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Health Supervision of the Well Child

By

Deborah M. Consolini

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Jul 2021| Content last modified Jul 2021
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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 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.

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

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

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General reference

Physical Examination

Growth

Blood pressure

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) 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 and girls Blood Pressure (BP) Percentile Levels for Girls by Age and Height (Measured and Percentile) 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 , 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.

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Head

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

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 Diagnosis 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 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 ). 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.

Table

Fluoride Supplementation Based on Fluoride Content in Drinking Water

Age

Fluoride < 0.3 ppm

Fluoride 0.3–0.6 ppm

Fluoride > 0.6 ppm

6 months–3 years

0.25 mg once a day

None

None

3–6 years

0.5 mg once a day

0.25 mg once a day

None

6–16 years

1.0 mg once a day

0.5 mg once a day

None

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 (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 Overview of Congenital Cardiovascular Anomalies ). 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 .

Abdomen

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 Hand washing is critical for all personnel to prevent transmission of infection. Active participation in the birth by the mother and her partner helps them adapt to parenting. Immediately at... 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.

Genital examination

Prevention

Safety

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

Nutrition

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 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.

More Information

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

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