Well-child visits aim to do the following:
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 for children who have no significant health problems and who are growing and developing satisfactorily. Children 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. The schedules are organized by age:
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 Overview of High-Risk Pregnancy In a high-risk pregnancy, the mother, fetus, or neonate is at increased risk of morbidity or mortality before, during, or after delivery. Risk assessment is part of routine prenatal care. Family... read more ) 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
Sometimes seeking information from outside sources such as teachers and child care providers
Tools (eg, the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up [M-CHAT-R/F]; 1 General reference 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... read more ) are available for office use to facilitate evaluation of cognitive and social development.
Both physical examination and screening are important parts of preventive health care in infants and children. Most parameters, such as weight Weight Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more , are included for all children; others are applicable to selected patients, such as lead screening in 1- and 2-year-olds.
Anticipatory guidance is also important to preventive health care. It includes
Obtaining information about the child and parents (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
Length Length Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more (crown-heel) or height (once children can stand) and weight Weight Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more should be measured at each visit. Head circumference Head Circumference Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more should be measured at each visit through 36 months. Growth rate should be monitored using a growth curve with percentiles; deviations in these parameters should be evaluated (see Physical Growth of Infants and Children Physical Growth of Infants and Children Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more ).
Starting at 3 years of age, blood pressure (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 95th percentiles for boys Blood Pressure (BP) Percentile Levels for Boys by Age and Height (Measured and Percentile) and girls Blood Pressure (BP) Percentile Levels for Girls by Age and Height (Measured and Percentile) , below). Systolic and diastolic BP measurements between the 90th and 95th percentiles are considered elevated and should prompt continued observation and assessment of hypertensive risk factors. If measurements are consistently ≥ 95th percentile but < 95th percentile + 12 mm Hg, children should be considered to have stage 1 hypertension, and a cause should be determined. Measurements that are ≥ 95th percentile + 12 mm Hg or ≥ 140/90, whichever is lower, represent stage 2 hypertension and should be evaluated by a specialist.
The most common abnormality is fluid in the middle ear (otitis media Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more with effusion), manifesting as a change in the appearance of the tympanic membrane and a loss of tympanic membrane mobility in response to air pressure (during pneumatic otoscopy). Clinicians should screen for hearing deficits Hearing tests Screening (along with physical examination) is an important part of preventive health care in infants, children, and adolescents. To detect iron deficiency, clinicians should determine hematocrit... read more .
Eyes should be assessed at each visit. Clinicians should check for all of the following:
Abnormalities in globe size: Suggesting congenital glaucoma Primary Infantile Glaucoma Primary infantile glaucoma is a rare developmental defect in the iridocorneal filtration angle of the anterior chamber that prevents aqueous fluid from properly draining from the eye. This obstruction... read more
A difference in pupil size, iris color, or both: Suggesting Horner syndrome Horner Syndrome Horner syndrome is ptosis, miosis, and anhidrosis due to dysfunction of cervical sympathetic output. (See also Overview of the Autonomic Nervous System.) Horner syndrome results when the cervical... read more , trauma, or neuroblastoma Neuroblastoma Neuroblastoma is a cancer arising in the adrenal gland or less often from the extra-adrenal sympathetic chain, including in the retroperitoneum, chest, and neck. Diagnosis is confirmed by biopsy... read more (asymmetric pupils may be normal or represent an ocular, autonomic, or intracranial disorder)
Absence or distortion of the red reflex: Suggesting cataract Congenital Cataract Congenital cataract is a lens opacity that is present at birth or shortly after birth. Diagnosis is clinical and sometimes with imaging. Treatment is surgical removal of the cataract. (See also... read more or retinoblastoma Retinoblastoma Retinoblastoma is a cancer arising from the immature retina. Symptoms and signs commonly include leukocoria (a white reflex in the pupil), strabismus, and, less often, inflammation and impaired... read more
Ptosis and eyelid hemangioma obscure vision and require attention. Infants born at < 32 weeks gestation should be assessed by an ophthalmologist for evidence of retinopathy of prematurity Retinopathy of Prematurity Retinopathy of prematurity is a bilateral disorder of abnormal retinal vascularization in premature infants, especially those of lowest birth weight. Outcomes range from normal vision to blindness... read more and for the development of refractive errors Overview of Refractive Error In the emmetropic (normally refracted) eye, entering light rays are focused on the retina by the cornea and the lens, creating a sharp image that is transmitted to the brain. The lens is elastic... read more , which are more common among infants in this age group.
Vision screening is recommended at ages 4 and 5 years. Children can be screened at 3 years as well if they are cooperative. In addition to the well-child visits at 3 through 5 years of age, instrument-based screening may be used to assess risk at 12 and at 24 months of age. 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 Diagnosis Caries is tooth decay, commonly called cavities. The symptoms—tender, painful teeth—appear late. Diagnosis is based on inspection, probing of the enamel surface with a fine metal instrument... read more is important, and referral to a dentist should be made if cavities are present, even in children who have only deciduous teeth. If the primary water source is deficient in fluoride, oral fluoride supplementation should begin when a child is 6 months old and be continued daily until the child is 16 years old ( see Table: Fluoride Supplementation Based on Fluoride Content in Drinking Water Fluoride Supplementation Based on Fluoride Content in Drinking Water ). Brushing with fluoride toothpaste in the appropriate dosage for age should be recommended. Once teeth are present, fluoride varnish may be applied to all children every 3 to 6 months in the primary care setting or until a dental home is established. Dentists typically begin seeing children at about age 3; after this time, clinicians may simply assess that children and adolescents are receiving appropriate dental care, including fluoride treatment if needed.
Fluoride Supplementation Based on Fluoride Content in Drinking Water
Fluoride < 0.3 ppm
Fluoride 0.3–0.6 ppm
Fluoride > 0.6 ppm
6 months–3 years
0.25 mg once a day
0.5 mg once a day
0.25 mg once a day
1.0 mg once a day
0.5 mg once a day
Thrush Candidiasis (Mucocutaneous) Candidiasis is skin and mucous membrane infection with Candida species, most commonly Candida albicans. Infections can occur anywhere and are most common in skinfolds, digital... read more is common among infants and not usually a sign of immunosuppression.
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 (see Overview of Congenital Heart Disease Overview of Congenital Cardiovascular Anomalies Congenital heart disease is the most common congenital anomaly, occurring in almost 1% of live births ( 1). Among birth defects, congenital heart disease is the leading cause of infant mortality... read more ). The chest wall is palpated for the apical impulse to check for cardiomegaly. Femoral pulses are palpated; if they are diminished and associated with a discrepancy between upper and lower extremity blood pressure measurements, the child may have aortic coarctation Coarctation of the Aorta Coarctation of the aorta is a localized narrowing of the aortic lumen that results in upper-extremity hypertension, left ventricular hypertrophy, and malperfusion of the abdominal organs and... read more .
Palpation is repeated at every visit because many masses, particularly Wilms tumor Wilms Tumor Wilms tumor is an embryonal cancer of the kidney composed of blastemal, stromal, and epithelial elements. Genetic abnormalities have been implicated in the pathogenesis, but familial inheritance... read more and neuroblastoma Neuroblastoma Neuroblastoma is a cancer arising in the adrenal gland or less often from the extra-adrenal sympathetic chain, including in the retroperitoneum, chest, and neck. Diagnosis is confirmed by biopsy... read more , 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 Idiopathic Scoliosis Idiopathic scoliosis is lateral curvature of the spine. Diagnosis is clinical and includes spinal x-rays. Treatment depends on the severity of the curvature. Idiopathic scoliosis is the most... read more by observing posture, shoulder tip and scapular symmetry, torso list, and especially paraspinal asymmetry when children bend forward.
At each visit before children start to walk, evaluation for developmental dysplasia of the hip Musculoskeletal system A thorough physical examination should be done within 24 hours. Doing the examination with the mother and other family members present allows them to ask questions and the clinician to point... read more should be done. The Barlow and Ortolani maneuvers are used until about age 4 months. 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 Tibial Torsion The tibia may be twisted at birth. Tibial torsion can be external (lateral) or internal (medial). (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders.) External tibial... read more , or femoral torsion Femoral Torsion (Twisting) The femoral head may be twisted at birth. (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders.) Femoral torsion is common among neonates and may be either Internal... read more . 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.
Girls should be offered a pelvic examination Adolescents Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more and Papanicolaou (Pap) testing Screening tests for cervical cancer Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more at age 21. All sexually active patients should be screened for sexually transmitted infections Screening for sexually transmitted infections Screening (along with physical examination) is an important part of preventive health care in infants, children, and adolescents. To detect iron deficiency, clinicians should determine hematocrit... read more .
Testicular and inguinal evaluation should be done at every visit, specifically looking for undescended testes Diagnosis Cryptorchidism is failure of one or both testes to descend into the scrotum; in younger children, it is typically accompanied by inguinal hernia. Diagnosis is by testicular examination, sometimes... read more in infants and young boys, testicular masses in older adolescents, and inguinal hernia Diagnosis An inguinal hernia is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the abdominal wall just above the inguinal ligament. Many inguinal... read more 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 Breast examination Breast symptoms (eg, masses, nipple discharge, pain) are common, accounting for > 15 million physician visits/year. Although > 90% of symptoms have benign causes, breast cancer is always... read more .
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 back Prevention Sudden infant death syndrome is the sudden and unexpected death of an infant or young child between 2 weeks and 1 year of age in which an examination of the death scene, thorough postmortem... read more , injury prevention, nutritional and exercise advice Overview of Exercise Exercise stimulates tissue change and adaptation (eg, increase in muscle mass and strength, cardiovascular endurance), whereas rest and recovery allow such change and adaptation to occur ( 1)... read more , and discussions of violence Violence Adolescence is a time for developing independence. Typically, adolescents exercise their independence by questioning or challenging their parents' (or guardians') rules, which at times leads... read more , firearms, and substance abuse Drug and Substance Use in Adolescents Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more .
Recommendations for injury prevention vary by age. Some examples follow.
For infants from birth to 6 months:
Using a rear-facing car seat
Reducing maximum home water temperature to < 49° C (< 120° F)
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 months:
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 years:
Using an age- and weight-appropriate car seat (infants and toddlers should use a rear-facing car seat until they exceed the rear-facing weight or height limits for their convertible child safety seat; most convertible car seats have limits that will allow children to ride rear-facing for ≥ 2 years)
Reviewing automobile safety both as passenger and pedestrian
Tying window cords
Using safety caps and latches
Installing outlet plug covers
Removing handguns from the home
For children ≥ 5 years:
All of the recommendations for children aged 1 to 4 years
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
Excessive caloric intake underlies the epidemic of obesity in children Children Obesity is excess body weight, defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders (particularly in people with excess abdominal fat)... read more . Recommendations for calorie intake vary by age; for children up to age 2 years, see Nutrition in Infants Nutrition in Infants If the delivery was uncomplicated and the neonate is alert and healthy, the neonate can be brought to the mother for feeding immediately. Successful breastfeeding is enhanced by putting the... read more .
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.
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 Screening for Sports Participation Athletes are commonly screened to identify risk before participation in sports, In the US, they are reevaluated every 2 years (if high school age) or every 4 years (if college age or older)... read more is recommended.
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.
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Bright Futures/American Academy of Pediatrics (AAP): Recommendations for preventive pediatric health care, 2021
Centers for Disease Control and Prevention (CDC): Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2021