Well-child visits

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The well-child visits are a vital component of pediatric and public health care, allowing for the prevention of disease through immunizations and anticipatory guidance, and early detection of existing individual health issues that require further follow-up. The schedule starts shortly after birth with the first well-child examination conducted at 3–5 days of age. The first 36 months of life is a time of rapid growth and development and children should be closely monitored with a series of regularly scheduled visits at gradually increasing intervals (from every 2 months to every 6 months). From the age of 3 years, children are assessed annually. Important components of the well-child check-up include age-specific screening recommendations, history taking and physical examination, growth and development assessment (including developmental milestones), administering immunizations, and proactive anticipatory guidance for children.

Schedule [2][3]

• Neonatal visits
  • 3–5 days after birth
  • Another visit by 1 month of age (typically at 2 weeks or 1 month)
• During the first three years: at 2, 4, 6, 9, 12, 15, 18, 24, and 30 months of age
• 3 years and older: annual visits

Approach

Perform the following at every well-child visit.

• Review the child's:
  • Past medical history, including any active medical issues
  • Results of pediatric screening questionnaires (e.g., developmental surveillance, risk assessments)
  • Vital signs and growth charts
• Perform a thorough review of systems and physical examination.
• Recommend and discuss age-appropriate:
  • Immunizations according to the ACIP schedule
  • Pediatric screening studies
  • Pediatric anticipatory guidance
• Arrange the following:
  • Further evaluation for abnormal findings, e.g., studies, treatment, follow-up
  • The next well-child visit appointment
• For children ≥ 11 years of age, see also “Adolescent health care.”

A sports physical, or preparticipation examination, involves additional history and physical examination components. [4]

Overview of visits by age [3]

The following tables are an outline of the recommended content of well-child checks for healthy children with no additional risk factors identified. If additional risk factors are identified at any point (e.g., risk factors for pediatric hypertension, risk factors for lead toxicity), more frequent screenings (e.g., at every visit) may be required.

Screen children once between birth and 21 years of age for risk factors for hepatitis B and if risk factors are present, send HBV serology, even if the child has been vaccinated. [3]

Infancy

Screen children for risk factors for dental caries once at 6 months and at 9 months. If the child does not have an established dentist by the recommended age of 12 months, continue to assess for risk factors and the need for fluoride varnish through 6 years of age.[3]

Toddlers and preschool children

School-aged children and adolescents

Approach [7][8]

• Obtain all indicated growth parameters at each visit.
• Plot measurements on a gender-specific growth chart.
  • < 2 years: WHO growth charts [7]
  • ≥ 2 years: CDC growth charts [9]
  • Special patient populations: Use a condition-specific growth curve, if available. [10]
• Calculate the mid-parental height in order to [10]
  • Determine the expected adult height based on genetic potential [11]
  • Compare current growth percentiles to the expected growth percentiles
• Track growth over time to identify pediatric growth patterns.

Pediatric growth patterns [8]

• Normal pediatric growth
  • Proportionate growth parameters
  • Growth parameters that follow closely to a percentile curve [8][10]
  • Expected height within 2 standard deviations (i.e., 10 cm or 4 inches) of the mid-parental height [10]
• Abnormal pediatric growth
  • Values that deviate ≥ 2 standard deviations from the mean, i.e. < 3% or > 97% percentiles
  • Crossing ≥ 2 major percentile lines on the growth curve [8]
  • Deviating > 10 cm (4 inches) from the mid-parental height [10]
  • Disproportionate parameters

To help identify abnormal growth patterns, compare the child's growth parameter percentiles to their expected adult height (i.e., mid-parental height). [10][11]

Children < 2–3 years may cross major percentiles, but after this time should track consistently. [8]

Growth parameters [8]

In children with normal development, examination, and no evidence of rapidly increasing FOC, macrocephaly is most likely benign (e.g., due to familial macrocephaly). If parental FOC suggests a genetic contribution to a child's macrocephaly, management involves reassurance and observation. [23]

• Routine screening allows early detection and early treatment of common healthcare problems.
• This section includes recommendations from the American Academy of Pediatrics (AAP) and the US Preventative Services Task Force (USPSTF).
• For additional recommendations (e.g., sexual health screening, substance use) in older children, see “Adolescent health care.”

• See also “Pediatric growth” for recommendations on monitoring height and weight.

Vision screening identifies conditions, e.g., cataracts, strabismus (in infants ≥ 4 months of age), amblyopia, that require interventions to prevent permanent vision loss. During a fundoscopic evaluation, the absence of a red reflex and/or the presence of leukocoria requires urgent ophthalmology referral and further evaluation. [41]

Hearing loss can be mistaken for other conditions. Always perform a pediatric hearing screening in children with communication disorders, neurodevelopmental disorders, and behavioral problems. [42][43]

Screening studies for anemia and dyslipidemia are required at set ages, regardless of risk factors. Screening studies for hepatitis B, lead toxicity, tuberculosis, and sudden cardiac death are only performed in patients with confirmed risk factors.

See also “Child development and milestones.”

History [24]

• Review the patient's medical and family history.
• Perform a pediatric review of systems, including
  • Constitutional symptoms (e.g., changes in weight, fevers)
  • Sleep-related concerns (e.g., deficient sleep, night terrors, napping, snoring)
  • Dietary concerns (e.g., picky eating, unhealthy eating habits, eating disorders)
  • Elimination disorders (e.g., daytime continence, encopresis, nocturnal enuresis, constipation in children)
  • Menstrual cycles (e.g., menarche, menstrual cycle abnormalities)
  • School-related concerns (e.g., ADHD symptoms, learning disorders, academic problems)
  • Behavioral concerns (e.g., temper tantrums, anxiety, depression)
• See “Pediatrics: history and physical examination” for more information.

Physical examination [24]

• Perform a thorough physical examination, including age-specific examinations.
• See “Pediatrics: history and physical examination” for further information.

Normal pediatric vital signs vary greatly by age.

Anticipatory guidance involves proactive counseling for expected age-appropriate topics (e.g., safety, healthy lifestyles, nutrition, and dental care). See also “Anticipatory guidance for pediatric development.”

Pediatric illness anticipatory guidance

• Illness prevention
  • Advise adherence to recommended immunizations in children.
  • Discuss strategies to prevent disease transmission (e.g., hand hygiene, respiratory hygiene), especially around at-risk populations.
  • Educate parents of newborns on neonatal umbilical hygiene.
• Illness management
  • Educate parents on signs of illness (e.g., clinical features of neonatal bacterial infection, clinical features of pediatric fever)
  • Discuss anticipatory guidance for pediatric fever.
  • Give examples of when to:
    • Seek emergency care (e.g., signs of respiratory distress, clinical features of dehydration, red flags for pediatric fever)
    • Contact the pediatrician's office
  • Follow school or childcare guidance on when to return to childcare or school.

Child safety [24][61][62]

• Sleeping [63]
  • Provide counseling on sudden infant death syndrome and prevention of SIDS.
  • Educate on proper swaddling: safe sleep swaddling, healthy hip swaddling.
• Secondhand smoke: Advise caregivers on the risks of secondhand smoke and offer assistance with smoking cessation.
• Child passenger safety: Children ≤ 13 years of age should ride in the back seat in a car safety seat that is approved for their age, weight, and height. ; [2][64][65][66]
  • Laws regarding minimum safety requirements for car safety seats vary between states.
  • The AAP recommends using car safety seats in the following order; advance to the next seat once the child reaches seat limits:
    • Rear-facing with harness: starting at birth until at least 2 years of age
    • Forward-facing with harness (convertible or dedicated forward seat)
    • Booster seat
  • Lap and shoulder seat belts can be used once they fit correctly.
• Supervision
  • Supervision must be provided by a responsible adult who is awake and not under the influence of alcohol or other substances. [67]
  • 3–5 years: Continuous supervision is necessary. [68]
  • 6–8 years: Supervision is necessary near bodies of water or during risky activities (e.g., climbing). [69]
• Bullying and abuse prevention: Teach verbal children (e.g., ≥ 3 years of age) how to recognize, respond to, and report inappropriate interactions.
• Street and recreational safety
  • Instruct children to wear protective gear when engaging in activities with an increased risk of injury (e.g., cycling, skateboarding).
  • Teach children road safety.
• Water safety: Encourage multiple preventive strategies.
  • Do not leave children unattended near bodies of water.
  • Consider survival swim lessons at an early age.
  • A self-locking fence should be installed around pools.
• Sun safety
  • Advise sun avoidance and protective clothing.
  • Use sunscreen in children ≥ 6 months of age.
• Childproofing the house
  • Pediatric poisoning prevention: Keep the following out of reach of children. [70]
    • Potentially harmful household products (e.g., laundry detergent pods, cleaning products)
    • Medications (prescription and nonprescription, including vitamins)
    • Alcohol containers and nicotine products
  • Set water heaters to 120°F (49°C) maximum temperature.
  • Firearms should be locked out of reach of children (unloaded with ammunition stored separately).
  • Anchoring furniture to walls can prevent accidental crush injuries.
  • Keep areas accessible to children (e.g., floors, tables) clear of small objects.
• Fire safety: Install smoke alarms and formulate a family escape plan.
• Medication safety for children
  • All medications should be stored in a secure location that is out of reach of children.
  • Educate caregivers on over-the-counter medications to avoid dosing errors. [71]
    • Ensure the medication is approved for the child's age.
    • Use single-ingredient medications whenever possible.
    • Follow dosing labels; weight-based dosing is preferred over age-based dosing.
    • See also “Home management of pediatric fever.”
  • Ask about use of complementary and alternative medicine. [72]

Pediatric lifestyle recommendations [24][73]

• Pacifier use [63][74]
  • Consider delaying pacifier use until breastfeeding has been well-established.
  • To assist in prevention of SIDS, encourage pacifier use during sleep in infants 1–6 months of age.
  • Limit pacifiers after 6 months of age to reduce the risk of otitis media.
  • Discontinue pacifiers at 2 to 4 years of age to prevent adverse dental effects (e.g., dental malocclusion).
• Behavior and discipline
  • Discuss age-appropriate behaviors to manage parent expectations.
  • Encourage consistency, positive reinforcement, and age-appropriate discipline.
  • For persistent behavioral problems (e.g., temper tantrums, aggression), recommend evidence-based parenting programs.
• Toilet training [75]
  • Initiation: At 2.5–3 years of age, when children are developmentally mature enough to begin toilet training. [76]
  • Use positive reinforcement.
  • Completion: typically by 4 years of age
• Screen time [24][68][73]
  • Children aged < 18 months: Avoid screen time, with the exception of video calls.
  • Children aged 18–24 months: Limit screen time solely to educational content.
  • Children aged 2–5 years: Restrict sedentary screen time to ≤ 1 hour/day.
  • For older children:
    • Encourage use of an agreed plan for caregiver supervision, limits on screen time, and scheduled screen-free time.
    • Avoid screen time within 1 hour of bedtime and keep devices out of children's bedrooms.
• Sleep: See also “Counseling on sleep hygiene.” [77]
  • 3–5 years: A total of 10–13 hours of sleep is recommended (including naps).
  • 6–12 years: Children should get 9–12 hours of sleep; daytime naps should not be forced.
• Physical exercise: Ensure at least 60 minutes of daily physical activity.
• Personal hygiene: Establish good hygiene habits, including hand hygiene, respiratory hygiene, regular bathing; in adolescents, this should also include the use of deodorant.
• Counseling on sexual activity, smoking, alcohol, and drug use: See “Adolescent health care.”

Do not attach pacifiers to sleeping infants or to items that present a suffocation risk (e.g., stuffed animals). [63]

Pediatric nutrition [24][78][79]

A healthy diet is essential for normal growth and development and helps prevent a variety of metabolic and other conditions, such as obesity and type 2 diabetes mellitus.

• Infant feeding: See also “Infant nutrition.”
  • Encourage exclusive breastfeeding for the first 6 months. [24]
  • Exclusively breastfed or partially breastfed infants require supplementation.
    • Vitamin D from birth until infants meet the recommended daily intake of vitamin D from other food sources
    • Iron from 4 months until they meet the recommended daily intake of iron from iron-containing foods [80]
  • Introduce complementary foods at 6 months of age if showing signs of complementary feeding readiness.
  • In addition to complementary foods, breastmilk and/or formula should be given until 12 months of age.
• Older children
  • Once eating solid foods, a healthy diet consists of [14]
    • Three meals and two snacks per day
    • Caloric intake appropriate for the child's age and level of activity
    • Fruits, vegetables, legumes, beans, grains (preferably whole grain), protein foods, and dairy
    • Limited saturated fats, salt, and sugar
  • Introduce whole milk (16–24 oz/day) at 12 months of age. [78][81]
  • At 24 months of age, switch from whole milk to 1% or skim milk. [82]

For children on specialized diets (e.g., for medical indications, vegetarians, vegans), consider referral to a dietitian to ensure proper dietary intake of macronutrients and micronutrients. [83]

Picky eating [84]

• Definition
  • The refusal to eat certain foods, try new foods, or eat sufficient amounts of food
  • Often associated with an excessive preference for certain foods
• Red flags in picky eating that merit further evaluation include:
  • Vomiting, diarrhea, or atopy (e.g., eczema)
  • Dysphagia (may manifest with coughing, choking, or recurrent lower respiratory tract infections)
  • Odynophagia (may manifest with crying while eating)
  • Failure to thrive, developmental delay
• Management: depends on the severity of the condition
  • Normal growth with no red flags
    • Diagnostic studies are not indicated.
    • Reassure parents and encourage them to continue offering a wide variety of foods.
  • Poor growth and/or red flags in picky eating
    • Perform a detailed history, including screening for eating disorders.
    • Obtain diagnostics studies as indicated.
    • Consider caloric supplementation.
    • If indicated, make appropriate referral(s).

Encourage caregivers to offer a variety of foods without pressuring children to eat.

Dental care and caries prevention in children [85][86]

• General care
  • Avoid juices in infants and limit to 4–6 oz (120–180 mL) per day for children ≥ 1 year of age [86][87]
  • Introduce a cup at 6 months of age; discourage bottles past 1 year old.
  • Before tooth eruption, wipe gums with a clean cloth after meals.
  • After tooth eruption
    • Brush teeth twice a day with fluoridated toothpaste.
    • Floss daily between teeth that touch.
  • Encourage dental visits every 6 months beginning with tooth eruption or at 12 months, whichever is first.
• Additional fluoride [85]
  • After tooth eruption: Consider applying fluoride varnish every 3–6 months. [85]
  • Consider fluoride supplementation in those who drink fluoride-deficient water. [85][88][89]

Oral health concerns

• Teething: the physiological process by which an infant's deciduous teeth emerge through the gums
  • Usually begins with the lower central incisors between 6 and 10 months of age and ends with the molars at 2–3 years of age [90]
• Teething syndrome: Manifestations fluctuate with the eruption of teeth and include drooling, irritability, disrupted sleep, and/or swelling/inflammation of the gums.
  • Providing infants with a chilled teething ring to chew on safely or applying pressure to the baby's gum using clean fingers or wet gauze can reduce discomfort.
  • Systemic analgesics (e.g., acetaminophen, ibuprofen) are reserved for teething pain not effectively managed with conservative interventions.
  • Advise parents against using topical numbing treatments due to the risk of adverse effects (e.g., methemoglobinemia). [91]
• Dental malocclusion: Discourage nonnutritive sucking habits, including thumb sucking and pacifier use, beyond 3 years of age. [92]

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