19. Oberklaid F, Drever K. Is my child normal?: Milestones and red flags for referral. Australian Family

Physician. 2011;40(9):666-670. (Level of Evidence 5c)

20. Alfaro-LeFevre R. Critical thinking, clinical reasoning, and clinical judgment: a practical approach.

5th ed. New York: Saunders Elsevier; 2013.

21. Chronic Conditions Manual: Section 3 child health checks. 1st ed. Queensland: Royal Flying

Doctors; 2015. Available from: https://publications.qld.gov.au/dataset/chronic-conditions-

manual/resource/a0d6e3e6-5ce4-4eeb-93c4-a4a9a09a4272

22. Lift the lip oral health resources http://qheps.health.qld.gov.au/lift-the-lip/

23. Thomson K, Tey D, Marks M. Paediatric Handbook. 8th ed. Melbourne Australia: Wiley- Blackwell;

2009.

24. Ainsworth et al. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale:

Erlbaun;1978.

25. Barlow J, Svanberg P. Keeping the baby in mind: Infant mental health in practice. London:

Routledge; 2009. (Level of Evidence 3a)

26. Karen R. Becoming attached: First relationships and how they shape our capacity to love.

Oxford: Oxford University Press;1994.

27. Mares S, Newman L. Clinical skills in infant mental health. Camberwell VIC: Acer Press; 2005.

28. Sharma A, Cockerill H. From birth to five years: Practical developmental examination. London:

Routledge; 2014.

29. Sheridan M, Sharma A, Cockerill H. From birth to five years: Children’s developmental progress. 4th

ed. London: Routledge; 2014.

30. Crossland D, et al. Weight change in the term baby in the first 2 weeks of life. Acta

Paediatrica, 2008 March; 97(4):425-429. doi:10.1111/j.1651-2227.2008.00685.x

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31. Nichols J. Normal growth patterns in infants and prepubertal children [Internet]. UpToDate; 2017

[Updated 2017 February]. Available from: http://www.uptodate.com/contents/normal-growth-

patterns-in-infants-and-prepubertal-

children?source=search_result&search=normal+growth+patterns+in&selectedTitle=1%7 E150

32. Statewide Maternity and Neonatal Clinical Guidelines Program. Examination of the newborn baby.

Brisbane: Queensland Health; 2009. Available from:

https://www.health.qld.gov.au/qcg/publications#maternity

33. Sheridan M, Alderson D. Play in early childhood: From birth to six years. 3rd ed. London:

Routledge; 2011.

34. Sharma A. Developmental examination: birth to 5 years. Arch Dis Child Educ Pract Ed. 2011 Mar

13; 96(5):162-175. doi:10.1136/adc.2009.175901

35. Queensland Child and Youth Clinical Network. Child health sub network breastfeeding position

statement. Department of Health. Available from:

https://www.childrens.health.qld.gov.au/chq/health-professionals/qcyc-network/

36. D’Agostino J. An evidentiary review regarding the use of chronological and adjusted age in the

assessment of preterm infants. Journal for Specialists in Pediatric Nursing, 2010;15(1):26-32.

Retrieved from https://search-proquest-

com.ezproxy2.acu.edu.au/docview/195760499?accountid=8194 (Level of Evidence 3a)

37. The Royal Children’s Hospital Melbourne. PEDS Brief administration and scoring guide. The Royal

Children’s Hospital Melbourne. Melbourne: Australia.

38. The Royal Children’s Hospital Melbourne. Child growth learning resource. Available from:

http://www.rch.org.au/childgrowth/Child_growth_e-learning/

39. Squires J, Twombly E, Bricker D, Potter L. ASQ-3 User’s Guide. Maryland: Brookes; 2009.

40. Day C. Family partnership model connecting and working in partnership with families. Australian

Journal of Child and Family Health Nursing. 2013 Jun; 10(1):4-10. (Level of Evidence 5c)

41. An overview of attachment theory. Community Paediatric Review. Centre for Community Child

Health. 2009;17(2). Available from: http://www.rch.org.au/ccch/publications-resources/cpr/ (Level of

Evidence 4a)

42. The Royal Children’s Hospital Melbourne. Clinical practice guidelines: poor growth. Available from:

http://www.rch.org.au/clinicalguide/guideline_index/Poor_growth/

43. The Royal Children’s Hospital Melbourne. Feeding development and difficulties: Mealtime

environment. Available from: http://www.rch.org.au/feedingdifficulties/development/mealtime-

environment/

44. PEDS developmental milestone checklist - CHQ Staff Resources

http://qheps.health.qld.gov.au/ccyfhs/html/resources.htm

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12. Level of Evidence

The Joanna Briggs Institute (JBI) levels of evidence have been applied to identify the study design of

research included in the guideline. Where applicable, the level of evidence is indicated at the end of the

reference in the reference list. The JBI Levels of Evidence can be accessed from:

http://joannabriggs.org/jbi-approach.html

13. Guideline Revision and Approval History

Version No. Modified by Amendments authorised by Approved by

1.0 T Button J Pratt QCYCN, CHSN

2.0 T Button Catherine Marron, Pamela Hueber QCYCN, CHSN

14. Keywords and Accreditation references

Keywords Assessing, nutrition, growth, development, child health, primary health care

Accreditation

references

NSQHS Standards (1-10): Standard 1: Governance and quality improvement systems,

Standard 2: Partnering with Consumers, Standard 6: Clinical Handover

EQuIPNational Standards (11-15): Standard 11: Service Delivery, Standard 12: Provision of

Care,

Child Health Sub Network Guideline: Assessing infant / child nutrition, growth and development within the primary health care setting

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Appendix 1

Assessing Nutrition from birth to 5 years of age8

0-4 weeks 2 months 4 months 6 months 12 months 18 months 2 ½ - 3 ½ years 4-5 years

Breastfeeding

Formula feeding

Breast and formula feeding

Safe use of EBM

Safe use of infant formula including availability, preparation & storage

No cow’s milk or solid foods

Elimination number of nappies; wet / bowel motions

Breastfeeding

Formula feeding


Safe use of EBM


No cow’s milk or solid foods


Breastfeeding

Formula feeding


Safe use of EBM


No cow’s milk

Introduce solid foods at around 6 months

Oral health


Breastfeeding

Formula feeding


Safe use of EBM


No cow’s milk to drink

Introduce solid foods at around 6 months

Starting solid foods and texture transition from 6-12 months

Cooled boiled water from a cup

Offer food that is age & developmentally appropriate

Mealtime environment

43

Transition to family foods, encouraging variety of foods from the core food groups

Healthy snacks & meals

Continuing breastfeeding

Stopping infant formula, work toward ceasing bottles

Introducing cow’s milk (full cream) and water from a cup

Offer appropriate amount of food & allow infant to decide for themselves how much they eat

Food security (availability, access, preparation & storage) e.g. If child is hungry is food always available

Mealtime environment43

Family foods, encouraging variety of foods from the core food groups

Healthy snacks & meals

Continuing breastfeeding

No formula / bottles

Full cream cow’s milk or water

No soft drinks, juice or cordial


Food security (availability, access, preparation & storage) e.g. If child is hungry is food always available


43


Healthy snacks &

meals

No bottles

Reduced fat cow’s

milk or water

No soft drinks, juice

or cordial

Offer appropriate

amount of food &

allow infant to

decide for

themselves how

much they eat

Food security

(availability, access,

preparation &

storage) e.g. If child

is hungry is food

always available

Mealtime

environment43


Healthy snacks/meals

No bottles

Reduced fat cow’s milk or water

No soft drinks, juice or cordial


Food security (availability, access, preparation & storage) e.g. If child is hungry is food always available?


43


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Assessing Nutrition from birth to 5 years of age8 (cont.)



Food security (availability, access, preparation & storage) e.g. If infant is hungry is food always available

Oral health (lift the lip)

22

Elimination

number of nappies; wet / bowel motions


Self-feeding


Elimination

Independent eating


Elimination

Oral health (lift the

lip)

Elimination


Elimination


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Growth and Physical assessment from birth to 5 years of age2,9-11


Measure and plot

on WHO growth

chart

• Weight

• Length

• Head

circumference

(HC)

Measure and plot

on WHO growth

chart

• Weight

• Length

• HC

Measure and plot

on WHO growth

chart

• Weight

• Length

• HC

Measure and plot

on WHO growth

chart

• Weight

• Length

• HC

Measure and plot

on WHO growth

chart

• Weight

• Length

• HC

Measure and plot

on WHO growth

chart

• Weight

• Length

• HC

Measure and plot

on CDC growth

chart

• Weight

• Height from 2 years

• HC up to 2 years

• BMI from 2 years

Measure and plot

on CDC growth

chart

• Weight

• Height

• BMI

General

appearance

Skin

Head / Fontanelle

Face, Eyes, Mouth,

Neck

Chest, Abdomen

Genitalia

Extremities

Hips

Back

Neurological

(posture, tone,

reflexes)

General

appearance

Skin

Head / Fontanelle

Face, Eyes, Mouth,

Neck

Chest, Abdomen

Genitalia

Extremities

Hips

Back

Neurological

(posture, tone,

reflexes)

General

appearance

Skin

Head / Fontanelle

Face, Eyes, Mouth,

Neck

Chest, Abdomen

Hips

Genitalia

Neurological

(posture, tone,

reflexes

General

appearance /

behaviour

Head / Fontanelle

Face, Eyes, Mouth

Neck

CLR

Hips

Genitalia

Neurological

(posture, tone,

reflexes)

General

appearance /

behaviour

Head / Fontanelle

Face, Eyes, Mouth

Neck

CLR

General

appearance /

behaviour

Head / Fontanelle

Face, Eyes, Mouth

Neck

CLR

Gait

General

appearance /

behaviour

Head, Face, Eyes,

Mouth, Neck

CLR

Gait

General

appearance /

behaviour

Head, Face, Eyes,

Mouth, Neck

CLR

Vision

• Acuity

• Cover test near

& far

Otoscopy

Hearing screening

Gait


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Additional Information for rural and remote populations

And

Aboriginal & Torres Strait Islander Children Chronic Conditions Manual – Section 2: Child Health Checks21


Clinical Measurement21 (p. 342)

• Breathing

• Heart sounds

• Breathing

• Heart sounds

• Breathing

• Heart sounds

• Breathing

• Heart sounds

• Haemoglobin

• Breathing

• Heart sounds

• Haemoglobin

• Breathing

• Heart sounds

• Haemoglobin

• Breathing

• Heart sounds

• Haemoglobin (<3 years of age)

• BMI (yearly from 2 years)

• Breathing

• Heart sounds

• BMI

Hearing21 (p.359)

• Ask hearing assessment questions


• Otoscopy


• Otoscopy


• Otoscopy

• Tympanometry


• Otoscopy

• Tympanometry


• Otoscopy

• Tympanometry


• Otoscopy

• Tympanometry


• Otoscopy

• Tympanometry

• Audiometry

Eyes and vision21 (p. 375)

• Eye appearance

• Red eye reflex

• Eye appearance

• Red eye reflex

• Eye appearance

• Red eye reflex

• Red eye reflex

• CLR

• Red eye reflex

• CLR

• Red eye reflex

• CLR

• Red eye reflex


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Development

Knowledge of typical infant/child development is required to undertake developmental assessment and screening. The following resources will provide some additional information regarding early childhood learning and development:

• From birth to five years: Practical developmental examination28

.

• From birth to five years: Children’s developmental progress29

• Laying the Foundations eLearning, Centre for Community Child Health http://www.rch.org.au/ccch/training-dev/Laying_the_Foundations_eLearning/

• PEDS developmental milestone checklist - CHQ Staff Resources http://qheps.health.qld.gov.au/ccyfhs/html/resources.htm

Social / emotional development24-27, 41


Infant momentarily looks at faces

Shows preference for people to inanimate objects

Turns head in response to familiar parental voice or smell

Mother (or primary care giver) is sensitive to and responds appropriately to infant’s cues

Social smile 6-8

weeks

Physiological

regulation

developing patterns

of settling, feeding,

and alertness

Mother (or primary

care giver) is

sensitive to and

responds

appropriately to

infant’s cues

Shows excitement in response to people

First signs of infant’s preference towards certain adults e.g. smiles, gestures

Engages in ‘peek-a-boo’

Mother (or primary

care giver) is

sensitive to and

responds

appropriately to

infant’s cues

Separation protest present - the beginning of ‘stranger anxiety’ Infant shows clear preference for certain adults Increasing need for infant to ‘check in’ with parent - with voice or visual cues

Mother (or primary

care giver) is

sensitive to and

responds

appropriately to

infant’s cues

Shows emotions e.g. may give affection hugs/kisses Waves ‘bye-bye’, claps hands together

Actively seeks their mother (or primary care giver) when distressed Readily comforted when reunited with their mother (or primary care giver)

Infant explores their

environment,

returning to their

mother (or primary

care giver) for

reassurance

Beginning to show recognition of themselves in the mirror

Shows verbal self -

identity when

speaking e.g. ‘I’,

‘me’, ‘mine’

Development of

imaginative play

Beginning to protest

e.g. ‘no’ and

experiments with

control over events

and people

Becoming less

fearful with

strangers

Explore their

environment,

returning to their

mother (or primary

care giver) for

reassurance

Notices gender differences e.g. I’m a girl At 3 years of age children begin to understand others i.e. empathy Possess a range of words for their own emotions Able to share and cooperate in play Can become wilful or possessive Begin to predict events Able to separate from parents more easily Can tolerate longer separations from mother (or primary care giver)

Symbolic and imaginative play becomes more elaborate

Increasingly aware of social expectations / responsibilities

Friendships develop and strengthen

Increasingly flexible and resilient under stress

Beginnings of capacity to know that others have thoughts and feelings separate from their own

Tolerates separation from mother (or primary care giver)


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Communication / Language9, 44


Cries to alert parent/s they require attention e.g. feeding, cuddle, nappy change Startles to loud noise

Cries to alert parent/s they require attention e.g. feeding, cuddle, nappy change Vocalizes coos

Cries to alert parent/s they require attention e.g. feeding, cuddle, nappy change Squeals

Cries to alert parent/s they require attention e.g. feeding, cuddle, nappy change Vocalizes; Begins to imitate sounds Smiles / vocalizes to mirror

Says 3-5 words Understands simple commands, responds to their own name being called Imitates animal sounds

Says > 10 words Forming word combinations Points to familiar people when named

Understands directions given Saying >300 words Using 2-3 word combinations

Uses sentences Likes telling stories Questions

Fine Motor 9

Hands mostly closed - fists

Hands more relaxed - often open

Looks at and plays with his/her hands

Transfers toys from one hand to the other

Pincer grasp – picks up small objects with thumb and forefinger

Scribbles Builds tower of 3-4 blocks

Holds crayon with fingers Draws circles and lines

Draws a person in three parts Uses scissors

Gross Motor9

In the prone position Infant can turn his/her head to the side

In the prone position infant can lift their head 45 degrees In the supine position moves arms & legs, generally spontaneous motor activity

In the prone position the infant is able to lift his/her head up and upper chest well with weight on forearms When pulled to the sitting position head follows (little or no head lag)

In the prone position the infant is able to lift his/her head and chest well up, pushes up on hands / extends arms When pulled to the sitting position head follows No head lag

Infant is able to walk holding onto furniture When sitting on the floor infant is well balanced in all directions and is able to get in & out of the sitting position independently

Walks well / runs stiffly Is able to seat them self in a chair

Walks up and down stairs Throws and kicks a ball

Hops on one foot Throws and catches a ball well


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Appendix 2

Nutrition2,8-10,35

Assessment Resources

• Breastfeeding provides infants (up to the age of 6 months) with all the nutrition they need for healthy growth and development.

• Assess infant / child’s nutritional intake at each child health check; ask

broad, open – ended questions e.g. what signs does your baby show

when she/he is hungry? Ask closed ended questions if you need

specific details e.g. how many wet nappies does your baby have each

day?

• Provide mothers with support to establish and maintain breastfeeding.

Ensuring they receive the help they need to achieve their

breastfeeding goal/s, and refer for further breastfeeding assessment

and support as required.

• Ensure mothers receive consistent, evidence-based breastfeeding

information. Refer to the Child and Youth Health Practice Manual,

section 2, Birth to five years, Assessing infant nutrition (P. 52-73) for

further information2

• When observing a breastfeed, pay particular attention to the positioning

and attachment.

• Assess safe use of infant formula; preparation and cleaning of infant

feeding equipment, storage and transport of infant formula.

• Provide parent/carer with accurate evidence-based information and

resources, based on the NHMRC Infant Feeding Guidelines (2013)

and Australian Dietary Guidelines (2013)

• Discuss with parent/carer developmental signs that indicate infant

readiness to start solid foods

• Provide culturally appropriate resources

• Provide messages consistent with National Physical Activity

Recommendations

• NHMRC Infant Feeding Guidelines, Information for health workers https://www.nhmrc.gov.au/guidelines-publications/n56

• Australian Dietary Guidelines (2013)

https://www.nhmrc.gov.au/guidelines-publications/n55

• Maternal and infant nutrition http://www.health.qld.gov.au/breastfeeding

• Breastfeeding Helpline 1800 mum 2 mum 1800 686 2 686

• Children’s health fact sheets https://www.childrens.health.qld.gov.au/chq/health-

professionals/fact-sheets/

• Australian Breastfeeding Association www.breastfeeding.asn.au

• Lactation Consultants of Australia and New Zealand (LCANZ) www.lcanz.org

• 13 HEALTH 13 43 25 84 (24 hr health information phone line)

• Child Health Information Your guide to the first 12 months

https://www.childrens.health.qld.gov.au/chq/information-for-families/personal-health-record/

• Promoting Optimal Maternal and Infant Nutrition Project (POMIN) http://qheps.health.qld.gov.au/childrenshealth/html/statewide/pomin/home.htm

• National Physical Activity Recommendations for Children (0-5 years) http://www.health.gov.au/internet/main/publishing.nsf/content/phd-physical-activity-0-5-pdf-cnt.htm

• Nutritional Education Materials Online (NEMO) https://www.health.qld.gov.au/nutrition/default.asp

• Centre for Children’s Health and Wellbeing, Baby’s first foods https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/centre-childrens-health-wellbeing/babys-first-foods/

• Good Start Program https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/good-start-program/

• Raising Children network, nutrition http://raisingchildren.net.au/nutrition/newborns_nutrition.html

• Lift the lip oral health resources http://qheps.health.qld.gov.au/lift-the-lip/

• Australian society of clinical immunology and allergy (ascia) https://www.allergy.org.au/


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Growth2,8,9,28,29,30,38


• Normal physical growth is an important indicator of an infant/child’s overall health and

nutritional status. Physical growth is best assessed by measuring weight, length/height and

head circumference2(p42-90)

• Following birth infants can lose up to 10% of their birth weight. By day 6 they should start to

regain this weight and should have regained their birth weight by 2 weeks. There should be

regular weight gain throughout the first year of life, approximately;

o birth to 3 months a gain of 150g – 200g per week

o 3 - 6 months a gain of 100g – 150g per week

o 6 - 12 months a gain of 70g – 90g per week

o Weight gain between 1-5 years of age approximately 2-3kg per year

It is recommended that children be weighed and measured (head circumference, length) at

regular intervals, as per the Personal Health Record1,38

. These recommendations are for

otherwise healthy children.

Refer to the Child and Youth Health Practice Manual2(p43-46)

for the recommended procedure for

measuring infant/child – weight, length / height and head circumference

• Plotting children’s growth on growth charts:

For preterm infants, use the Fenton Advanced Growth Chart from 22-50 weeks.

Once the infant reaches their expected birth date use the WHO 0 - 2 years

growth chart.

From 2 years of age use the CDC 2 – 20-year growth chart.

Other growth charts are available for children with specific conditions42

• Interpreting growth charts

After measuring the infant/child and plotting measurements on the appropriate chart for

age and gender, assess the child’s growth curve against the growth percentile lines.

Serial measurements over time are needed to assess a child’s growth. Growth

assessment involves looking at the overall tracking of weight, length / height on a

growth chart. One-off measurements show a child’s size but not their growth. Growth

charts are not a diagnostic tool, but contribute to forming an overall clinical impression

of the child.

• Body Mass Index (BMI) for age (not standard adult BMI) can be calculated and plotted

for weight and height from 2 years; refer to Child and Youth Health Practice Manual2.

• Child and Youth Health Practice Manual (Child Health Sub Network-key

documents) https://www.childrens.health.qld.gov.au/chq/health-

professionals/qcyc-network/ 2

• Chronic Conditions Manual: Section 3 Child Health Checks24

https://publications.qld.gov.au/dataset/chronic-conditions-

manual/resource/a0d6e3e6-5ce4-4eeb-93c4-a4a9a09a4272

• Growth chart within infant/child’s PHR

https://www.childrens.health.qld.gov.au/chq/information-for-

families/personal-health-record/

• Child growth learning resource

http://www.rch.org.au/childgrowth/Child_growth_e-learning/

• The WHO Child Growth Standards www.who.int/childgrowth/standards/en

• Centres for Disease Control www.cdc.gov/growthcharts

• The Royal Children’s Hospital Melbourne. Clinical practice guidelines: poor

growth http://www.rch.org.au/clinicalguide/guideline_index/Poor_growth/

BMI is the standard tool to assess child overweight and obesity in children over 2

years38


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Growth2,8,9,28,29 (cont.)


• Poor growth generally describes a child whose current weight, or rate of weight gain, is

significantly below that expected of similar children of the same age and sex. Adequacy

of growth is best evaluated by plotting serial measurements on a centile weight chart. A

child who is tracking downwards on the charts may have poor growth and needs thorough

assessment and evaluation for nutritional or other causes42

• Indicators of poor growth

o Weight and/or length tracking downwards on the percentile growth chart.

• Indicators of excessive growth

o Weight and/or length for age tracking upwards on the percentile growth chart.

o If measuring BMI for children over 2 years of age, a BMI above the 85th

percentile.

• Monitor

o Weight or length/height for age less than the 3rd

percentile

o Weight or length/height for age greater than the 97th

percentile

NOTE: that there will always be a bottom and top 3% and that these measures do not

necessarily indicate a growth problem.

• Further investigate

o Unexplained weight loss or weight not re-gained following acute illness

o Weight or length/height ‘plateau’

o Weight for age, length/height for age, increasing or decreasing percentiles on the

growth chart

o Head circumference above the 97th

percentile or below the 3rd

percentile2

o BMI increasing or decreasing percentiles on the growth chart, or a BMI greater

than the 85th

percentile


of 27


Physical Assessment2,9-11,29


• General appearance – Infant’s response to parent/carer & examiner, state of alertness,

activity, range of spontaneous movement, posture, muscle tone, odour, how infant is

dressed i.e. clean / dressed appropriately for weather.

• Skin – integrity, turgor, colour, marks, pigmentation, rashes, lesions, sores, bites, jaundice,

bruising, anomalies

• Head

o Shape and symmetry

o Fontanelle; posterior fontanelle closed by 8 weeks, anterior fontanelle closes 12-18

months.

o Sutures

o Face

o Symmetry

o Note any unusual facial proportions e.g. small receding chin, wide or close set eyes

o Ears – position, structure –including patency of the external auditory meatus, startle

reflex present to sudden loud noise, check that Neonatal hearing screen has been

completed

o Eyes – pupil restricts in response to light, No opacities or haziness, white / clear sclera,

0-4 weeks- infants ability to look at faces and by 6 months their ability to follow moving

objects.

o Mouth – hard and soft palates, mucosal lining of lips cheeks, gums, tongue and

frenulum

o Nose – patent nares

Neck

o Normal range of movement – limited range of movement may indicate torticollis or

wryneck

• Wong’s Nursing Care of Infants and Children

• Pocket Guide to Paediatric Assessment

• Paediatric Handbook

• State wide Maternity Clinical Guideline: Examination of the newborn baby

http://www.health.qld.gov.au/qcg/

• Newborn screening laboratory 36 36 70 51

• Child and Youth Health Practice Manual (Child Health Sub Network-key

documents) https://www.childrens.health.qld.gov.au/chq/health-

professionals/qcyc-network/ 2


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Physical Assessment2,9-11,29 (cont.)


Back

o Symmetry of scapulae and buttocks

o Spine intact

Hips

o Equal hip abduction

o Supine – equal leg length

o Prone - symmetrical thigh and gluteal folds

Nervous system

o Behaviour

o Posture

o Muscle tone

o Movement

Reflexes → Moro, Suck, Rooting, Grasp, Stepping/Walking

Arrange appropriate referral or review when problems are identified


of 27


Development2,19,25,26,28,34


• Ask the parent/carer if they have any concerns regarding their infant/ child’s development.

• Observe infant – paternal interaction. Refer to Appendix 2(p19)

and the Child Health Manual for milestones in the development of attachment

2(p107,120)

• Gather information by asking the parent/carer and by observing the infant/child

• Perform age appropriate developmental assessment

• Correct age for prematurity when assessing the growth and development of infants born before 37 completed weeks’ gestation until 2 years of age. Infants born at 37 weeks or beyond do not require age correction

36-39

• To correct age for prematurity, subtract the number of weeks the infant was born prematurely from the chronological age (in weeks) and assess the child’s growth and development for the corrected age:

Corrected age = Actual age in weeks - number of weeks premature 2,38

• Promote development – using evidence-based information and resources

• The Red Flags Early Intervention Guide (for children aged birth to five years); Second Edition can assist parents/carers and health professionals to identify developmental concerns (red flags) that require further developmental assessment.

• Follow the referral guidelines for the developmental screening tool being used, and refer developmental delays for further assessment

• Refer any regression of developmental milestones for further developmental assessment

• Brain Builders, video clip, Centre for Community Child Health Laying the Foundations eLearning, Centre for Community Child Health http://www.rch.org.au/ccch/training-dev/Laying_the_Foundations_eLearning/

• PEDS developmental milestone checklist - CHQ Staff Resources http://qheps.health.qld.gov.au/ccyfhs/html/resources.htm

• PEDS Training eLearning, Centre for Community Child Health http://www.rch.org.au/ccch/training-dev/PEDS_training/

• Ages and stages parent information sheets https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/child-health-service/

• Raising Children Network – Grow & Learn Together http://raisingchildren.net.au/growandlearn/intro

• Red Flags Early Intervention Guide (for children aged birth to five years); Second Edition https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/child-development-program/

• Children’s Health Queensland (CHQ), Queensland Centre for Perinatal and Infant Mental Health website https://www.childrens.health.qld.gov.au/chq/our-services/mental-health-services/babies-and-parents/qcpimh/

• CHQ, Queensland Centre for Perinatal and Infant Mental Health http://qheps.health.qld.gov.au/qcpimh/

• Department of Communities, Child Safety and Disability Services

https://www.communities.qld.gov.au/disability

• Text Books:

o From birth to five years: Practical developmental examination28

o From birth to five years: Children’s developmental progress29

o Play in early childhood: from birth to six years33

o Wong’s Nursing Care of Infants and Children9

o Pocket Guide to Pediatric Assessment10


of 27


Additional Information for rural and remote populations And

Aboriginal & Torres Strait Islander Children21


Perform additional child health assessments / screening for rural and remote populations, as outlined in the Chronic Conditions Manual

• Perform additional child health checks at 9, 15 and 21 months → The purpose of these additional child health checks are to ensure follow up for those children who have not met growth and nutrition targets at previous checks

• Fontanelle → Check at each well child health check from 0-4 weeks up to and including 2 years

• Ears and hearing (There is a high level of hearing loss in Aboriginal and Torres Strait Islander people)

• Eyes and vision → Appearance of the eye, Red eye reflex and Corneal light reflex

• Haemoglobin → Check haemoglobin at 6 months of age (if preterm or LBW infant check from 4 months) then 3 monthly to 2 years

• BMI yearly from 2 years of age. BMI is calculated using the following formula:

BMI = weight (kg) / height (m2)38

• Refer to the Chronic Conditions Manual – Section 2: Child Health Checks for detailed information regarding health check content and procedures - including when to refer

21

• Growing Strong - Pregnancy, breastfeeding, food and drink for children https://www.health.qld.gov.au/nutrition/pregnancy-indigenous

• Australian Indigenous HealthInfoNet http://www.healthinfonet.ecu.edu.au/

child health sub network guideline€¦ · 4.1 prior to assessing the infant / child’s nutrition,...

Documents