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Health Supervision of the Well Child

by Deborah M. Consolini, MD

Well-child visits aim to do the following:

  • Promote health

  • Prevent disease through routine vaccinations and education

  • Detect and treat disease early

  • Guide parents to optimize the child’s emotional and intellectual development

The American Academy of Pediatrics (AAP) has recommended preventive health care schedules (see Table: Recommendations for Preventive Care During Infancy a, Recommendations for Preventive Care During Early and Middle Childhood a, and Recommendations for Preventive Care During Adolescence a ) 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 delay, psychosocial problems, or chronic disease may require more frequent counseling and treatment visits that are separate from preventive care visits. If the pregnancy is high risk (see Overview of High-Risk Pregnancy) or if the parents are first time parents 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 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

  • Obtaining information about the child and parents (eg, via questionnaire, interview, or evaluation)

  • Working with parents to promote health (forming a therapeutic alliance)

  • Teaching parents what to expect in their child’s development, how they can help enhance development (eg, by establishing a healthy lifestyle), and what the benefits of a healthy lifestyle are

Recommendations for Preventive Care During Infancy a

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 pressure b

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 surveillance c

X

X

X

X

X

X

Developmental screening d

X

Psychosocial and behavioral assessment

X

X

X

X

X

X

X

Physical examination

X

X

X

X

X

X

X

Laboratory testing e

Neonatal metabolic and hemoglobinopathy screening f

←––––––––––––––––––X–––––––––––––––––→

Hematocrit or hemoglobin

RA

Lead screening g

RA

RA

Tuberculin test h

RA

RA

Other

X

X

X

X

X

X

X

Oral health j

RA

RA

Anticipatory guidance

X

X

X

X

X

X

X

a These guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright Futures.

b If infants and children have certain high-risk conditions, BP should be measured at visits before age 3 yr.

c Developmental 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).

d Developmental 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.

e Testing may be modified, depending on when the child enters the schedule and what the child’s needs are.

f For metabolic and hemoglobinopathy screening, state law should be followed. Clinicians should review results at visits and retest or refer as needed.

g If children are at risk of lead exposure, clinicians should consult the AAP statement, Lead exposure in children: prevention, detection, and management 2005 (available at pediatrics.aappublications.org/content/116/4/1036.full; reaffirmed 5/09), and should screen children according to state law where applicable.

h For 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.

i Clinicians 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.

j Children 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 .

Recommendations for Preventive Care During Early and Middle Childhood a

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 pressure b

RA

RA

RA

RA

RA

X

X

X

X

X

X

X

X

Sensory screening

Vision

RA

RA

RA

RA

RA

X c

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 surveillance d

X

X

X

X

X

X

X

X

X

X

X

Developmental screening e

X

X

Autism f

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 testing g

Hematocrit or hemoglobin

X

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Lead screening h

X or RA

RA

X or RA

RA

RA

RA

RA

Tuberculin test i

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Dyslipidemia screening j

RA

RA

RA

RA

RA

Other

X

X

X

X

X

X

X

X

X

X

X

X

X

Oral health l

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

a These guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright Futures.

b If infants and children have certain high-risk conditions, BP should be measured at visits before age 3 yr.

c If children are uncooperative, they can be rescreened within 6 mo.

d Developmental 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).

e Developmental 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.

f Screening 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 .

g Testing may be modified, depending on when the child enters the schedule and what the child’s needs are.

h If 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.

i For 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.

j The 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.

k Clinicians 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.

l Children 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 .

Recommendations for Preventive Care During Adolescence a

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 surveillance b

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

Testing c

Hematocrit or hemoglobin

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Tuberculin test d

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Dyslipidemia screening e

RA

RA

RA

RA

RA

RA

RA

←–––––--------------------X--------------------–––––→

STD screening f

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Cervical dysplasia screening g

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Other

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.

b Developmental 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).

c Testing may be modified, depending on when the child enters the schedule and what the child’s needs are.

d For 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.

e The 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.

f All sexually active patients should be screened for STDs.

g All sexually active girls should be screened for cervical dysplasia as part of a pelvic examination beginning within 3 yr of first vaginal intercourse or at age 21 (whichever comes first).

h Clinicians 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 brightfutures.aap.org/tool_and_resource_kit.html .

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 36 mo. Growth rate should be monitored using a growth curve with percentiles; deviations in these parameters should be evaluated (see Growth and Development).

Blood pressure

Starting at age 3 yr, BP should be routinely checked by using an appropriate-sized cuff. The cuff should cover at least two thirds of the upper arm, and the bladder should encircle 80 to 100% of the circumference of the arm. 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.

BP Levels for the 50th to 99th Percentiles of BP for Boys Aged 1 to 17 Yr by Percentiles of Height

SBP (mm Hg)

DBP (mm Hg)

Percentile of Height

Percentile of Height

Age

BP Percentile

5th

10th

25th

50th

75th

90th

95th

5th

10th

25th

50th

75th

90th

95th

1

50th

80

81

83

85

87

88

89

34

35

36

37

38

39

39

90th

94

95

97

99

100

102

103

49

50

51

52

53

53

54

95th

98

99

101

103

104

106

106

54

54

55

56

57

58

58

99th

105

106

108

110

112

113

114

61

62

63

64

65

66

66

2

50th

84

85

87

88

90

92

92

39

40

41

42

43

44

44

90th

97

99

100

102

104

105

106

54

55

56

57

58

58

59

95th

101

102

104

106

108

109

110

59

59

60

61

62

63

63

99th

109

110

111

113

115

117

117

66

67

68

69

70

71

71

3

50th

86

87

89

91

93

94

95

44

44

45

46

47

48

48

90th

100

101

103

105

107

108

109

59

59

60

61

62

63

63

95th

104

105

107

109

110

112

113

63

63

64

65

66

67

67

99th

111

112

114

116

118

119

120

71

71

72

73

74

75

75

4

50th

88

89

91

93

95

96

97

47

48

49

50

51

51

52

90th

102

103

105

107

109

110

111

62

63

64

65

66

66

67

95th

106

107

109

111

112

114

115

66

67

68

69

70

71

71

99th

113

114

116

118

120

121

122

74

75

76

77

78

78

79

5

50th

90

91

93

95

96

98

98

50

51

52

53

54

55

55

90th

104

105

106

108

110

111

112

65

66

67

68

69

69

70

95th

108

109

110

112

114

115

116

69

70

71

72

73

74

74

99th

115

116

118

120

121

123

123

77

78

79

80

81

81

82

6

50th

91

92

94

96

98

99

100

53

53

54

55

56

57

57

90th

105

106

108

110

111

113

113

68

68

69

70

71

72

72

95th

109

110

112

114

115

117

117

72

72

73

74

75

76

76

99th

116

117

119

121

123

124

125

80

80

81

82

83

84

84

7

50th

92

94

95

97

99

100

101

55

55

56

57

58

59

59

90th

106

107

109

111

113

114

115

70

70

71

72

73

74

74

95th

110

111

113

115

117

118

119

74

74

75

76

77

78

78

99th

117

118

120

122

124

125

126

82

82

83

84

85

86

86

8

50th

94

95

97

99

100

102

102

56

57

58

59

60

60

61

90th

107

109

110

112

114

115

116

71

72

72

73

74

75

76

95th

111

112

114

116

118

119

120

75

76

77

78

79

79

80

99th

119

120

122

123

125

127

127

83

84

85

86

87

87

88

9

50th

95

96

98

100

102

103

104

57

58

59

60

61

61

62

90th

109

110

112

114

115

117

118

72

73

74

75

76

76

77

95th

113

114

116

118

119

121

121

76

77

78

79

80

81

81

99th

120

121

123

125

127

128

129

84

85

86

87

88

88

89

10

50th

97

98

100

102

103

105

106

58

59

60

61

61

62

63

90th

111

112

114

115

117

119

119

73

73

74

75

76

77

78

95th

115

116

117

119

121

122

123

77

78

79

80

81

81

82

99th

122

123

125

127

128

130

130

85

86

86

88

88

89

90

11

50th

99

100

102

104

105

107

107

59

59

60

61

62

63

63

90th

113

114

115

117

119

120

121

74

74

75

76

77

78

78

95th

117

118

119

121

123

124

125

78

78

79

80

81

82

82

99th

124

125

127

129

130

132

132

86

86

87

88

89

90

90

12

50th

101

102

104

106

108

109

110

59

60

61

62

63

63

64

90th

115

116

118

120

121

123

123

74

75

75

76

77

78

79

95th

119

120

122

123

125

127

127

78

79

80

81

82

82

83

99th

126

127

129

131

133

134

135

86

87

88

89

90

90

91

13

50th

104

105

106

108

110

111

112

60

60

61

62

63

64

64

90th

117

118

120

122

124

125

126

75

75

76

77

78

79

79

95th

121

122

124

126

128

129

130

79

79

80

81

82

83

83

99th

128

130

131

133

135

136

137

87

87

88

89

90

91

91

14

50th

106

107

109

111

113

114

115

60

61

62

63

64

65

65

90th

120

121

123

125

126

128

128

75

76

77

78

79

79

80

95th

124

125

127

128

130

132

132

80

80

81

82

83

84

84

99th

131

132

134

136

138

139

140

87

88

89

90

91

92

92

15

50th

109

110

112

113

115

117

117

61

62

63

64

65

66

66

90th

122

124

125

127

129

130

131

76

77

78

79

80

80

81

95th

126

127

129

131

133

134

135

81

81

82

83

84

85

85

99th

134

135

136

138

140

142

142

88

89

90

91

92

93

93

16

50th

111

112

114

116

118

119

120

63

63

64

65

66

67

67

90th

125

126

128

130

131

133

134

78

78

79

80

81

82

82

95th

129

130

132

134

135

137

137

82

83

83

84

85

86

87

99th

136

137

139

141

143

144

145

90

90

91

92

93

94

94

17

50th

114

115

116

118

120

121

122

65

66

66

67

68

69

70

90th

127

128

130

132

134

135

136

80

80

81

82

83

84

84

95th

131

132

134

136

138

139

140

84

85

86

87

87

88

89

99th

139

140

141

143

145

146

147

92

93

93

94

95

96

97

The 90th percentile is 1.28 standard deviations (SDs), the 95th percentile is 1.645 SDs, and the 99th percentile is 2.326 SDs over the mean.

BP Levels for the 50th to 99th Percentiles of BP for Girls Aged 1 to 17 Yr by Percentiles of Height

SBP (mm Hg)

DBP (mm Hg)

Percentile of Height

Percentile of Height

1

50th

83

84

85

86

88

89

90

38

39

39

40

41

41

42

90th

97

97

98

100

101

102

103

52

53

53

54

55

55

56

95th

100

101

102

104

105

106

107

56

57

57

58

59

59

60

99th

108

108

109

111

112

113

114

64

64

65

65

66

67

67

2

50th

85

85

87

88

89

91

91

43

44

44

45

46

46

47

90th

98

99

100

101

103

104

105

57

58

58

59

60

61

61

95th

102

103

104

105

107

108

109

61

62

62

63

64

65

65

99th

109

110

111

112

114

115

116

69

69

70

70

71

72

72

3

50th

86

87

88

89

91

92

93

47

48

48

49

50

50

51

90th

100

100

102

103

104

106

106

61

62

62

63

64

64

65

95th

104

104

105

107

108

109

110

65

66

66

67

68

68

69

99th

111

111

113

114

115

116

117

73

73

74

74

75

76

76

4

50th

88

88

90

91

92

94

94

50

50

51

52

52

53

54

90th

101

102

103

104

106

107

108

64

64

65

66

67

67

68

95th

105

106

107

108

110

111

112

68

68

69

70

71

71

72

99th

112

113

114

115

117

118

119

76

76

76

77

78

79

79

5

50th

89

90

91

93

94

95

96

52

53

53

54

55

55

56

90th

103

103

105

106

107

109

109

66

67

67

68

69

69

70

95th

107

107

108

110

111

112

113

70

71

71

72

73

73

74

99th

114

114

116

117

118

120

120

78

78

79

79

80

81

81

6

50th

91

92

93

94

96

97

98

54

54

55

56

56

57

58

90th

104

105

106

108

109

110

111

68

68

69

70

70

71

72

95th

108

109

110

111

113

114

115

72

72

73

74

74

75

76

99th

115

116

117

119

120

121

122

80

80

80

81

82

83

83

7

50th

93

93

95

96

97

99

99

55

56

56

57

58

58

59

90th

106

107

108

109

111

112

113

69

70

70

71

72

72

73

95th

110

111

112

113

115

116

116

73

74

74

75

76

76

77

99th

117

118

119

120

122

123

124

81

81

82

82

83

84

84

8

50th

95

95

96

98

99

100

101

57

57

57

58

59

60

60

90th

108

109

110

111

113

114

114

71

71

71

72

73

74

74

95th

112

112

114

115

116

118

118

75

75

75

76

77

78

78

99th

119

120

121

122

123

125

125

82

82

83

83

84

85

86

9

50th

96

97

98

100

101

102

103

58

58

58

59

60

61

61

90th

110

110

112

113

114

116

116

72

72

72

73

74

75

75

95th

114

114

115

117

118

119

120

76

76

76

77

78

79

79

99th

121

121

123

124

125

127

127

83

83

84

84

85

86

87

10

50th

98

99

100

102

103

104

105

59

59

59

60

61

62

62

90th

112

112

114

115

116

118

118

73

73

73

74

75

76

76

95th

116

116

117

119

120

121

122

77

77

77

78

79

80

80

99th

123

123

125

126

127

129

129

84

84

85

86

86

87

88

11

50th

100

101

102

103

105

106

107

60

60

60

61

62

63

63

90th

114

114

116

117

118

119

120

74

74

74

75

76

77

77

95th

118

118

119

121

122

123

124

78

78

78

79

80

81

81

99th

125

125

126

128

129

130

131

85

85

86

87

87

88

89

12

50th

102

103

104

105

107

108

109

61

61

61

62

63

64

64

90th

116

116

117

119

120

121

122

75

75

75

76

77

78

78

95th

119

120

121

123

124

125

126

79

79

79

80

81

82

82

99th

127

127

128

130

131

132

133

86

86

87

88

88

89

90

13

50th

104

105

106

107

109

110

110

62

62

62

63

64

65

65

90th

117

118

119

121

122

123

124

76

76

76

77

78

79

79

95th

121

122

123

124

126

127

128

80

80

80

81

82

83

83

99th

128

129

130

132

133

134

135

87

87

88

89

89

90

91

14

50th

106

106

107

109

110

111

112

63

63

63

64

65

66

66

90th

119

120

121

122

124

125

125

77

77

77

78

79

80

80

95th

123

123

125

126

127

129

129

81

81

81

82

83

84

84

99th

130

131

132

133

135

136

136

88

88

89

90

90

91

92

15

50th

107

108

109

110

111

113

113

64

64

64

65

66

67

67

90th

120

121

122

123

125

126

127

78

78

78

79

80

81

81

95th

124

125

126

127

129

130

131

82

82

82

83

84

85

85

99th

131

132

133

134

136

137

138

89

89

90

91

91

92

93

16

50th

108

108

110

111

112

114

114

64

64

65

66

66

67

68

90th

121

122

123

124

126

127

128

78

78

79

80

81

81

82

95th

125

126

127

128

130

131

132

82

82

83

84

85

85

86

99th

132

133

134

135

137

138

139

90

90

90

91

92

93

93

17

50th

108

109

110

111

113

114

115

64

65

65

66

67

67

68

90th

122

122

123

125

126

127

128

78

79

79

80

81

81

82

95th

125

126

127

129

130

131

132

82

83

83

84

85

85

86

99th

133

133

134

136

137

138

139

90

90

91

91

92

93

93

The 90th percentile is 1.28 standard deviations (SDs), the 95th percentile is 1.645 SDs, and the 99th percentile is 2.326 SDs over the mean.

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 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 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 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 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 Care of Newborns and Infants: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. Asymmetric toeing (toeing-in on one side and toeing-out on the other—windswept appearance) typically requires orthopedic evaluation.

Genital examination

Girls should be offered a pelvic examination and Papanicolaou (Pap) testing within 3 yr of first vaginal intercourse or at age 21—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.Adolescent boys should be taught how to do testicular self-examination to check for masses, and adolescent girls should be taught how to do breast self-examination.

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 with any of the following risk factors: moderate to heavy menses, chronic weight loss, a nutritional deficit, or participation in athletic activity. Testing for Hb S can be done at age 6 to 9 mo (see Sickle Cell Disease : 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 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 they have a family history of hyperlipidemia or early-onset heart disease or stroke. If other risk factors (eg, obesity) are present or family history is uncertain, testing is at the discretion of the physician. All children should have lipid screening at 9 to 11 yr and at 17 to 21 yr.

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: 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.

Normal Hearing in Very Young Children*

Age

Expected Response

3 mo

Startles to a nearby loud sound

Stirs or awakens from sleep when someone talks or makes a sound

Is soothed by mother’s voice

6 mo

Looks toward an interesting sound

Turns when name is called

Makes “moo,” “ma,” “da,” “di” sounds to toys

Coos when listening to music

10 mo

Makes own sounds

Imitates some sounds

Understands “no” and “bye-bye”

18 mo

Understands many single words or commands

Babbles in sentence-like patterns

*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.

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.

Routine laboratory screening for common sexually transmitted diseases (STDs) is indicated for sexually active adolescents (see also Screening). All sexually active females aged ≤ 25 yr and those who are no longer active but have a history of an STD should be screened annually for Chlamydia trachomatis and Neisseria gonorrhoeae. Pregnant women ≤ 25 yr are also screened during their initial prenatal visit and again during the 3rd trimester. Heterosexually active young men should be screened in clinical settings associated with high prevalence of STDs (eg, in adolescent and STD clinics, at entrance into correctional facilities). Men who have sex with men should be screened if they have been sexually active within the previous year. Nucleic acid amplification tests (NAATs) are the most sensitive tests for detecting C. trachomatis and N. gonorrhoeae infection. NAATs using urine, cervical, and urethral specimens are available. HIV screening should be discussed with all adolescents and encouraged for those who are sexually active and those who use injection drugs. 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:

  • Using a rear-facing car seat

  • Reducing home water temperature to < 49° C (< 120° F)

  • Preventing falls

  • Using sleeping precautions: Placing infants on their back, not sharing a bed, using a firm mattress, and not allowing stuffed animals, pillows, and blankets in the crib

  • Avoiding foods and objects that children can aspirate

For infants from 6 to 12 mo:

  • Continuing to use a rear-facing car seat

  • Continuing to place infants on their back to sleep

  • Not using baby walkers

  • Using safety latches on cabinets

  • Preventing falls from changing tables and around stairs

  • Vigilantly supervising children when in bathtubs and while learning to walk

For children aged 1 to 4 yr:

  • Using an age- and weight-appropriate car seat (infants and toddlers should use a rear-facing car seat until they are at least 2 yr of age or until they exceed the rear-facing weight or height limits for their convertible child safety seat)

  • Reviewing automobile safety both as passenger and pedestrian

  • Tying window cords

  • Using safety caps and latches

  • Preventing falls

  • Removing handguns from the home

For children 5 yr:

  • All of the above

  • Using a bicycle helmet and protective sports gear

  • Instructing children about safe street crossing

  • Closely supervising swimming and sometimes requiring the use of life jackets during swimming

Nutrition

Excessive caloric intake underlies the epidemic of obesity in children (see Children). Recommendations vary by age; for children up to 2 yr, see 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 and excessive fruit juice consumption have been implicated as major contributors 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 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.

Resources In This Article

* This is a professional Version *