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

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Introduction0:00–0:25

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.

H&P0:25–2:08

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.

Anticipatory Guidance2:08–4:33

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!

15 Months4:33–5:27

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!

18 Months5:27–6:08

At this age, you should administer developmental and autism screening tools, to assess the toddler’s development, and to identify any developmental delay.
Next, administer the hepatitis A vaccine as well as the COVID-19 vaccine, if they have not started the series yet, or if they are due for a booster.Finally, in addition to the developmental screening, look for newly-acquired developmental milestones.
At this age, toddlers should be able to run well, enjoy pretend play, and use spoons and cups.Next let’s talk about the 24 month or two year visit.

24 Months6:08–6:57

Again, administer an autism screening tool, and obtain a blood lead level if your patient has risk factors for lead exposure, or if they live in a high-prevalence area.With respect to immunizations, the influenza vaccine should be given annually during the fall and winter months, when influenza peaks in incidence.
In addition, give the COVID-19 vaccine, if they still need to begin or complete the series. Finally, assess for new developmental milestones, which include the ability to parallel play, the use of two-word sentences, and a vocabulary of more than 50 words.
Additionally, you should be able to understand about half of their speech. Now let’s switch gears and talk about the 30 month visit.

30 Months6:57–7:22

During this visit, use a developmental screening tool to look for developmental delays, and give the COVID-19 vaccine as indicated.
Then, determine whether your patient has achieved expected developmental milestones, including the ability to jump, solve simple problems, and match colors and shapes.Next up is the 3 year visit.

3 Years7:22–7:53

At this age, you should administer the annual influenza vaccine and the COVID-19 vaccine series if needed. New developmental milestones to look for include the ability to draw circles, pedal a tricycle, and enjoy imaginative play.
By this age, children can make three-word sentences, and most have a vocabulary of over 200 words. Additionally, you should be able to understand about three quarters of their speech.
Moving on to the 4 year visit, it’s time for another round of immunizations! Between the ages of 4 and 6 years, it is recommended that children receive the DTaP, inactivated poliovirus, measles, mumps, and rubella, or MMR; and varicella vaccines, as well as the annual influenza and COVID-19 vaccines.

4 Years7:53–8:33

As far as developmental milestones go, a 4-year-old can draw squares, enjoys group play, and has friends. Additionally, their vocabulary has grown to over 400 words, and their speech is now fully intelligible to strangers.Next let’s talk about the 5 and 6 year visits.

5-6 Years8:33–9:29

If your patient hasn’t received the DTaP, inactivated poliovirus, MMR, and varicella vaccines yet, administer them now, and don’t forget the annual influenza and COVID-19 vaccines!
As far as developmental milestones go, 5-year-olds have acquired new skills, including the ability to draw triangles, count to 10, write their name, and read around 25 words.
Most children start school at this age, which can offer a new perspective on the child’s development. Be sure to ask the family about academic performance and teacher feedback.
A child who is succeeding in school is likely to be developmentally on track, while a child who is struggling in school may have a developmental delay or learning disability, and might benefit from additional evaluation and support.Alright, now let’s shift gears and talk about the 7 and 8 year visits.

7-8 Years9:29–10:09

With respect to immunizations, all children should receive annual influenza and COVID-19 vaccines at this age. Next, assess development by asking the family about in-school behavior and academic performance.
Be sure to discuss early signs of puberty, and encourage caregivers to talk with their kids about expected body changes.
Families can also promote mental health and well-being by frequently checking in with their child and helping their child recognize, process, and effectively express strong emotions.
Finally, let’s discuss the 9 and 10 year visits! During this visit, don’t forget to order a lipid panel to screen for dyslipidemia.

9-10 Years10:09–10:55

As far as immunizations go, you can offer the human papillomavirus vaccine starting at age 9, although some families may wait until the 11 to 12 year visit.
Additionally, give the annual influenza and COVID-19 vaccines.Next, assess development by asking the family about academic performance and teacher feedback.
This is also a good time to discuss concerns about gender identity, sexuality, and mental health. Encourage families to talk openly with their child about values, identity, and self-expression; and to welcome questions as their child matures.Alright, as a quick recap… Well-child visits promote the health and well-being of children, from birth through adolescence.

Review10:55–11:18

Each visit starts with a comprehensive history and physical exam, and includes anticipatory guidance on nutrition, oral health, and safety topics.
Then the visit proceeds with age-appropriate screenings and immunizations, and concludes with a developmental assessment.