|
Well-child visits aim to prevent disease through routine vaccinations and education, detect and treat disease early, and guide parents to optimize the child's emotional and intellectual development. The American Academy of Pediatrics (AAP) has recommended preventive health care schedules (see Fig. 2: Approach to the Care of Normal Infants and Children: Recommendations for preventive pediatric health care. ) 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 a child comes under care for the 1st time late on the schedule or if any items are not accomplished at the suggested age, the child should be brought up to date as soon as possible.
In addition to physical evaluation, providers should evaluate the child's intellectual 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 intellectual and social development (see Physical Growth and Development: Development).
Both physical examination and screening procedures are important parts of preventive health care in infants and children. Most parameters, such as weight, are included for all children, whereas others are applicable to selected patients, such as lead screening in 1- and 2-yr-olds.
Physical
Examination
Growth:
Length (crown-heel) or height (once the child can stand) and weight should be measured at each visit. Head circumference should be measured at each visit through 24 mo. The child's growth rate should be monitored using a growth curve with percentiles; evaluation of deviations in these parameters is discussed in Physical Growth and Development: Physical Growth.
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, it is better to use the larger cuff.
A child's systolic and diastolic BPs are considered normal if they are < 90th percentile; actual values for each percentile vary by gender, age, and size (as height percentile), so reference to published tables is essential. 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, the child 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. Screening for hearing deficits is discussed below.
Eyes should be assessed at each visit for alignment (esotropia or exotropia); abnormalities in globe size suggesting congenital glaucoma; difference in pupil size, iris color, or both, suggesting Horner's syndrome, trauma, or neuroblastoma; and asymmetric pupils, which may be normal or represent an ocular, autonomic, or intracranial disorder. Absence or distortion of the red reflex suggests 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 3 or 4 yr, vision testing by Snellen charts or newer testing machines can be performed. 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 a child who has only deciduous teeth. Thrush is common in infants and not usually a sign of immunosuppression.
Heart:
Auscultation is performed to identify new murmurs or rhythm disturbances; benign flow murmurs are common and need to be distinguished from pathologic murmurs. Palpation of the chest wall for the apical impulse may suggest cardiomegaly; palpation of asymmetric femoral pulses suggests aortic coarctation.
Abdomen:
Palpation is repeated at every visit, because many masses, particularly Wilms' tumor and neuroblastoma, may be apparent only as the child grows. Stool often is palpable in the left lower quadrant.
Spine
and extremities:
Children old enough to stand should be screened for scoliosis with observations of posture, shoulder tip and scapular symmetry, torso list, and especially paraspinal asymmetry on forward bending (see Bone and Connective Tissue Disorders in Children: Idiopathic Scoliosis). Unequal leg length, adductor tightness, asymmetry of abduction or leg creases, or palpable, audible clunking of the femoral head as it slides into the hip socket are signs of developmental dysplasia of the hip. Toeing-in can result from adduction of the forefoot, tibial torsion, or femoral torsion. Only pronounced cases require therapy, and those children should be referred to an orthopedist.
Genital
examination:
All sexually active patients should be screened for sexually transmitted diseases; in girls, a pelvic examination is needed. Young women between the ages of 18 yr and 21 yr should be offered a pelvic examination and routine Papanicolaou test. Testicular and inguinal evaluation should be performed at every visit, specifically looking for undescended testes in infancy and early childhood, testicular masses in later adolescent years, and inguinal hernia at all ages.
Screening
Blood
tests:
To detect iron deficiency, Hct or Hb should be determined at age 9 to 12 mo for term infants, at age 5 to 6 mo for premature infants, and annually in menstruating adolescents. Testing for Hb S can be performed at age 6 to 9 mo (see Anemias Caused by Hemolysis: Diagnosis) if not performed 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 the 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, believing 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:
(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 5: Approach to the Care of Normal Infants and Children: Normal Hearing in the Very Young Child* ). 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.
|
Table 5
|
 | | |
|
Normal Hearing
in the Very Young Child*
|
|
Age
|
Expected Response
|
|
3 mo
|
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, and “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
|
|
*Children who do not pass these minimal performance standards or whose parents suspect there is a hearing loss at any age should be referred for testing.
|
|
Audiometry can be performed in the primary care setting; most other audiologic procedures (electrophysiologic tests, eg, otoacoustic emission testing and brain stem auditory evoked response) should be done by an audiologist. Conventional audiometry can be used for children beginning at about age 3; young children also can 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 a child of any age and is useful for determining middle ear function. Abnormal tympanograms often denote eustachian tube dysfunction or the presence of middle ear fluid that cannot be appreciated on otoscopic examination. Although pneumatic otoscopy is helpful in evaluating middle ear status, combining it with tympanometry is more informative than either procedure alone.
Other
screening tests:
Tuberculin testing should be performed when TB exposure is suspected, on all children born in developing countries, and on children of new immigrants from those countries. Sexually active adolescents should have dipstick analysis for leukocytes annually; some clinicians add urinary testing for Chlamydia infection.
Vaccination
Vaccination follows a schedule recommended by the Centers for Disease Control and Prevention, the AAP, and the American Academy of Family Physicians (see Fig. 3: Approach to the Care of Normal Infants and Children: Recommended childhood and adolescence immunization schedule.). The latest recommendations can be obtained at www.cdc.gov/nip; vaccination status should be reassessed at every visit. Adolescents should receive tetanus boosters on schedule and are now recommended to receive meningococcal vaccine at age 11 to 12.
|
Fig. 3
|
| | |
|
Recommended childhood and adolescence immunization schedule.
|
 |
|
See www.cdc.gov/nip for latest updates to recommended schedule. (Adapted from the National Immunization Program, Centers for Disease Control and Prevention: 2005 Childhood and Adolescence Immunization Schedule.)
|
|
Prevention
Preventive counseling is part of every well-child visit and covers a broad spectrum of topics, from urging parents to have infants sleep on their backs to injury prevention, from nutritional advice to discussions of violence, firearms, and substance abuse.
Safety:
Recommendations for injury prevention vary by age.
For infants from birth to 6 mo, safety recommendations focus on use of a rear-facing car seat, reduction of home water temperature < 49° C (< 120° F), prevention of falls, placing the infant to sleep on the back, and avoidance of foods and objects that the child can aspirate.
For infants from 6 to 12 mo, recommendations include continued car seat use (infants can face forward when the child reaches 9 kg [20 lb] and 1 yr of age, but rear-facing is still the safest position), avoidance of baby walkers, use of safety latches on cabinets, prevention of falls from changing tables and around stairs, and vigilant supervision of the child in bathtubs and while learning to walk.
For children aged 1 to 2 yr, recommendations include review of automobile safety both as passenger and pedestrian, tying of window cords, use of safety caps and latches, prevention of falls, and removal of handguns from the home. Precautions for children aged 2 to 4 yr include all of the above plus use of an age- and weight-appropriate car seat. At ≥ 5 yr, prevention involves the above measures plus use of a bicycle helmet, protective sports gear, instructions about safe street crossing, and close supervision and sometimes use of life jackets when swimming.
Nutrition:
Poor nutrition underlies the epidemic of obesity in children (see Obesity and the Metabolic Syndrome: Children). Recommendations vary by age; those for children up to 2 yr are discussed above. As the child grows older, parents can allow the child some discretion in food choices, while keeping the diet within healthy parameters. The child 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. In 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 the child grows 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 for sports participation is discussed in 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 the child grows older.
Last full review/revision November 2005
Content last modified November 2005
| 
