SECTION SUBJECT

Pediatrics Approach to the Care of Normal Infants and Children

Health Supervision of the Well Child

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 5: Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Infancya , Table 6: Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Early and Middle Childhooda , and Table 7: Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Adolescencea ) 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, psychosocial, or chronic disease may require more frequent counseling and treatment visits that are separate from preventive care visits. If parents are high risk, are parents for the first time, 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 Physical Growth and Development: 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 them 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

Table 5
Recommendations for Preventive Care During Infancya
Age Item
History (initial or interval) Measurements Length or height and weight Head circumference Weight for length Blood pressure b Sensory screening Vision Hearing RA X RA RA RA RA RA RA RA RA RA RA RA RA X X X X X X X X X X X X X X

Neonate

35 days

By 1 mo

2 mo

4 mo

6 mo

9 mo

X X RA

X X RA

X X RA

X X RA

X X RA

X X RA

X X RA

Developmental and behavioral assessment Developmental surveillancec Developmental screeningd Psychosocial and behavioral assessment Physical examination Laboratory testinge Neonatal metabolic and hemoglobin screeningf Hematocrit or hemoglobin Lead screeningg Tuberculin testh Other RA RA X X X X X X X X X X X X X X X X X X X X X X

RA RA

RA

Immunizationi (see Table 10: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 06 yr , and Table 12: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo 18 yr )

Oral healthj Anticipatory guidance X X X X X

RA X

RA X

aThese

guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright Futures. and children have certain high-risk conditions, BP should be measured at visits before age 3

bIf infants

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, and findings). 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.

dDevelopmental

eTesting

may be modified, depending on when the child enters the schedule and what the child's needs are. and hemoglobinopathy screening, state law should be followed. Clinicians should review results at visits and retest or refer as needed. are at risk of lead exposure, clinicians should consult the AAP statement, Lead exposure in children: prevention, detection, and management, 2005 (available at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1036; reaffirmed 5/09) and should screen children according to state law where applicable.

f For metabolic gIf children

hFor 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.

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.
jChildren

iClinicians

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.

X = age at which evaluation should be done; X = range during which evaluation may be done, with X indicating the preferred age; AAP = American Academy of Pediatrics; RA = age at which risk assessment should be done, followed, if results are positive, by appropriate examination or testing. 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.

Table 6
Recommendations for Preventive Care During Early and Middle Childhooda
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) Measurements Height and weight Head circumference Weight for length Body mass index Blood pressureb Sensory screening Vision Hearing RA RA RA RA RA RA RA RA RA RA Xc RA X X X X X X RA RA X X RA RA X X RA RA RA X X X X X X X X X X X X X X X X X X X X X X X X X X

RA

RA

Developmental and behavioral assessment Developmental surveillanced Developmental screeninge Autism f Psychosocial and behavioral assessment X X X X X X X X X X X X X X X 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 testingg Hematocrit or hemoglobin Lead screeningh Tuberculin testi Dyslipidemia screeningj Other RA RA RA RA RA X RA RA RA RA RA RA RA RA RA RA

X or RA RA

RA

X or RA RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Immunizationk (see Table 10: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 06 yr , Table 11: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 718 yr and Table 12: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo18 yr )

Oral healthl

X or RA X X

X or RA X

X or RA X

X or RA X

Anticipatory guidance

aThese

guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright Futures. and children have certain high-risk conditions, BP should be measured at visits before age 3 yr. are uncooperative, they can be rescreened within 6 mo.

bIf infants

cIf children

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, and findings).

eDevelopmental

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.

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. may be modified, depending on when the child enters the schedule and what the child's needs are. are at risk of lead exposure, clinicians should consult the AAP statement, Lead exposure in children: prevention, detection, and management, 2005 (available at http://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.

gTesting

hIf children

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 highrisk children are identified, they should be tested.

AAP recommends screening children who have a family history of high cholesterol, 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 35 yr. 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. should be referral 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. X = age at which evaluation should be done; AAP = American Academy of Pediatrics; RA = age at which risk assessment should be done, followed, if results are positive, by appropriate examination or testing. 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.
lChildren kClinicians

jThe

Table 7
Recommendations for Preventive Care During Adolescencea
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) Measurements Height and weight Body mass index Blood pressure Sensory screening Vision Hearing RA RA X RA RA RA RA RA X RA RA RA RA RA X RA RA RA RA RA RA RA X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Developmental/behavioral assessment Developmental surveillanceb Psychosocial and behavioral assessment Alcohol and drug use assessment Physical examination X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

RA

Testingc Hematocrit or hemoglobin Tuberculin testd Dyslipidemia screeninge STD screeningf Cervical dysplasia screeningg Other Immunizationh(see Table 11: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 718 yr and Table 12: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo18 yr Anticipatory guidance ) X X X X X X X X X X X X X X X X X X X X X X RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA RA

RA RA

RA RA

RA RA

RA RA

RA RA

RA RA

RA RA

RA

RA

RA

RA

a These

guidelines represent a consensus by the American Academy of Pediatrics (AAP) and Bright

Futures.
bDevelopmental

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, and findings).

cTesting

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.

AAP recommends screening for children who have a family history of high cholesterol, 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 35 yr.
f All

eThe

sexually active patients should be screened for STDs.

g All

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

hClinicians

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. X = age at which evaluation should be done; X = range during which evaluation may be done,

with X indicating the preferred age; AAP = American Academy of Pediatrics; RA = age at which risk assessment should be done, followed, if results are positive, by appropriate examination or testing; STDs = sexually transmitted diseases. 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.

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 24 mo. Growth rate should be monitored using a growth curve with percentiles; deviations in these parameters should be evaluated (see Physical Growth and Development). Blood pressure Starting at age 3 yr, BP should be routinely checked by using an appropriate-sized cuff. The width of the inflatable rubber bag portion of the BP cuff should be about 40% of the circumference of the upper arm, and its length should cover 80 to 100% of the circumference. 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.

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 below).
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's 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).

BP Levels for the 50th to 99th Percentiles of BP for Boys Aged 1 to 17 Yr by Percentiles of Height This table is presented as a PDF and requires the free Adobe PDF reader. Get Adobe Reader

BP Levels for the 50th to 99th Percentiles of BP for Girls Aged 1 to 17 Yr by Percentiles of Height This table is presented as a PDF and requires the free Adobe PDF reader. Get Adobe Reader

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 Perinatal Problems: 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 Bone and Connective Tissue Disorders in Children: 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 Approach to the Care of Normal Infants and Children: 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.

Genital examination Girls should be offered a pelvic examination and Papanicolaou (Pap) testing at age 18 or when they become sexually activewhichever 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.

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. Testing for Hb S can be done at age 6 to 9 mo (see Anemias Caused by Hemolysis: 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 be repeated at 24 mo. If the clinician is not sure of a child's risk, testing should be done. Levels > 10 g/dL (> 0.48 mol/L) pose a risk of neurologic damage (see Poisoning: 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 of family history. If other risk factors are present or family history is uncertain, testing is at the discretion of the physician.

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 8: Approach to the Care of Normal Infants and Children: 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.
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.

Table 8
Normal Hearing in Very Young Children*
Age
3 mo

Expected Response
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

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

*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.

those countries or have been recently incarcerated. For sexually active adolescents, dipstick analysis for leukocytes and urinary testing for chlamydial infection should be done annually. 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 can face forward when they reach 9 kg [20 lb] and age 12 mo, but rear-facing is still the safest position) 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 Poor nutrition underlies the epidemic of obesity in children (see Obesity and the Metabolic Syndrome: Children). Recommendations vary by age; for children up to 2 yr, see Approach to the Care of Normal Infants and Children: 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 has been implicated as a major contributor 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 Exercise and Sports Injury: 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.
Last full review/revision February 2010 by Eve R. Colson, MD; Rachel L. Chapman, MD; Melissa R. Held, MD