SECTION Pediatrics

SUBJECT 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 Neonate 3–5 By 1 2 mo 4 mo 6 mo 9 mo
days mo
History (initial or interval)

— X X X X X X X

Measurements

Length or height and X X X X X X X

weight

Head circumference X X X X X X X

Weight for length X X X X X X X

Blood pressure b RA RA RA RA RA RA RA

Sensory screening

Vision RA RA RA RA RA RA RA

Hearing X RA RA RA RA RA RA

Developmental and behavioral assessment

Developmental X X X X X X
surveillancec

Developmental X
screeningd

Psychosocial and X X X X X X X
behavioral assessment

Physical examination

— X X X X X X X

Laboratory testinge

Neonatal metabolic and ←–––––––––X–––––––––→

hemoglobin screeningf

Hematocrit or RA
hemoglobin

Lead screeningg RA RA

Tuberculin testh RA RA

Other
Immunizationi (see Table X X X X X X X
10: Approach to the Care
of Normal Infants and
Children: Recommended
Immunization Schedule
for Ages 0–6 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 RA RA

Anticipatory guidance X X X X X X X

aThese guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and
Bright Futures.
bIf infants and children have certain high-risk conditions, BP should be measured at visits before age 3
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).
dDevelopmental 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.
eTestingmay be modified, depending on when the child enters the schedule and what the child's
needs are.
f For metabolicand hemoglobinopathy screening, state law should be followed. Clinicians should
review results at visits and retest or refer as needed.
gIf childrenare 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.
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.
iClinicians
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 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 15 18 24 30 3 4 yr 5 6 7 8 9 10
mo mo mo mo mo yr yr yr yr yr yr yr
History (initial or interval)

— X X X X X X X X X X X X X

Measurements

Height and X X X X X X X X X X X X X
weight

Head X X X X
circumference

Weight for X X X
length

Body mass X X X X X X X X X X
index

Blood RA RA RA RA RA X X X X X X X X
pressureb

Sensory screening

Vision RA RA RA RA RA Xc X X X RA X RA X

Hearing RA RA RA RA RA RA X X X RA X RA X

Developmental and behavioral assessment

Developmental X X X X X X X X X X X
surveillanced

Developmental X X
screeninge

Autism f X X

Psychosocial X X X X X X X X X X X X X
and behavioral
assessment

Physical examination

— X X X X X X X X X X X X X

Laboratory testingg

Hematocrit or X RA RA RA RA RA RA RA RA RA RA
hemoglobin

Lead X RA X RA RA RA RA
screeningh or or
RA RA

Tuberculin RA RA RA RA RA RA RA RA RA RA RA
testi

Dyslipidemia RA RA RA RA RA
screeningj

Other
Immunizationk X X X X X X X X X X X X X
(see Table 10:
Approach to
the Care of
Normal Infants
and Children:
Recommended
Immunization
Schedule for
Ages 0–6 yr
, Table 11:
Approach to
the Care of
Normal Infants
and Children:
Recommended
Immunization
Schedule for
Ages 7–18 yr
and Table
12: Approach
to the Care of
Normal Infants
and Children:
Catch-up
Immunization
Schedule for
Ages 4 mo–18
yr )

Oral healthl X X X X X X
or or or or
RA RA RA RA

Anticipatory X X X X X X X X X X X X X
guidance

aThese guidelines are based on a consensus by the American Academy of Pediatrics (AAP) and Bright
Futures.
bIf infants and children have certain high-risk conditions, BP should be measured at visits before age 3 yr.
cIf children are uncooperative, they can be rescreened within 6 mo.
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.
f 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.
gTesting may be modified, depending on when the child enters the schedule and what the child's needs are.
hIf childrenare 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.
iFor 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.
jThe 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 3–5 yr.
kCliniciansshould 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.
lChildren 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.

Table 7
Recommendations for Preventive Care During Adolescencea
Age
Item 11 12 13 14 15 16 17 18 19 20 21
yr yr yr yr yr yr yr yr yr yr yr
History (initial or interval)

— X X X X X X X X X X X

Measurements

Height and weight X X X X X X X X X X X

Body mass index X X X X X X X X X X X

Blood pressure X X X X X X X X X X X

Sensory screening

Vision RA X RA RA X RA RA X RA RA RA

Hearing RA RA RA RA RA RA RA RA RA RA RA

Developmental/behavioral assessment

Developmental X X X X X X X X X X X
surveillanceb

Psychosocial and X X X X X X X X X X X
behavioral
assessment

Alcohol and drug RA RA RA RA RA RA RA RA RA RA RA

use assessment

Physical examination

— X X X X X X X X X X X
Testingc

Hematocrit or RA RA RA RA RA RA RA RA RA RA RA
hemoglobin

Tuberculin testd RA RA RA RA RA RA RA RA RA RA RA

Dyslipidemia RA RA RA RA RA RA RA ←–––––X–––––→
screeninge

STD screeningf RA RA RA RA RA RA RA RA RA RA RA

Cervical dysplasia RA RA RA RA RA RA RA RA RA RA RA
screeningg

Other

Immunizationh(see X X X X X X X X X X X
Table 11: Approach
to the Care of
Normal Infants and
Children:
Recommended
Immunization
Schedule for Ages
7–18 yr and
Table 12: Approach
to the Care of
Normal Infants and
Children: Catch-up
Immunization
Schedule for Ages 4
mo–18 yr )

Anticipatory X X X X X X X X X X X
guidance

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).
cTestingmay 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.
eThe 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 3–5 yr.
f All 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).
hCliniciansshould 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).
BP Levels for the 50th to 99th Percentiles of BP
for Boys Aged 1 to 17 Yr by Percentiles of Height
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Eyes should be assessed at each visit. Clinicians

should check for esotropia or exotropia, for
abnormalities in globe size (suggesting congenital BP Levels for the 50th to 99th Percentiles of BP
for Girls Aged 1 to 17 Yr by Percentiles of Height
glaucoma); for a difference in pupil size, iris color, or
both (suggesting Horner's syndrome, trauma, or
This table is presented as a PDF and requires the
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represent an ocular, autonomic, or intracranial
disorder); and for absence or distortion of the red reflex
(suggesting cataract or retinoblastoma).

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 active—whichever 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 μg/dL (> 0.48 μmol/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 Table 8
emission testing, brain stem auditory evoked response) Normal Hearing in Very Young
should be done by an audiologist. Conventional Children*
audiometry can be used for children beginning at about Age Expected Response
age 3 yr; young children can also be tested by 3 mo Startles to a nearby loud sound
observing their responses to sounds made through Stirs or awakens from sleep when
headphones, watching their attempts to localize the someone talks or makes a sound

sound or complete a simple task. Tympanometry, Is soothed by mother's voice

another in-office procedure (see Hearing Loss: 6 mo Looks toward an interesting sound
Testing), can be used with children of any age and is Turns when name is called
useful for evaluating middle ear function. Abnormal Makes “moo,” “ma,” “da,” “di” sounds
tympanograms often denote eustachian tube to toys
Coos when listening to music
dysfunction or the presence of middle ear fluid that
cannot be detected during otoscopic examination. 10 mo Makes own sounds
Pneumatic otoscopy is helpful in evaluating middle ear Imitates some sounds
status, but combining it with tympanometry is more Understands “no” and “bye-bye”
informative than either procedure alone. 18 mo Understands many single words or
commands
Other screening tests Babbles in sentence-like patterns
Tuberculin testing should be done if children have been
exposed to TB (eg, to an infected family member or *If a child does not pass these minimal
performance standards or if parents suspect a
close contact), if they have had a family member with a hearing loss in their child at any age, the child
positive tuberculin test, if they were born in developing should be referred for testing.
countries, or if their parents are new immigrants from
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