Well-Child Visits for Infants and Young Children

The well-child visit allows for comprehensive assessment of a kid and the opportunity for further evaluation if abnormalities are detected. A complete history during the well-child visit includes information about birth history; prior screenings; diet; slumber; dental care; and medical, surgical, family, and social histories. A head-to-toe exam should be performed, including a review of growth. Immunizations should be reviewed and updated as appropriate. Screening for postpartum depression in mothers of infants up to six months of age is recommended. Based on expert opinion, the American University of Pediatrics recommends developmental surveillance at each visit, with formal developmental screening at nine, xviii, and 30 months and autism-specific screening at 18 and 24 months; the U.S. Preventive Services Task Force plant insufficient bear witness to brand a recommendation. Well-kid visits provide the opportunity to reply parents' or caregivers' questions and to provide age-advisable guidance. Machine seats should remain rear facing until ii years of historic period or until the superlative or weight limit for the seat is reached. Fluoride utilize, limiting or avoiding juice, and weaning to a loving cup past 12 months of age may improve dental health. A i-time vision screening betwixt three and five years of age is recommended by the U.South. Preventive Services Task Force to detect amblyopia. The American Academy of Pediatrics guideline based on expert stance recommends that screen time be avoided, with the exception of video chatting, in children younger than 18 months and express to one hour per day for children two to five years of historic period. Abeyance of breastfeeding before six months and transition to solid foods earlier six months are associated with babyhood obesity. Juice and sugar-sweetened beverages should be avoided earlier one year of age and provided only in limited quantities for children older than ane year.

Well-child visits for infants and young children (upwardly to five years) provide opportunities for physicians to screen for medical issues (including psychosocial concerns), to provide anticipatory guidance, and to promote skilful health. The visits also allow the family doctor to establish a relationship with the parents or caregivers. This commodity reviews the U.S. Preventive Services Task Strength (USPSTF) and the American Academy of Pediatrics (AAP) guidelines for screenings and recommendations for infants and young children. Family physicians should prioritize interventions with the strongest evidence for patient-oriented outcomes, such as immunizations, postpartum depression screening, and vision screening.

SORT: Central RECOMMENDATIONS FOR Exercise

Clinical recommendation Evidence rating References

Postpartum depression screening is recommended for mothers.

B

22, 23

Developmental surveillance should be performed at each visit, with formal screenings at 9, 18, and xxx months.

C

14

Immunization history should exist reviewed and updated (if appropriate) at each visit.

C

32, 33

Visual acuity screening should exist performed once betwixt three and five years of age.

B

26, 27

Clinical Examination

  • Abstract
  • Clinical Examination
  • Screenings
  • Anticipatory Guidance
  • References

HISTORY

The history should include a brief review of nascence history; prematurity tin can exist associated with complex medical conditions.one Evaluate breastfed infants for whatsoever feeding problems,2 and assess formula-fed infants for type and quantity of atomic number 26-fortified formula existence given.3  For children eating solid foods, feeding history should include everything the child eats and drinks. Sleep, urination, defecation, nutrition, dental intendance, and child safety should exist reviewed. Medical, surgical, family unit, and social histories should be reviewed and updated. For newborns, review the results of all newborn screening tests (Table onefour–7) and schedule follow-up visits as necessary.2

Tabular array ane.

Recommendations for Newborn Screenings

Screening Method Follow-up, if aberrant upshot

Congenital heart defect

Measure pulse oximetry for preductal and postductal saturation 24 hours after delivery4

Diagnostic echocardiography4

Genetic and metabolic disorders

Obtain blood work subsequently 24 hours of age5

Evaluate and stabilize babe if necessary; refer to regional subspecialist for further evaluation5

Hearing impairment

Screen by auditory brain-stalk response6

Refer to audiologist6

Hyperbilirubinemia

Obtain serum or transcutaneous bilirubin level7

Repeat bilirubin based on previous level and risk factors7

Physical EXAMINATION

A comprehensive caput-to-toe examination should be completed at each well-child visit. Interval growth should be reviewed by using advisable age, sex, and gestational age growth charts for peak, weight, caput circumference, and body mass index if 24 months or older. The Centers for Disease Control and Prevention (CDC)-recommended growth charts can be found at https://world wide web.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts. Percentiles and observations of changes forth the nautical chart's bend should be assessed at every visit. Include cess of parent/caregiver-child interactions and potential signs of abuse such as bruises on exceptionally injured areas, burns, human being seize with teeth marks, bruises on nonmobile infants, or multiple injuries at different healing stages.8

Screenings

  • Abstruse
  • Clinical Exam
  • Screenings
  • Anticipatory Guidance
  • References

The USPSTF and AAP screening recommendations are outlined in Table 2.three,9–27 A summary of AAP recommendations tin can exist found at https://www.aap.org/en-us/Documents/periodicity_schedule.pdf. The American Academy of Family Physicians (AAFP) more often than not adheres to USPSTF recommendations.28

Tabular array 2.

Screening Recommendations for Children from Birth to half-dozen Years of Age

Screening Preferred Method USPSTF recommendation AAP recommendation

Autism

Modified Checklist for Autism in Toddlers

Insufficient show to screen children without clinical concerns (Grade I)9

Screen at eighteen- and 24-month visits (SOR C)10

Dental intendance

Fluoride supplementation and varnish

Oral fluoride supplementation if water is fluoride scarce (Grade B)11 Master intendance physicians apply fluoride varnish to primary teeth commencement at tooth eruption (Grade B)eleven

Fluoride supplementation (SOR B)12 Use fluoride varnish in primary intendance setting to main teeth offset at tooth eruption (SOR B)12

Evolution

Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, Parents' Evaluation of Developmental Condition-Developmental Milestones, Survey of Well-Being of Immature Children

Insufficient testify to screen for speech and linguistic communication delays without clinical concerns (Grade I)13

Screening at 9-, 18-, and 30-month visits (SOR C)fourteen

Dyslipidemia

Fasting lipid panel

Insufficient evidence (Grade I)15

Risk-based screening at 2, 4, and half-dozen years of age (SOR C)xvi

Hypertension

Measure out blood pressure level

Insufficient testify (Class I)17

Screen annually beginning at 3 years of age (SOR C)18

Iron deficiency

Complete blood count

Insufficient evidence (Grade I)xix

Screen at 12 months; consider supplements for preterm or exclusively breastfed newborns (SOR C)3

Lead poisoning

Lead level

Insufficient evidence to recommend screening in children ane to 5 years of age without increased hazard (Form I)20 Recommend against screening in children 1 to v years of age with average risk (Grade D)twenty

Screen high-risk individuals 6 months to 6 years of age (SOR C)21

Maternal depression

Standardized depression screening (Patient Health Questionnaire-2 or Edinburgh Postnatal Depression Scale)

Screen postpartum women (Grade B)22

Screen at ane-, 2-, 4-, and 6-month visits (SOR B)23

Psychosocial assessments

No standardized tool; may consider Baby Pediatric Symptom Checklist, Preschool Pediatric Symptom Checklist, Strengths and Difficulties Questionnaire

Insufficient evidence to recommend screening for low (Grade I)24

Screen for mental health disorders and perform psychosocial assessment at each well-kid visit (SOR C)25

Vision

Visual vigil test

Insufficient evidence to screen earlier 3 years of age (Class I)26 Screening once between 3 and v years of age (Grade B)26

Instrument-based screening at 12 to 24 months of historic period (SOR C)27 Screen annually offset at 3 years of age (SOR B)27

MATERNAL DEPRESSION

Prevalence of postpartum low is effectually 12%,22 and its presence tin can impair baby development. The USPSTF and AAP recommend using the Edinburgh Postnatal Depression Scale (bachelor at https://www.aafp.org/afp/2010/1015/p926.html#afp20101015p926-f1) or the Patient Wellness Questionnaire-2 (available at https://www.aafp.org/afp/2012/0115/p139.html#afp20120115p139-t3) to screen for maternal depression. The USPSTF does not specify a screening schedule; notwithstanding, based on skillful stance, the AAP recommends screening mothers at the one-, 2-, four-, and six-month well-kid visits, with further evaluation for positive results.23 At that place are no recommendations to screen other caregivers if the mother is not present at the well-child visit.

PSYCHOSOCIAL

With nearly one-half of children in the Us living at or most the poverty level, assessing home safety, food security, and access to safe drinking water tin improve awareness of psychosocial issues, with referrals to appropriate agencies for those with positive results.29 The prevalence of mental health disorders (i.east., primarily feet, depression, behavioral disorders, attention-deficit/hyperactivity disorder) in preschool-aged children is effectually 6%.30 Gamble factors for these disorders include having a lower socioeconomic status, being a member of an ethnic minority, and having a non–English-speaking parent or chief caregiver.25 The USPSTF plant insufficient testify regarding screening for depression in children upwards to xi years of age.24 Based on expert stance, the AAP recommends that physicians consider screening, although screening in immature children has non been validated or standardized.25

DEVELOPMENT AND SURVEILLANCE

Based on expert opinion, the AAP recommends early on identification of developmental delays14 and autism10; however, the USPSTF constitute insufficient testify to recommend formal developmental screening13 or autism-specific screening9 if the parents/caregivers or doc have no concerns. If physicians cull to screen, developmental surveillance of language, advice, gross and fine movements, social/emotional development, and cerebral/problem-solving skills should occur at each visit past eliciting parental or caregiver concerns, obtaining interval developmental history, and observing the child. Any expanse of business organisation should be evaluated with a formal developmental screening tool, such as Ages and Stages Questionnaire, Parents' Evaluation of Developmental Condition, Parents' Evaluation of Developmental Condition-Developmental Milestones, or Survey of Well-Being of Young Children. These tools can exist found at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx. If results are aberrant, consider intervention or referral to early intervention services. The AAP recommends completing the previously mentioned formal screening tools at nine-, xviii-, and xxx-month well-child visits.14

The AAP also recommends autism-specific screening at 18 and 24 months.10 The USPSTF recommends using the ii-stride Modified Checklist for Autism in Toddlers (1000-CHAT) screening tool (available at https://m-conversation.org/) if a dr. chooses to screen a patient for autism.ten The M-CHAT can be incorporated into the electronic medical tape, with the possibility of the parent or caregiver completing the questionnaire through the patient portal before the role visit.

Iron DEFICIENCY

Multiple reports have associated atomic number 26 deficiency with impaired neurodevelopment. Therefore, it is essential to ensure adequate iron intake. Based on expert opinion, the AAP recommends supplements for preterm infants beginning at one month of age and exclusively breastfed term infants at six months of age.3 The USPSTF constitute insufficient testify to recommend screening for iron deficiency in infants.19 Based on practiced opinion, the AAP recommends measuring a child'south hemoglobin level at 12 months of age.iii

Lead

Lead poisoning and elevated lead blood levels are prevalent in young children. The AAP and CDC recommend a targeted screening approach. The AAP recommends screening for serum lead levels between six months and six years in high-risk children; loftier-chance children are identified past location-specific risk recommendations, enrollment in Medicaid, being foreign born, or personal screening.21 The USPSTF does non recommend screening for lead poisoning in children at average risk who are asymptomatic.twenty

VISION

The USPSTF recommends at least one vision screening to detect amblyopia between three and 5 years of age. Testing options include visual acuity, ocular alignment test, stereoacuity test, photoscreening, and autorefractors. The USPSTF establish insufficient testify to recommend screening before iii years of age.26 The AAP, American Academy of Ophthalmology, and the American Academy of Pediatric Ophthalmology and Strabismus recommend the employ of an instrument-based screening (photoscreening or autorefractors) between 12 months and three years of historic period and annual visual vigil screening beginning at four years of age.31

IMMUNIZATIONS

The AAFP recommends that all children be immunized.32 Recommended vaccination schedules, endorsed by the AAP, the AAFP, and the Advisory Commission on Immunization Practices, are plant at https://world wide web.cdc.gov/vaccines/schedules/hcp/kid-adolescent.html. Immunizations are normally administered at the two-, four-, six-, 12-, and 15- to 18-calendar month well-child visits; the 4- to six-year well-child visit; and annually during flu flavor. Additional vaccinations may be necessary based on medical history.33 Immunization history should be reviewed at each health visit.

Anticipatory Guidance

  • Abstract
  • Clinical Examination
  • Screenings
  • Anticipatory Guidance
  • References

Safe

Injuries remain the leading cause of death amongst children,34 and the AAP has fabricated several recommendations to decrease the take chances of injuries.35–42 Appropriate use of child restraints minimizes morbidity and mortality associated with motor vehicle collisions. Infants need a rear-facing car safety seat until two years of age or until they attain the height or weight limit for the specific car seat. Children should then switch to a forward-facing auto seat for as long equally the seat allows, unremarkably 65 to fourscore lb (30 to 36 kg).35 Children should never be unsupervised around cars, driveways, and streets. Young children should wear bike helmets while riding tricycles or bicycles.37

Having operation fume detectors and an escape plan decreases the risk of burn down- and fume-related deaths.36 H2o heaters should be set to a maximum of 120°F (49°C) to prevent scald burns.37 Infants and young children should be watched closely around whatever body of water, including h2o in bathtubs and toilets, to prevent drowning. Swimming pools and spas should be completely fenced with a self-endmost, cocky-latching gate.38

Infants should not be left alone on whatever loftier surface, and stairs should exist secured by gates.43 Infant walkers should exist discouraged because they provide no benefit and they increase falls down stairs, even if stair gates are installed.39 Window locks, screens, or limited-opening windows decrease injury and decease from falling.xl Parents or caregivers should besides ballast furniture to a wall to prevent heavy pieces from toppling over. Firearms should be kept unloaded and locked.41

Young children should be closely supervised at all times. Small objects are a choking chance, particularly for children younger than iii years. Latex balloons, round objects, and food can cause life-threatening airway obstacle.42 Long strings and cords can strangle children.37

DENTAL CARE

Infants should never have a bottle in bed, and babies should exist weaned to a cup by 12 months of age.44 Juices should be avoided in infants younger than 12 months.45 Fluoride utilise inhibits molar demineralization and bacterial enzymes and likewise enhances remineralization.eleven The AAP and USPSTF recommend fluoride supplementation and the application of fluoride varnish for teeth if the water supply is insufficient.11,12 Begin brushing teeth at tooth eruption with parents or caregivers supervising brushing until mastery. Children should visit a dentist regularly, and an assessment of dental health should occur at well-child visits.44

SCREEN TIME

Easily-on exploration of their environs is essential to development in children younger than ii years. Video chatting is acceptable for children younger than 18 months; otherwise digital media should be avoided. Parents and caregivers may use educational programs and applications with children eighteen to 24 months of age. If screen time is used for children two to 5 years of historic period, the AAP recommends a maximum of ane hr per day that occurs at least i hour before bedtime. Longer usage can cause sleep problems and increases the risk of obesity and social-emotional delays.46

SLEEP

To subtract the take chances of sudden infant expiry syndrome (SIDS), the AAP recommends that infants slumber on their backs on a firm mattress for the start year of life with no blankets or other soft objects in the crib.45 Breastfeeding, pacifier use, and room sharing without bed sharing protect against SIDS; infant exposure to tobacco, alcohol, drugs, and sleeping in bed with parents or caregivers increases the risk of SIDS.47

Diet AND ACTIVITY

The USPSTF, AAFP, and AAP all recommend breastfeeding until at least six months of historic period and ideally for the start 12 months.48 Vitamin D 400 IU supplementation for the first year of life in exclusively breastfed infants is recommended to prevent vitamin D deficiency and rickets.49 Based on expert stance, the AAP recommends the introduction of certain foods at specific ages. Early transition to solid foods before 6 months is associated with higher consumption of fatty and sugary foods50 and an increased risk of atopic illness.51 Delayed transition to cow'southward milk until 12 months of age decreases the incidence of iron deficiency.52 Introduction of highly allergenic foods, such equally peanut-based foods and eggs, before one year decreases the likelihood that a kid will develop food allergies.53

With approximately 17% of children existence obese, many strategies for obesity prevention take been proposed.54 The USPSTF does not have a recommendation for screening or interventions to prevent obesity in children younger than six years.54 The AAP has made several recommendations based on expert opinion to foreclose obesity. Cessation of breastfeeding earlier six months and introduction of solid foods earlier half dozen months are associated with childhood obesity and are not recommended.55 Drinking juice should be avoided earlier one year of age, and, if given to older children, only 100% fruit juice should be provided in express quantities: four ounces per day from one to three years of age and iv to 6 ounces per day from four to six years of age. Intake of other sugar-sweetened beverages should be discouraged to help prevent obesity.45 The AAFP and AAP recommend that children participate in at to the lowest degree lx minutes of active gratuitous play per day.55,56

Data Sources: Literature search was performed using the USPSTF published recommendations (https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations) and the AAP Periodicity table (https://www.aap.org/en-united states/Documents/periodicity_schedule.pdf). PubMed searches were completed using the cardinal terms pediatric, obesity prevention, and allergy prevention with search limits of infant less than 23 months or pediatric less than 18 years. The searches included systematic reviews, randomized controlled trials, clinical trials, and position statements. Essential Evidence Plus was also reviewed. Search dates: May through October 2017.

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The Author

KATHERINE TURNER, Doctor, is an assistant professor in the Department of Family unit Medicine at Carle Foundation Hospital, Urbana, Ill.

Accost correspondence to Katherine Turner, Md, Carle Foundation Infirmary, 611 West. Park St., Urbana, IL 61801. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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37. Gardner HG; American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics. 2007;119(i):202–206.

38. American Academy of Pediatrics Commission on Injury, Violence, and Poison Prevention. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003;112(two):437–439.

39. American Academy of Pediatrics Committee on Injury and Poison Prevention. Injuries associated with babe walkers. Pediatrics. 2001;108(3):790–792.

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51. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary brake, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(ane):183–191.

52. American University of Pediatrics Committee on Diet. The use of whole moo-cow's milk in infancy. Pediatrics. 1992;89(six pt one):1105–1109.

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