Well-child visit (toddler and child): Clinical sciences

Well-child visits promote the health and well-being of children, from birth through adolescence. For toddlers and children, each well child visit starts with a comprehensive history and physical exam, followed by anticipatory guidance and age-specific developmental assessments, interventions, and recommendations.

Now, when a pediatric patient presents for a well child visit, you should start by obtaining a comprehensive history and physical exam. Review the birth and interval histories, including any health changes since their last visit; and ask the caregiver if they have questions or concerns about the child. As far as the physical exam goes, first consider the patient’s general appearance, and then perform a full body exam, including a chaperoned genitourinary exam starting around age 7 or 8.

Your next step is to review the patient’s growth chart, which includes trends in the height, weight, and calculated body mass index, or BMI. Remember to also review blood pressure measurements starting at 3 years of age, and the results of vision screenings or hearing screenings.

For vision screening, you can begin instrument-based testing at 1 year of age, until chart-based acuity testing can be started from 3 years on; while hearing screening begins at 4 years of age.

Finally, you should assess puberty-related changes, using the sexual maturity rating, or SMR, which is also called Tanner staging. SMR is used to track the development of secondary sex characteristics, starting with Stage 1, which is prepubertal, and ending at Stage 5, which is complete sexual maturity. The Tanner scale consists of two independent criteria, including the appearance of pubic hair in both sexes; and either the increase in testicular volume and penis size and length in biological males; or the breast development in biological females.

Okay, once you complete your comprehensive history and physical exam, your next step is to provide anticipatory guidance.

Start by recommending balanced nutrition and encouraging healthy foods and snacks, like fruits, vegetables, whole grains, and lean proteins. Additionally, encourage families to provide drinks like milk and water, while limiting or avoiding high-sugar drinks like juice and sodas. You should also encourage children to be physically active, since children need at least 1 hour of physical activity every day!

Another component of a healthy lifestyle is oral health and hygiene. By now, children should brush their teeth twice daily with fluoridated toothpaste, and older children should floss daily. Ideally, every child should visit the dentist every 6 months for routine cleaning and fluoride varnishes. If your patient hasn’t seen a dentist yet, consider applying a fluoride varnish to their teeth, to strengthen tooth enamel and prevent cavities.

The last component of anticipatory guidance is safety. First, discuss car safety, including the use of car seats, booster seats, and seat belts. You can also share tips on how to childproof the home, like blocking access to electrical outlets and keeping household products like cleaners locked up. Also, be sure to discuss firearm safety, noting that the safest option is to avoid having firearms in the home. However, if a family does have firearms, they should be stored unloaded and locked separate from ammunition. Additionally, remind parents to supervise children during outdoor play, especially when playing in or near water. Advise caregivers to use sun protection, like sunscreen, and ensure that children are consistently using safety equipment when needed, such as bike helmets.

All children should be taught how to recognize bullying behaviors and situations with individuals that make them feel unsafe. Additionally, encourage children to identify a trusted adult, such as a caregiver or a teacher, whom they can approach if they don’t feel safe. Finally, encourage families to teach their children about internet safety, and to supervise children while they are online.

Okay, once you finish providing anticipatory guidance, you should assess the patient’s age to decide next steps.

Let’s start with the 15 month visit! First, administer immunizations, which include the diphtheria, tetanus, and acellular pertussis, or DTaP vaccine, as well as the influenza vaccine and the COVID-19 vaccine if the child is unvaccinated or partially vaccinated.

Now, here’s a clinical pearl! The COVID-19 vaccine schedule varies by age group. Starting at 6 months through 4 years, children receive a 2- to 3-dose series, depending on the specific vaccine formulation. Once a child is 5 years or older, they should receive 1 dose annually.

Next, determine if your patient is meeting expected developmental milestones. For example, most 15 month olds can walk well, build a three block tower, show affection, and say 3 to 5 words.

Now let’s move on to the 18 month visit! At this age, you should administer developmental and autism screening tools, to assess the toddler’s development, and to identify any developmental delay.