 |
Well-child visits aim to do the following:
The American Academy of Pediatrics (AAP) has recommended preventive health care schedules (see Table 5: Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Infancya , Table 6: Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Early and Middle Childhooda, and Table 7: Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Adolescencea ) for children who have no significant health problems and who are growing and developing satisfactorily. Those who do not meet these criteria should have more frequent and intensive visits. If children come under care for the first time late on the schedule or if any items are not done at the suggested age, children should be brought up to date as soon as possible. Children who have developmental, psychosocial, or chronic disease may require more frequent counseling and treatment visits that are separate from preventive care visits. If parents are high risk, are parents for the first time, or wish to have a conference, a prenatal visit with the pediatrician is appropriate.
In addition to physical examination, practitioners should evaluate the child's motor, cognitive, and social development and parent-child interactions. These assessments can be made by taking a thorough history from parents and child, making direct observations, and sometimes seeking information from outside sources such as teachers and child care providers. Tools are available for office use to facilitate evaluation of cognitive and social development (see Physical Growth and Development: Childhood Development).
Both physical examination and screening are important parts of preventive health care in infants and children. Most parameters, such as weight, are included for all children; others are applicable to selected patients, such as lead screening in 1- and 2-yr-olds.
Anticipatory guidance is also important to preventive health care. It includes
|
Table 5
|
| | |
| Recommendations for Preventive Care During Infancya
|
|
|
|
|
|
Age
|
|
|
|
|
Item
|
Neonate
|
3–5 days
|
By 1 mo
|
2 mo
|
4 mo
|
6 mo
|
9 mo
|
|
History (initial or interval)
|
|
—
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Measurements
|
|
Length or height and weight
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Head circumference
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Weight for length
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Blood pressureb
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Sensory screening
|
|
Vision
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Hearing
|
X
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Developmental and behavioral assessment
|
|
Developmental surveillancec
|
X
|
X
|
X
|
X
|
X
|
X
|
|
|
Developmental screeningd
|
|
|
|
|
|
|
X
|
|
Psychosocial and behavioral assessment
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Physical examination
|
|
—
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Laboratory testinge
|
|
Neonatal metabolic and hemoglobinopathy screeningf
|
←–––––––––X–––––––––→
|
|
|
|
|
Hematocrit or hemoglobin
|
|
|
|
|
RA
|
|
|
Lead screeningg
|
|
|
|
|
|
RA
|
RA
|
|
Tuberculin testh
|
|
|
RA
|
|
|
RA
|
|
|
Other
|
|
Immunizationi (see Table 12: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 0–6 yr and Table 14: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo–18 yr)
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Oral healthj
|
|
|
|
|
|
RA
|
RA
|
|
Anticipatory guidance
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
aThese guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright Futures.
bIf infants and children have certain high-risk conditions, BP should be measured at visits before age 3 yr.
cDevelopmental surveillance is an ongoing process. It involves determining what concerns parents have about their child's development, accurately observing the child, identifying risk and protective factors, and recording the process (child's developmental history, methods used, findings).
dDevelopmental screening involves using a standardized test and is routinely done at 9, 18, and 30 mo. However, screening is also done when risk factors are identified or when developmental surveillance detects a problem; in such cases, screening focuses on the area of concern.
eTesting may be modified, depending on when the child enters the schedule and what the child's needs are.
fFor metabolic and hemoglobinopathy screening, state law should be followed. Clinicians should review results at visits and retest or refer as needed.
gIf children are at risk of lead exposure, clinicians should consult the AAP statement, Lead exposure in children: prevention, detection, and management, 2005 (available at aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1036; reaffirmed 5/09), and should screen children according to state law where applicable.
hFor tuberculosis testing, recommendations of the Committee on Infectious Diseases, published in the current edition of Red Book: Report of the Committee on Infectious Diseases, should be followed. As soon as high-risk children are identified, they should be tested.
iClinicians should follow schedules recommended by the Committee on Infectious Diseases, which are published annually in the January issue of Pediatrics. Every visit should be used as an opportunity to update and complete a child's immunizations.
jChildren should be referred to a dentist, if available. Otherwise, clinicians should assess oral health risk. If the primary water source is fluoride-deficient, oral fluoride supplementation should be considered.
|
|
RA = age at which risk assessment should be done followed, if results are positive, by appropriate examination or testing; X = age at which evaluation should be done; ←X→ = range during which evaluation may be done, with X indicating the preferred age.
|
|
Adapted from the Bright Futures/Academy of Pediatrics. Recommendations for preventive pediatric health care, 2008. Available at http://practice.aap.org/content.aspx?aid=1599.
|
|
|
Table 6
|
| | |
| Recommendations for Preventive Care During Early and Middle Childhooda
|
|
|
|
|
|
|
|
|
Age
|
|
|
|
|
|
|
|
Item
|
12 mo
|
15 mo
|
18 mo
|
24 mo
|
30 mo
|
3 yr
|
4 yr
|
5 yr
|
6 yr
|
7 yr
|
8 yr
|
9 yr
|
10 yr
|
|
History (initial or interval)
|
|
—
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Measurements
|
|
Height and weight
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Head circumference
|
X
|
X
|
X
|
X
|
|
|
|
|
|
|
|
|
|
|
Weight for length
|
X
|
X
|
X
|
|
|
|
|
|
|
|
|
|
|
|
Body mass index
|
|
|
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Blood pressureb
|
RA
|
RA
|
RA
|
RA
|
RA
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Sensory screening
|
|
Vision
|
RA
|
RA
|
RA
|
RA
|
RA
|
Xc
|
X
|
X
|
X
|
RA
|
X
|
RA
|
X
|
|
Hearing
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
X
|
X
|
X
|
RA
|
X
|
RA
|
X
|
|
Developmental and behavioral assessment
|
|
Developmental surveillanced
|
X
|
X
|
|
X
|
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Developmental screeninge
|
|
|
X
|
|
X
|
|
|
|
|
|
|
|
|
|
Autismf
|
|
|
X
|
X
|
|
|
|
|
|
|
|
|
|
|
Psychosocial and behavioral assessment
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Physical examination
|
|
—
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Laboratory testingg
|
|
Hematocrit or hemoglobin
|
X
|
|
RA
|
RA
|
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Lead screeningh
|
X or RA
|
|
RA
|
X or RA
|
|
RA
|
RA
|
RA
|
RA
|
|
|
|
|
|
Tuberculin testi
|
RA
|
|
RA
|
RA
|
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Dyslipidemia screeningj
|
|
|
|
RA
|
|
|
RA
|
|
RA
|
|
RA
|
|
RA
|
|
Other
|
|
Immunizationk (see Table 12: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 0–6 yr, Table 13: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 7–18 yr, and Table 14: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo–18 yr)
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Oral healthl
|
X or RA
|
|
X or RA
|
X or RA
|
X or RA
|
X
|
|
|
X
|
|
|
|
|
|
Anticipatory guidance
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
aThese guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright Futures.
bIf infants and children have certain high-risk conditions, BP should be measured at visits before age 3 yr.
cIf children are uncooperative, they can be rescreened within 6 mo.
dDevelopmental surveillance is an ongoing process. It involves determining what concerns parents have about their child's development, accurately observing the child, identifying risk and protective factors, and recording the process (child's developmental history, methods used, findings).
eDevelopmental screening involves using a standardized test and is routinely done at 9, 18, and 30 mo. However, screening is also done when risk factors are identified or when developmental surveillance detects a problem; in such cases, screening focuses on the area of concern.
fScreening with an autism-specific tool at age 18 mo is recommended. Screening is repeated at age 24 mo because parents may not notice problems by age 18 mo (the mean age that parents report autistic regression is 20 mo). See Gupta VB, Hyman SL, Johnson CP, et al. Identifying children with autism early? Pediatrics 2007;119:152-153. Available at http://pediatrics.aappublications.org/cgi/content/full/119/1/152.
gTesting may be modified, depending on when the child enters the schedule and what the child's needs are.
hIf children are at risk of lead exposure, clinicians should consult the AAP statement, Lead exposure in children: prevention, detection, and management, 2005 (available at aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1036; reaffirmed 5/09), and should screen children according to state law where applicable. Risk is assessed or screening is done based on universal screening requirements for patients with Medicaid or in high-prevalence areas.
iFor tuberculosis testing, recommendations of the Committee on Infectious Diseases, published in the current edition of Red Book: Report of the Committee on Infectious Diseases, should be followed. As soon as high-risk children are identified, they should be tested.
jThe AAP recommends screening children who have a family history of high cholesterol or coronary artery disease or risk factors for coronary artery disease (eg, diabetes, obesity, hypertension). Screening is also recommended when the family history is unknown. Screening should take place after age 2 yr, but no later than age 10 yr. Most useful is a fasting lipid profile. If values are within the normal range, testing should be repeated in 3–5 yr.
kClinicians should follow schedules recommended by the Committee on Infectious Diseases, which are published annually in the January issue of Pediatrics. Every visit should be used as an opportunity to update and complete a child's immunizations.
lChildren should be referred to a dentist, if available. Otherwise, clinicians should assess oral health risk. If the primary water source is fluoride-deficient, oral fluoride supplementation should be considered. At the 3-yr and 6-yr visits, the clinician should determine whether the child has a dental home and, if not, should refer the child to one.
|
|
RA = age at which risk assessment should be done followed, if results are positive, by appropriate examination or testing; X = age at which evaluation should be done.
|
|
Adapted from the Bright Futures/Academy of Pediatrics. Recommendations for preventive pediatric health care, 2008. Available at http://practice.aap.org/content.aspx?aid=1599.
|
|
|
Table 7
|
| | |
| Recommendations for Preventive Care During Adolescencea
|
|
|
|
|
|
|
|
Age
|
|
|
|
|
|
|
Item
|
11 yr
|
12 yr
|
13 yr
|
14 yr
|
15 yr
|
16 yr
|
17 yr
|
18 yr
|
19 yr
|
20 yr
|
21 yr
|
|
History (initial or interval)
|
|
—
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Measurements
|
|
Height and weight
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Body mass index
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Blood pressure
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Sensory screening
|
|
Vision
|
RA
|
X
|
RA
|
RA
|
X
|
RA
|
RA
|
X
|
RA
|
RA
|
RA
|
|
Hearing
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Developmental/behavioral assessment
|
|
Developmental surveillanceb
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Psychosocial and behavioral assessment
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Alcohol and drug use assessment
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Physical examination
|
|
—
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Testingc
|
|
Hematocrit or hemoglobin
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Tuberculin testd
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Dyslipidemia screeninge
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
←–––––X–––––→
|
|
STD screeningf
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Cervical dysplasia screeningg
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
RA
|
|
Other
|
|
Immunizationh(see Table 13: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 7–18 yr and Table 14: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo–18 yr)
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Anticipatory guidance
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
a These guidelines represent a consensus by the American Academy of Pediatrics (AAP) and Bright Futures.
bDevelopmental surveillance is an ongoing process. It involves determining what concerns parents have about their child's development, accurately observing the child, identifying risk and protective factors, and recording the process (child's developmental history, methods used, findings).
cTesting may be modified, depending on when the child enters the schedule and what the child's needs are.
dFor tuberculosis testing, recommendations of the Committee on Infectious Diseases, published in the current edition of Red Book: Report of the Committee on Infectious Diseases, should be followed. As soon as high-risk children are identified, they should be tested.
eThe AAP recommends screening for children who have a family history of high cholesterol or coronary artery disease or risk factors for coronary artery disease (eg, diabetes, obesity, hypertension). Screening is also recommended when the family history is unknown. Screening should take place after age 2 yr, but no later than age 10 yr. Most useful is a fasting lipid profile. If values are within the normal range, testing should be repeated in 3–5 yr.
fAll sexually active patients should be screened for STDs.
gAll sexually active girls should be screened for cervical dysplasia as part of the a pelvic examination beginning within 3 yr of first vaginal intercourse or at age 21 (whichever comes first).
hClinicians should follow schedules recommended by the Committee on Infectious Diseases, which are published annually in the January issue of Pediatrics. Every visit should be used as an opportunity to update and complete a child's immunizations.
|
|
RA = age at which risk assessment should be done followed, if results are positive, by appropriate examination or testing; STDs = sexually transmitted diseases; X = age at which evaluation should be done; ←X→ = range during which evaluation may be done, with X indicating the preferred age.
|
|
Adapted from the Bright Futures/Academy of Pediatrics. Recommendations for preventive pediatric health care, 2008. Available at http://practice.aap.org/content.aspx?aid=1599.
|
|
Physical Examination
Growth:
Length (crown-heel) or height (once children can stand) and weight should be measured at each visit. Head circumference should be measured at each visit through 24 mo. Growth rate should be monitored using a growth curve with percentiles; deviations in these parameters should be evaluated (see Physical Growth and Development).
Blood pressure:
Starting at age 3 yr, BP should be routinely checked by using an appropriate-sized cuff. The width of the inflatable rubber bag portion of the BP cuff should be about 40% of the circumference of the upper arm, and its length should cover 80 to 100% of the circumference. If no available cuff fits the criteria, using the larger cuff is better.
Systolic and diastolic BPs are considered normal if they are < 90th percentile; actual values for each percentile vary by sex, age, and size (as height percentile), so reference to published tables is essential (see tables for BP levels for the 50th to 99th percentiles for boys and girls, below). Systolic and diastolic BP measurements between the 90th and 95th percentiles should prompt continued observation and assessment of hypertensive risk factors. If measurements are consistently ≥ 95th percentile, children should be considered hypertensive, and a cause should be determined.
Head:
The most common abnormality is fluid in the middle ear (otitis media with effusion), manifesting as a change in the appearance of the tympanic membrane. Clinicians should screen for hearing deficits (see see Approach to the Care of Normal Infants and Children: Hearing tests).
Eyes should be assessed at each visit. Clinicians should check for esotropia or exotropia; for abnormalities in globe size (suggesting congenital glaucoma); for a difference in pupil size, iris color, or both (suggesting Horner's syndrome, trauma, or neuroblastoma; asymmetric pupils may be normal or represent an ocular, autonomic, or intracranial disorder); and for absence or distortion of the red reflex (suggesting cataract or retinoblastoma).
Ptosis and eyelid hemangioma obscure vision and require attention. Infants born at < 32 wk gestation should be assessed by an ophthalmologist for evidence of retinopathy of prematurity (see Perinatal Problems: Retinopathy of Prematurity) and for refractive errors, which are more common. By age 3 or 4 yr, vision testing by Snellen charts or newer testing machines can be used. E charts are better than pictures; visual acuity of < 20/30 should be evaluated by an ophthalmologist.
Detection of dental caries is important, and referral to a dentist should be made if cavities are present, even in children who have only deciduous teeth. Thrush is common among infants and not usually a sign of immunosuppression.
Heart:
Auscultation is done to identify new murmurs, heart rate abnormalities, or rhythm disturbances; benign flow murmurs are common and need to be distinguished from pathologic murmurs. The chest wall is palpated for the apical impulse to check for cardiomegaly; femoral pulses are palpated to check for asymmetry, which suggests aortic coarctation.
Abdomen:
Palpation is repeated at every visit because many masses, particularly Wilms' tumor and neuroblastoma, may be apparent only as children grow. Stool is often palpable in the left lower quadrant.
Spine and extremities:
Children old enough to stand should be screened for scoliosis by observing posture, shoulder tip and scapular symmetry, torso list, and especially paraspinal asymmetry when children bend forward (see Bone Disorders in Children: Idiopathic Scoliosis)
At each visit before children start to walk, they should be checked for developmental dysplasia of the hip. The Barlow and Ortolani maneuvers (see Approach to the Care of Normal Infants and Children: Musculoskeletal system) are used until about age 4 mo. After that, dysplasia may be suggested by unequal leg length, adductor tightness, or asymmetry of abduction or leg creases.
Toeing-in can result from adduction of the forefoot, tibial torsion, or femoral torsion. Only pronounced cases require therapy and referral to an orthopedist.
Genital examination:
Girls should be offered a pelvic examination and Papanicolaou (Pap) testing at age 18 or when they become sexually active—whichever occurs first. All sexually active patients should be screened for sexually transmitted diseases.
Testicular and inguinal evaluation should be done at every visit, specifically looking for undescended testes in infants and young boys, testicular masses in older adolescents, and inguinal hernia in boys of all ages.
Screening
Blood tests:
To detect iron deficiency, clinicians should determine Hct or Hb at age 9 to 12 mo in term infants, at age 5 to 6 mo in premature infants, and annually in menstruating adolescents. Testing for Hb S can be done at age 6 to 9 mo (see Anemias Caused by Hemolysis: Diagnosis) if not done as part of neonatal screening.
Recommendations for blood testing for lead exposure vary by state. In general, testing should be done between ages 9 mo and 1 yr in children at risk of exposure (those living in housing built before 1980) and should be repeated at 24 mo. If the clinician is not sure of a child's risk, testing should be done. Levels > 10 μg/dL (> 0.48 μmol/L) pose a risk of neurologic damage (see Poisoning: Lead Poisoning), although some experts question this threshold because they believe that any lead in the system can be toxic.
Cholesterol screening is indicated for children > 2 yr who are at high risk because of family history. If other risk factors are present or family history is uncertain, testing is at the discretion of the physician.
Hearing tests:
(See also Hearing Loss.) Parents may suspect a hearing deficit if their child ceases responding appropriately to noises or voices or does not understand or develop speech (see Table 10: Approach to the Care of Normal Infants and Children: Normal Hearing in Very Young Children*). Because hearing deficits impair language development, hearing problems must be remedied as early as possible. The clinician therefore should seek parental input about hearing at every visit during early childhood and be prepared to do formal testing or refer to an audiologist whenever there is any question of the child's ability to hear.
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Table 10
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| Normal Hearing in Very Young Children* |
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Age
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Expected Response
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3 mo
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Startles to a nearby loud sound
Stirs or awakens from sleep when someone talks or makes a sound
Is soothed by mother's voice
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6 mo
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Looks toward an interesting sound
Turns when name is called
Makes “moo,” “ma,” “da,” “di” sounds to toys
Coos when listening to music
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10 mo
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Makes own sounds
Imitates some sounds
Understands “no” and “bye-bye”
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18 mo
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Understands many single words or commands
Babbles in sentence-like patterns
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*If a child does not pass these minimal performance standards or if parents suspect a hearing loss in their child at any age, the child should be referred for testing.
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Audiometry can be done in the primary care setting; most other audiologic procedures (eg, otoacoustic emission testing, brain stem auditory evoked response) should be done by an audiologist. Conventional audiometry can be used for children beginning at about age 3 yr; young children can also be tested by observing their responses to sounds made through headphones, watching their attempts to localize the sound or complete a simple task. Tympanometry, another in-office procedure (see Hearing Loss: Testing), can be used with children of any age and is useful for evaluating middle ear function. Abnormal tympanograms often denote eustachian tube dysfunction or the presence of middle ear fluid that cannot be detected during otoscopic examination. Pneumatic otoscopy is helpful in evaluating middle ear status, but combining it with tympanometry is more informative than either procedure alone.
Other screening tests:
Tuberculin testing should be done if children have been exposed to TB (eg, to an infected family member or close contact), if they have had a family member with a positive tuberculin test, if they were born in developing countries, or if their parents are new immigrants from those countries or have been recently incarcerated.
For sexually active adolescents, dipstick analysis for leukocytes and urinary testing for chlamydial infection should be done annually. Screening for cervical dysplasia should be begun within 3 yr of onset of sexual activity.
Prevention
Preventive counseling is part of every well-child visit and covers a broad spectrum of topics, such as recommendations to have infants sleep on their backs, injury prevention, nutritional and exercise advice, and discussions of violence, firearms, and substance abuse.
Safety:
Recommendations for injury prevention vary by age. Some examples follow.
For infants from birth to 6 mo:
For infants from 6 to 12 mo:
For children aged 1 to 4 yr:
For children ≥ 5 yr:
Nutrition:
Poor nutrition underlies the epidemic of obesity in children (see Obesity and the Metabolic Syndrome: Children). Recommendations vary by age; for children up to 2 yr, see Approach to the Care of Normal Infants and Children: Nutrition in Infants. As children grow older, parents can allow them some discretion in food choices, while keeping the diet within healthy parameters. Children should be guided away from frequent snacking and foods that are high in calories, salt, and sugar. Soda has been implicated as a major contributor to obesity.
Exercise:
Physical inactivity also underlies the epidemic of obesity in children, and the benefits of exercise in maintaining good physical and emotional health should induce parents to make sure their children develop good habits early in life. During infancy and early childhood, children should be allowed to roam and explore in a safe environment under close supervision. Outdoor play should be encouraged from infancy.
As children grow older, play becomes more complex, often evolving to formal school-based athletics. Parents should set good examples and encourage both informal and formal play, always keeping safety issues in mind and promoting healthy attitudes about sportsmanship and competition. Participation in sports and activities as a family provides children with exercise and has important psychologic and developmental benefits. Screening of children before sports participation is recommended (see Exercise and Sports Injury: Screening for Sports Participation ).
Limits to television watching, which is linked directly to inactivity and obesity, should start at birth and be maintained throughout adolescence. Similar limits should be set for video games and noneducational computer time as children grow older.
Last full review/revision February 2010 by Eve R. Colson, MD; Rachel L. Chapman, MD; Melissa R. Held, MD
Content last modified February 2010
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