II. History

  1. Consider questionnaire
  2. All ages
    1. Living situation (split families, step-siblings... )
      1. Home safety
    2. Dietary intake
      1. See Nutrition Guidelines
      2. Food security (for children living in poverty)
      3. Safe drinking water
      4. Consider introducing highly allergic foods (peanuts, eggs) age <1 to prevent food allergies
      5. Obesity prevention
        1. Avoid solid food introduction age <6 months
        2. Avoid juice <1 year old
        3. Limit 100% juice to 4 oz/day at 1-3 years, 4-6 oz/day at 4-6 years
    3. Toileting
      1. Urination Problems
      2. Defecation Problems
    4. Physical Activity
      1. Encourage at least 60 minutes of moderate to vigorous aerobic exertion (active free play) daily
    5. Screen Time (television, computer, video games)
      1. Avoid screen use in under age 18 months (except video chatting)
      2. Educational applications may be used starting at 18 to 24 months
      3. At age 2-5 years limit Screen Time to 1 hour
      4. For older children limit Screen Time to <1-2 hours of high quality programming daily
      5. Screen Time averages 7.5 hours daily in the U.S.
      6. Over 4 hours of daily Screen Time is associated with Obesity
    6. Sleeping
      1. See Crib Safety
      2. Infants should sleep on their back on a firm mattress for the first year (no blankets, soft objects)
      3. Average school aged child sleeps more than 9 hours per night (11 hours per night is ideal)
      4. See Sleep Problems in Children
      5. See Obstructive Sleep Apnea in Children
    7. Dental care practices
      1. See Oral Health in Children
      2. See a dentist every 2 years
      3. Brush twice daily with pea-sized amount of fluoride-containing toothpaste
      4. Flouride varnish applied to Primary Teeth at clinic visit
      5. Wean bottle by age 12 months
      6. Avoid juices under age 12 months
    8. Unintentional Childhood Injuries (leading cause of death among children)
      1. Car and Bike Safety
        1. Car Seats
        2. Seat Belts
        3. Bicycle helmets
      2. Home safety
        1. Stair gates
        2. Window locks
        3. Cabinet locks
        4. Crib Safety
        5. Furniture anchors
        6. Smoke Alarms
        7. Water heaters set to maximum of 120 F (49 C)
        8. Gun Safety
      3. Other
        1. Drowning Prevention
        2. Poisoning Prevention
        3. Choke Hazards
    9. Skin protection
      1. Sunscreen
  3. Infants
    1. Birth history
      1. Gestational age
      2. Pregnancy and delivery complications
      3. Newborn Screening results
    2. Infant Feeding Problems
      1. Breast Feeding
      2. Formula Feeding
    3. Postpartum Depression (screen at 1, 2, 4 and 6 month visits)
      1. Edinburgh Postnatal Depression Scale
      2. PHQ-2 with reflex to PHQ-9
  4. Adolescents (starting at age 11-12 years old)
    1. Major Depression screening
      1. See Adolescent Depression
      2. See Childhood Depression
    2. Substance Abuse Screening
      1. See CRAFFT questionnaire
      2. See Adolescent Chemical Dependency
      3. Tobacco abuse
      4. Alcohol Abuse
      5. Drug Abuse
    3. Sexual activity screening
      1. Annual Chlamydia testing (urine Chlamydia PCR testing)
      2. Consider Gonorrhea test, HIV Test, Syphilis test
      3. Pap Smears start at age 21 regardess of sexual activity

III. Exam: Vital Signs

  1. Body Temperature (until after age 18 months)
  2. Blood Pressure (annual screening starting at age 3 years of age)
    1. See Hypertension Criteria

IV. Exam: Growth (review on growth curves at each visit)

  1. See Growth Assessment
  2. See Height Measurement in Children
  3. See Weight Measurement in Children
  4. Head Circumference (until age 2 years)
  5. Body Mass Index annually starting at age 2 years old
    1. Obesity Screening at Well Child Visits is a high yield activity (affects 17% of children in U.S.)
    2. BMI >85% for age and gender is considered Overweight (>95% is Obesity)
    3. See Childhood Obesity for management

V. Exam

  1. See Newborn Exam
  2. Complete physical examination
    1. Overall yield is low in healthy, asymptomatic children with normal growth
    2. Observe for signs of abuse (~1 Million children affected annually in U.S.)
    3. Scoliosis screening is not recommended by either USPTF or AAP
    4. Testicular exam is recommended annually by AAP starting at age 11 years old (but not USPTF)
      1. Documenting descended Testicles pre-Puberty is critical (Cryptorchidism risk)
  3. Eye Exam
    1. Red Reflex (until after age 2 years)
    2. Strabismus testing such as cover-uncover (until after age 2 years)
    3. Vision (AAP)
      1. See Pediatric Vision Screening
      2. Instrument based screening (Autoscreening, Photorefractors) at age 12 and 36 months
      3. Formally check vision (Snellen Chart) annually starting at age 4 years (per AAP, AAOS)
        1. Minimum Vision Screening once between age 3 and 5 years (USPTF)
      4. Refer if visual acquity worse than 20/40
  4. Hearing exam
    1. Subjective hearing screening until age 3 years, then formal hearing screening
    2. See Pediatric Hearing Screening
  5. Skin Exam
    1. Nonaccidental Trauma Signs

VI. Evaluation: Developmental Screening

  1. General Screening (at each schedule well visit or at 9, 18 and 30 month visits)
    1. Age 2-4 months: Edinburgh Questionnaire or INI Questionnaire
    2. Age 4-18 months: ASQ Questionnaire, PEDS Questionnaire or INI Questionnaire
    3. Age 18-60 months: ASQ Questionnaire, PEDS Questionnaire or CDR Questionnaire
  2. Specific Screening: Perform for all children at specific visits
    1. Modified Checklist for Autism in Toddlers (M-CHAT): Perform at 18 and 24 months (AAP)
    2. ASQ: SE Behavioral Screening: Perform at 6,12, 18, 24, 30, 36, 48 and 60 months
  3. School readiness (age 4-5 years)
    1. Social and emotional development are key to success
    2. Assess ability to follow directions, attention
    3. Consider referral for support services
    4. Avoid delaying school entry (not helpful and may exacerbate behavioral problems)
      1. Byrd (1997) Pediatrics 100(4): 654-61 [PubMed]
  4. As needed screening in school age children
    1. See ADHD Diagnosis
    2. Mood Disorder (Major Depression, Anxiety Disorder)
    3. Behavioral Disorder

VII. Labs

  1. Newborn Screening (review results at first Well Child Visit)
  2. Hemoglobin At 9-12 months (AAP)
  3. Serum Lead level
    1. Screen high risk children between ages 6 months and 6 years old (AAP:)
  4. Lipid panel
    1. Risk based screening 2, 4, 6 and 8 years, and annually from 10 years old on (AAP, not USPTF)

VIII. Management: Immunizations

  1. See Pediatric Vaccination for schedule
    1. National Vaccination compliance is excellent until after age 6 years old in the U.S.
      1. Primary Series at 2, 4, 6, 12, and 15-18 months, as well as 4-6 years
    2. More than 60% of adolescents are not up-to-date on their Vaccines as of age 11 years old
      1. Tdap (Adacel, Boostrix)
      2. Meningococcal Vaccine (Menactra)
      3. HPV Vaccine (Gardasil)
  2. Influenza Vaccine
    1. October to March
    2. Give second dose in first season

IX. Management: Medications

  1. Iron Supplementation
    1. Preterm Infants starting at 1 month of age
    2. Exclusively Breast fed infants starting at 6 months of age
  2. Fluoride Supplementation
    1. Flouride varnish applied to Primary Teeth at clinic visit
    2. Fluoride Supplementation if inadequate fluoride in drinking water (0.6 ppm or less) for age 0.5 to 16 years
  3. Vitamin D 400 IU daily (more if deficient)
    1. Vitamin D Deficiency may approach 50% Incidence (especially in northern latitudes)
    2. Vitamin D Supplementation 400 IU daily in exclusively Breast fed infants
    3. Consider Vitamin D Deficiency screening

X. Management: Referrals

  1. Dental visits starting at age 3 years
    1. See Oral Health in Children

XI. Management: Anticipatory Guidance Education

  1. Newborn: Jaundice, eating, sleep, maternal bonding
  2. Month 2: Colic, growth, sleep, sibling adjustment
  3. Month 4: Childcare, sleep, solid introduction
  4. Month 6: Child proofing
  5. Month 9: Child proofing, stranger anxiety
  6. Month 12: Discipline, shoes, walking, turning Car Seat
  7. Month 15: Discipline, Time-Out
  8. Month 18: Temper tantrums, sleep problems
  9. Month 24: Toilet Training, sleep problems, speech development
  10. Month 36: Eating patterns, socialization, books
  11. Month 48: Speech, school readiness
  12. Month 60: Behavioral consequences

XII. Resources

  1. Recommendations for Preventive Pediatric Health Care (AAP, Bright Futures)
    1. https://www.aap.org/en-us/Documents/periodicity_schedule.pdf
  2. AAP Screening Tools
    1. https://screeningtime.org/star-center/#/screening-tools

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