Health Supervision of the Well Child

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 ).

(See also Hypertension in Children Hypertension in Children Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both; the pressures considered abnormal in children vary based on age up to age 13. Hypertension... read more .)

Starting at 3 years of age, blood pressure (BP) should be routinely checked by using an appropriate-size cuff. The cuff should cover at least two thirds of the upper arm, and the bladder (inflatable bag inside the cuff) should encircle 80 to 100% of the circumference of the arm. If no available cuff fits the criteria, using a 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 and , 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, indicate stage 2 hypertension, and children 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 Screening Tests for Infants, Children, and Adolescents 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:

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 ).

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. Brushing with fluoride toothpaste in the appropriate dosage for age should be recommended.

It is recommended that every child have a dental home (an ongoing relationship between the dentist and the patient) by 1 year of age.

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, if severe, malperfusion of the abdominal... 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.

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 of a newborn should be done within 24 hours of birth. Doing the examination with parents present allows them to ask questions and allows 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.

At a minimum, examination of the external genitalia should be included as part of the annual comprehensive physical examination of children and adolescents of all ages.

Most adolescent girls do not need an internal 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 involving a speculum or bimanual examination except girls who have the following:

Cervical cancer screening guidelines vary regarding starting age, recommending either age 21 or age 25 years for average-risk women (1 Genitals references Well-child visits aim to do the following: Promote health Prevent disease through routine vaccinations and education Detect and treat disease early Guide parents and caregivers to optimize the... read more , 2 Genitals references Well-child visits aim to do the following: Promote health Prevent disease through routine vaccinations and education Detect and treat disease early Guide parents and caregivers to optimize the... read more ). For women with immunosuppression or HIV infection, cervical cancer screening should be initiated within at least 2 years of the onset of receptive sexual activity or by age 21 years (3 Genitals references Well-child visits aim to do the following: Promote health Prevent disease through routine vaccinations and education Detect and treat disease early Guide parents and caregivers to optimize the... read more ).

With the availability of urine-based and vaginal swab–based sexually transmitted infection (STI) testing, an internal pelvic examination in an asymptomatic patient is not necessary for diagnosing STIs. Other non-STIs, such as bacterial vaginosis Bacterial Vaginosis (BV) Bacterial vaginosis is a dysbiosis, a complex alteration of vaginal flora, in which lactobacilli decrease and anaerobic pathogens overgrow. Symptoms include a yellow-green or gray, thin, malodorous... read more and yeast infections Candidal Vaginitis Candidal vaginitis is vaginal infection with Candida species, usually C. albicans. Symptoms are usually a thick, white vaginal discharge and vulvovaginal pruritus that is often... read more , can also be diagnosed with a vaginal swab test.

All sexually active adolescents and young adults should be screened annually for STIs Screening for Sexually Transmitted Infections (STIs) 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 .

In boys, 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.Breast self-examination (BSE) alone as a screening method has not shown a benefit and may result in higher rates of unnecessary breast biopsy. Adolescent girls may be taught breast self-awareness, and if they notice changes in how their breasts appear or feel (eg, masses, thickening, enlargement), they should be encouraged to have a medical evaluation.

Recommendations for injury prevention vary by age. Some examples follow.

For infants from birth to 6 months:

For infants from 6 to 12 months:

For children aged 1 to 4 years:

For children ≥ 5 years:

Excessive caloric intake underlies the epidemic of obesity in children Children Obesity is a chronic, multifactorial, relapsing disorder characterized by excess body weight and defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders... 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 is recommended.

Limits to screen time (for example, television, video games, cell phones and other handheld devices, and noneducational computer time), which is linked directly to inactivity and obesity, should start at birth and be maintained throughout adolescence.