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Health Supervision of the Well Child


Deborah M. Consolini

, MD, Thomas Jefferson University Hospital

Reviewed/Revised May 2023
Topic Resources

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 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 normally.

The Bright Futures/AAP recommendations for preventive pediatric health care (2022), also called the periodicity schedule, are a schedule of screenings and assessments recommended at each well-child visit for newborns through adolescents 21 years of age. The periodicity schedule shows the recommendations in chart form and is updated annually. More details regarding health promotion interventions at these specific developmental stages can be found in the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition (2017).

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.

In addition to physical examination, clinicians 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

Developmental screening using a validated screening tool is recommended for all children during regular well-child visits at 9, 18, and 30 months of age (eg, Ages and Stages Questionnaires; PEDS: Developmental Milestones). Screening specifically for autism spectrum disorder Autism Spectrum Disorders Autism spectrum disorders are neurodevelopmental disorders characterized by impaired social interaction and communication, repetitive and stereotyped patterns of behavior, and uneven intellectual... read more is recommended during regular well-child visits at 18 and 24 months of age. Validated screening tools (eg, the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up [M-CHAT-R/F]) are available for clinic use to facilitate evaluation of motor, cognitive, language, and social development (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 and caregivers to optimize the... read more ).

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

General reference

Physical Examination


Blood pressure

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.


Ears, eyes, and mouth

Eyes should be assessed at each visit. Clinicians should check for all of the following:

Ptosis and eyelid hemangioma obscure vision and require attention.

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.

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.


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



3–6 years

0.5 mg once a day

0.25 mg once a day


6–16 years

1.0 mg once a day

0.5 mg once a day



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 .


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 Idiopathic Scoliosis 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 Musculoskeletal System 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.


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.

  • Persistent vaginal discharge

  • Lower abdominal pain (if evaluation is negative for a urinary or gastrointestinal tract etiology)

  • Severe dysmenorrhea

  • Amenorrhea (if a structural abnormality is suspected)

  • Abnormal vaginal bleeding

  • Contraceptive counseling for an intrauterine device or diaphragm

  • Suspected rape or sexual abuse

  • Pregnancy

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.

Genitals references



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)

  • 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 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

  • Preventing falls

  • 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


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.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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