II. History: Social History

  1. Consider questionnaire
  2. All ages
    1. Living situation (split families, step-siblings... )
    2. Dietary intake
      1. See Nutrition Guidelines
    3. Physical Activity
      1. Encourage at least 60 minutes of moderate to vigorous aerobic exertion daily
    4. Screen time (television, computer, video games)
      1. Limit screen time to no more than 1-2 hours of high quality programming daily
      2. Screen time averages 7.5 hours daily in the U.S.
      3. Over 4 hours of daily screen time is associated with Obesity
    5. Sleep per night
      1. Average school aged child sleeps more than 9 hours per night (11 hours per night is ideal)
      2. See Sleep Problems in Children
      3. See Obstructive Sleep Apnea in Children
    6. Dental care practices
      1. See Oral Health in Children
      2. See a dentist every 2 years
      3. Brush twice daily with pea-sized amount of fluoride-containing toothpaste
    7. Unintentional Childhood Injuries
      1. Seat Belts
      2. Bicycle helmets
      3. Gun Safety
      4. Drowning prevention
    8. Skin protection (e.g. Sunscreen)
  3. Adolescents (starting at age 11-12 years old)
    1. Major Depression screening
      1. See Adolescent Depression
      2. See Childhood Depression
    2. Substance Abuse Screening
      1. See CRAFFT questionnaire
      2. See Adolescent Chemical Dependency
      3. Tobacco abuse
      4. Alcohol Abuse
      5. Drug Abuse
    3. Sexual activity screening
      1. Annual Chlamydia testing (urine Chlamydia PCR testing)
      2. Consider Gonorrhea test, HIV Test, Syphilis test
      3. Pap Smears start at age 21 regardess of sexual activity

III. Exam: Vital Signs

  1. Body Temperature (until after age 18 months)
  2. Blood Pressure (starting at age 3 years of age)
    1. See Hypertension Criteria

IV. Exam: Growth (review on growth curves at each visit)

  1. See Growth Assessment
  2. See Height Measurement in Children
  3. Weight Measurement in Children
  4. Head Circumference (until after age 2 years)
  5. Body Mass Index annually starting at age 6 years old
    1. Obesity Screening at Well Child Visits is a high yield activity (affects 17% of children in U.S.)
    2. BMI >85% for age and gender is considered Overweight (>95% is Obesity)
    3. See Childhood Obesity for management

V. Exam

  1. Complete physical examination
    1. Overall yield is low in healthy, asymptomatic children with normal growth
    2. Observe for signs of abuse (~1 Million children affected annually in U.S.)
    3. Scoliosis screening is not recommended by either USPTF or AAP
    4. Testicular exam is recommended annually by AAP starting at age 11 years old (but not USPTF)
      1. Documenting descended Testicles pre-Puberty is critical (Cryptorchidism risk)
  2. Eye Exam
    1. Red Reflex (until after age 2 years)
    2. Strabismus testing such as cover-uncover (until after age 2 years)
    3. Vision
      1. See Pediatric Vision Screening
      2. Subjective until age 3 years
      3. Formally check vision (Snellen Chart) at 5,6,8,10 and 12 years old (per AAP guidelines)
      4. Refer if visual acquity worse than 20/40
  3. Hearing exam
    1. Subjective hearing screening until age 3 years, then formal hearing screening
    2. See Pediatric Hearing Screening

VI. Evaluation: Developmental Screening

  1. General Screening (at each schedule well visit)
    1. Age 2-4 months: Edinburgh Questionnaire or INI Questionnaire
    2. Age 4-18 months: ASQ Questionnaire, PEDS Questionnaire or INI Questionnaire
    3. Age 18-60 months: ASQ Questionnaire, PEDS Questionnaire or CDR Questionnaire
  2. Specific Screening: Perform for all children at specific visits
    1. Modified Checklist for Autism in Toddlers (M-CHAT): Perform at 18 and 24 months
    2. ASQ: SE Behavioral Screening: Perform at 6,12, 18, 24, 30, 36, 48 and 60 months
  3. School readiness (age 4-5 years)
    1. Social and emotional development are key to success
    2. Assess ability to follow directions, attention
    3. Consider referral for support services
    4. Avoid delaying school entry (not helpful and may exacerbate behavioral problems)
      1. Byrd (1997) Pediatrics 100(4): 654-61 [PubMed]
  4. As needed screening in school age children
    1. See ADHD Diagnosis

VII. Labs

  1. Newborn Screening (review results at first Well Child Visit)
  2. Hemoglobin At 9-12 months
  3. Serum Lead level at 9-12 months and 18-24 months
  4. Lipid panel is recommended by AAP at 6 and 8 years, and annually from 10 years old on (not recommended by USPTF)

VIII. Management: Immunizations

  1. See Pediatric Vaccination for schedule
    1. National vaccination compliance is excellent until after age 6 years old in the U.S.
    2. More than 60% of adolescents are not up-to-date on their Vaccines as of age 11 years old
      1. Tdap (Adacel, Boostrix)
      2. Meningococcal Vaccine (Menactra)
      3. HPV Vaccine (Gardasil)
  2. Influenza Vaccine
    1. October to March
    2. Give second dose in first season

IX. Management: Medications

  1. Fluoride Supplementation
    1. Indicated if inadequate fluoride in drinking water (0.6 ppm or less) for ages 6 months to 16 years old
  2. Vitamin D 400 IU daily (more if deficient)
    1. Vitamin D Deficiency may approach 50% Incidence (especially in northern latitudes)
    2. Consider Vitamin D Deficiency screening

X. Management: Referrals

  1. Dental visits starting at age 3 years
    1. See Oral Health in Children

XI. Management: Anticipatory Guidance Education

  1. Newborn: Jaundice, eating, sleep, maternal bonding
  2. Month 2: Colic, growth, sleep, sibling adjustment
  3. Month 4: Childcare, sleep, solid introduction
  4. Month 6: Child proofing
  5. Month 9: Child proofing, stranger anxiety
  6. Month 12: Discipline, shoes, walking, turning Car Seat
  7. Month 15: Discipline, Time-Out
  8. Month 18: Temper tantrums, sleep problems
  9. Month 24: Toilet Training, sleep problems, speech development
  10. Month 36: Eating patterns, socialization, books
  11. Month 48: Speech, school readiness
  12. Month 60: Behavioral consequences

XII. References

  1. Neale (2008) Park Nicollet Primary Care Update Lecture, St. Louis Park, MN
  2. Riley (2011) Am Fam Physician 83(6): 689-94 [PubMed]
  3. Riley (2011) Am Fam Physician 83(6): 683-8 [PubMed]

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