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Committee on Obstetric Practice, the American Institute of Ultrasound in Medicine, and the Society
for Maternal-Fetal Medicine. Committee opinion no. 700: methods for estimating the due date.
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Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); July 2010.
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Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: part II. Third-trimester care and
prevention of infectious diseases. Am Fam Physician. 2005;71(8):1555-1560.
National Collaborating Centre for Women’s and Children’s Health. Antenatal Care: Routine Care for the
Healthy Pregnant Woman. London, UK: RCOG Press; June 2008.
United States Preventive Services Task Force. Gestational diabetes mellitus, screening. https://www
.uspreventiveservicestaskforce.org/uspstf/recommendation/gestational-diabetes-mellitus-screening
Accessed January 27, 2019.
Veterans Health Administration, Department of Defense. DoD/VA Clinical Practice Guidelines for the
Management of Uncomplicated Pregnancy, version 2.0. Washington, DC: Department of Veteran
Affairs; 2009.
Wang M. Common questions about late-term postterm pregnancy. Am Fam Physician. 2014;
90(3):160-165.
Wapner R, Thom E, Simpson JL, et al. First-trimester screening for trisomies 21 and 18. N Engl J Med.
2003;349:1405-1413.
Zolotor A, Carlough MC. Update on prenatal care. Am Fam Physician. 2014;89(3):199-208.
CASE 5
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A 6-month-old boy is brought to your office by his mother for a routine well-child
visit. His mother is concerned that he is not yet saying “mama” because her best
friend’s baby said “mama” by age 6 months. She also asks when she can place
her son in a front-facing car seat. Your patient was born via an uncomplicated
pregnancy to a 23-year-old gravida 1, para 1 mother. He was delivered by a
spontaneous vaginal delivery at full term, and there were no complications in
the neonatal period. You have been following him since his birth. He has had
appropriate growth and development up to this age and is up to date on his
routine immunizations. He had one upper respiratory infection at age 5 months
that was treated symptomatically. There is no family history of any developmental,
hearing, or speech disorders. He has been fed since birth with an iron-fortified
infant formula. Cereals and other baby foods were added starting at age 4 months.
He lives with both parents, neither of whom smokes cigarettes.
On examination, he is a vigorous infant who is at the 50th percentile for length
and weight and 75th percentile for head circumference. His physical examination
is normal. On developmental examination, he is seen to sit for a short period of
time without support, reach out with one hand for your examining light, pick up a
Cheerio with a raking grasp and put it in his mouth, and babble frequently.
▶ What immunizations would be recommended at this visit?
▶ By what age should an infant say “mama” and “dada”?
▶ What is your recommendation regarding front-facing versus rear-facing
car seats?
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ANSWERS TO CASE 5:
Well-Child Care
Summary: A 6-month-old healthy child presents with
Appropriate growth and development up to this age and up-to-date status on routine
immunizations
History of an upper respiratory infection at age 5 months that was treated
symptomatically
Normal physical examination
Concerned mother with questions about when child will say “mama” and when he can
be in a front-facing car seat
Recommended immunizations: Third dose of diphtheria, tetanus, and acellular
pertussis (DTaP); hepatitis B; Haemophilus influenzae type b (Hib); pneumococcal
conjugate vaccine (PCV13); and rotavirus dose no. 3. The third dose of inactivated polio vaccine (IPV) can be given between ages 6 months and 18 months. If
the encounter is during “flu season,” annual influenza vaccination is recommended
beginning at 6 months of age.
Age by which a child should say “mama” and “dada”: Most children will start to say
“dada” or “mama” nonspecifically between ages 6 and 9 months. It usually becomes
specific between ages 8 and 15 months.
Recommendations for front-facing versus rear-facing car seats: A child should stay in
a rear-facing car seat until the child reaches the maximum height and weight limit
for the car seat.
ANALYSIS
Objectives
1. List the basic components of a well-child examination. (EPA 1, 12)
2. Know the routine immunization schedule for children. (EPA 12)
3. Know common developmental milestones for young children. (EPA 7, 12)
Considerations
The pediatric well-child examination serves many valuable purposes. It provides an
opportunity for parents, especially first-time parents, to ask questions, and for the provider to address specific concerns regarding the child. It allows the clinician to assess the
child’s growth and development in a systematic fashion and to perform an appropriate physical examination. It also allows for a review of both acute and chronic medical
conditions. When performed at recommended time intervals, it gives the opportunity
to provide age-appropriate immunizations, screening tests, and anticipatory guidance.
Finally, it supports the development of a good provider-patient-family relationship,
which can promote health and serve as an effective tool in the management of illnesses.
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APPROACH TO:
Well-Child Care
DEFINITIONS
AMBLYOPIA: Monocular childhood vision reduction caused by abnormal vision
development. Strabismus is the most common cause of amblyopia.
STRABISMUS: Ocular misalignment.
CLINICAL APPROACH
Pediatric History
For the purposes of routine well-child visits, a comprehensive history should be
obtained at the initial visit, with more focused, interval histories obtained at subsequent encounters. The initial history should include an opportunity for the parent
to raise any questions or concerns that the parent may have. New parents, especially first-time parents and young parents, often have many questions or anxieties about their child. The ability to discuss them with the provider will help to
engender a positive provider-patient-family relationship and improve the parent’s
satisfaction with their child’s care.
Past Medical History. A complete past medical history should be obtained.
This should start with a detailed prenatal and pregnancy history, including the
duration of the pregnancy, any complications of pregnancy, the type of delivery
performed, the child’s birth weight, and any neonatal problems. Any significant
chronic or acute illnesses should be recorded. The use of any medications, both
prescription and over the counter, should be reviewed. Old medical records should
be obtained if available. Growth charts, immunization records, results of screening
tests, and other valuable information that can assist with the child’s assessment can
often be found and reduce the unnecessary duplication of previously performed
interventions.
Family History. A detailed family history, including information (when available)
on both maternal and paternal relatives, should be obtained. A thorough social
history is critical in pediatric care; information such as the parents’ education levels, relationships, religious beliefs, use of substances (tobacco, alcohol, drugs), and
socioeconomic factors can provide significant insight into the health and development of the child.
Growth
At each well-child visit, the child’s height and weight should be recorded and plotted on a standard growth chart. Head circumference is measured and plotted in
children 3 years of age and younger. Children older than age 3 years should have
their blood pressure recorded using an appropriate-size pediatric cuff. Significant
variances from accepted, age-adjusted, population norms or predicted growth
curves may warrant further evaluation. The Centers for Disease Control and
Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend
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Table 5–1 • BMI CLASSIFICATIONS IN CHILDREN
Definition BMI
Obese > 95th percentile
Overweight 85th-95th percentile
Healthy body weight 5th-85th percentile
Underweight < 5th percentile
measuring body mass index (BMI) to screen for overweight and obese states in
children age 2years and older. The measurement of BMI in children is calculated
the same way it is for adults, and it is compared to typical values for other children of the same age. Weight classifications based on BMI in children are listed
in Table 5–1.
Failure to thrive is defined by some as weight below the third or fifth percentile for age and by others as decelerations of growth that have crossed two major
growth percentiles in a short period of time. Either significant loss or gain of weight
may prompt an in-depth discussion of nutrition and caloric intake.
Development
An assessment of the child’s development in the areas of gross motor, fine motor/
adaptive, language, and social/personal skills is an important aspect of each well-
child visit. Numerous screening tools, such as the Denver II developmental screening test, the Parents’ Evaluations of Developmental Status (PEDS), and others, are
available to assist with these assessments. These assessments typically involve both
responses from the parents regarding the child’s behavior at home and observations
of the child in the office setting. Persistent delays in development, either globally or
in individual skill areas, should prompt a more in-depth developmental assessment,
as early intervention may effectively aid in the management of some developmental
abnormalities.
Bilingual Children. Children who are raised in a bilingual environment may have
some language “mixing” at first (eg, saying some words in English and some in Spanish
in the same sentence). This tends to improve over time, and proficiency in both
languages is often reached by age 5. The threshold for referral to a specialist should
be the same for bilingual children as monolingual children. Table 5–2 summarizes
many of the important motor, language, and social developmental milestones of
early childhood.
Screening Tests
A variety of screening tests are used to prevent disease and promote proper developmental and physical growth. These include tests for congenital diseases, lead
screening, evaluating children for anemia, and hearing and vision screens.
Newborn Screening. Each state requires screening of all newborns for specified
congenital diseases; however, the specific diseases for which screening is done vary
from state to state. All states require testing for phenylketonuria (PKU) and congeni-
tal hypothyroidism, as early treatment can prevent the development of profound
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Table 5–2 • DEVELOPMENTAL MILESTONES
Age Motor Language Social Mnemonics
1 mo Reacts to pain Responds to noise Regards human
face
Establishes eye
contact
2 mo Eyes follow object to
midline
Head up prone
4 mo Eyes follow object
past midline
Rolls over
6 mo Sits well unsupported
Transfers objects hand
to hand (switches
hands)
Rolls prone to supine
9 mo Crawls
Cruises (walks holding
furniture)
Pincer grasp (10 mo)
12 mo Walks
Throws object
2 y Walks up and down
stairs
Copies a line
Runs
Kicks ball
3 y Copies a circle
Pedals a tricycle
Can build a bridge of
3 cubes
Repeats 3 numbers
4 y Identifies body parts
Copies a cross
Copies a square (4½ y)
Hops on one foot
Throws overhand
Vocalizes Social smile
Recognizes
parent
Laughs and squeals Regards hand
Babbles Recognizes
strangers
Says “mama,” “dada,”
and “bye-bye”
1-3 words
Follows 1-step
commands
2- to 3-word phrases
Half of speech is
understood by
strangers
Refers to self by
name
Pronouns
Speaks in sentences
Three-fourths of
speech is understood
by strangers
Recognizes 3 colors
Speech is completely
understood by
strangers
Uses past tense to
speak of things that
happened before
Tells a story
Starts to explore Can crawl and
Stranger and separation anxiety
Parallel play Puts 2 words
Group play
Plays simple
games
Knows gender
Knows first and
last name
Plays with kids,
social interaction
Six strangers switch
sitting at 6 mo
therefore explore
It takes 9 mo to be a
“mama”
Knows 1 word at 1 y
together at 2
At age 2, 2/4 (1/2) of
speech understood
by strangers
Tricycle, 3 cubes,
3numbers, 3 colors,
3 kids make a group
At age 3, 3/4 of
speech understood
by strangers
Song “head,
shoulder, knees,
and toes,” 4 parts
reminds you that at
age 4 can identify
body parts
At age 4, 4/4 of
speech is understood by strangers
(Continued)
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Table 5–2 • DEVELOPMENTAL MILESTONES
Age Motor Language Social Mnemonics
5 y Copies a triangle
Catches a ball
Partially dresses self
6 y Draws a person with
6 parts
Ties shoes
Skips with alternating
feet
Modified with permission, from Hay WW, Hayword AR, Levin MJ, Sondheimer JM. Current Pediatric Diagnosis and Treatment. 17th ed. 2005. Copyright © McGraw Hill LLC. All rights reserved.
Writes name
Counts 10 objects
Identifies left and
right
continued
A 4-year-old can
copy 2 lines to
draw a cross and a
square, which has
4 sides
Skips, shoes, person
with parts
intellectual disability. Diseases for which testing commonly occurs include hemoglobinopathies (including sickle cell disease), galactosemia, and other inborn errors
of metabolism. This screening is done by collecting blood from newborns prior to
discharge from the hospital. In some states, newborn screening is repeated at the
first routine well visit, usually at about 2 weeks of age.
Lead Poisoning Screening. Nationwide, the prevalence of childhood lead poisoning has declined, primarily because of the use of unleaded gasoline and lead-free
paints. However, in some communities, the risk of lead exposure is higher. The
AAP’s Bright Futures program recommends screening all children between the
ages of 6 months and 6 years for their risk of elevated blood lead levels. Those children identified as having a high risk based upon answers to a questionnaire should
have blood testing (Table 5–3). Consideration should be given to test all children,
regardless of risk, with blood testing at age 12 and 24 months. All children born
outside of the United States should have a blood level measured on arrival to the
United States.
Anemia Screening. Iron deficiency is the most common cause of anemia in children. Iron-containing formula and cereals have helped to reduce the occurrence of
iron deficiency. Children at higher risk include those who drink more than 24 oz of
cow’s milk, have iron-restricted diets, were low birth weight or preterm, or whose
mother was iron deficient. In 2010, the AAP recommended universal screening
for anemia in all children at 1 year of age. Additional laboratory screening for iron
deficiency is recommended at later ages in those children at high risk for irondeficiency anemia. The American Academy of Family Physicians (AAFP) and the US
Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening asymptomatic children for anemia. An anemic child
can empirically be given a trial of an iron supplement and dietary modification.
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Table 5–3 • ELEMENTS OF A LEAD RISK QUESTIONNAIRE
Recommended questions
• Does your child live in or regularly visit a house built before 1950? This could include a day care
center, preschool, the home of a babysitter or relative, and so on.
• Does your child live in or regularly visit a house built before 1978 with recent, ongoing, or
planned renovation or remodeling?
• Does your child have a sister or brother, housemate, or playmate who is being followed for
lead poisoning?
Questions that may be considered by region or locality
• Does your child live with an adult whose job (eg, at a brass/copper foundry, firing range,
automotive or boat repair shop, or furniture-refinishing shop) or hobby (eg, electronics,
fishing, stained-glass making, pottery making) involves exposure to lead?
• Does your child live near a work or industrial site (eg, smelter, battery recycling plant) that
involves the use of lead?
• Does your child use pottery or ingest medications that are suspected of having a high
lead content?
• Does your child have exposure to burning lead-painted wood?
Reproduced with permission, from Stead LG, Stead SM, Kaufman MS. First Aid for the Pediatrics Clerkship. 2004.
Copyright © McGraw Hill LLC. All rights reserved.
Failure to respond to iron therapy should warrant further evaluation of other
causes of anemia.
Hearing Screening. Most states now mandate newborn hearing screening
by auditory brainstem response or evoked otoacoustic emission. All high-risk
infants, regardless of requirement, should be screened. High-risk infants include
those with a family history of childhood hearing loss, craniofacial abnormalities,
syndromes associated with hearing loss (eg, neurofibromatosis), or infections
associated with hearing loss (eg, bacterial meningitis). Older infants and toddlers
can be assessed for hearing problems by questioning the parents or performing
office testing by snapping fingers or by using rattles or other noisemakers. Officebased audiometry should be performed in children aged 4 years and older. Any
hearing loss should be promptly evaluated and referred for early intervention, if
necessary.
Vision Screening. Vision screening can also start in the newborn nursery. Evaluation of the neonate for red reflexes on ophthalmoscopy should be a standard part
of the newborn examination. The presence of red reflexes helps to rule out the
possibility of congenital cataracts and retinoblastoma. The evaluation of an older
infant should include a subjective evaluation of the child’s vision by the parent.
Infants should be able to focus on a face by age 1 month and should move their
eyes consistently and symmetrically by age 6 months. An examining light should
reflect symmetrically off of both corneas; asymmetric light reflex may be a sign of
strabismus. The cover-uncover test also is a screening examination for strabismus.
The child focuses on an object with both eyes and the examiner covers one eye.
Strabismus is suggested when the uncovered eye deviates to focus on the object.
Strabismus should be referred to a pediatric ophthalmologist as soon as it is detected,
as early intervention results in a lower incidence of amblyopia. After the age of
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Table 5–4 • FIRSTTIME LIPIDSCREENING RECOMMENDATIONS
Perform first-time lipid screening in children ages 2-10 years if
• Family history of dyslipidemia
• Family history of premature (men < 55 y or women < 65 y) cardiovascular disease or dyslipidemia
• Parent with total cholesterol ≥ 240 mg/dL
• Patient with other cardiovascular risk factors:
• Overweight (BMI > 85th percentile and < 95th percentile)
• Obese (BMI > 95th percentile)
• Hypertension (blood pressure > 95th percentile)
• Cigarette smoking
• Diabetes mellitus
Data from Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung, and Blood Institute, 2011. Available at: https://www.nhlbi.nih.gov/files/docs/peds_guidelines_
sum.pdf.
3years, most children can be tested for visual acuity using a Snellen chart, modified
with a “tumbling E” or pictures instead of letters.
Other Screening Tests. Other screening tests may be recommended for high-risk
children. Tuberculosis (TB) screening is recommended for children who were born
or live in a region of high TB prevalence or who have close contact with someone
known to have TB. The Mantoux test (an intradermal injection of PPD [purified
protein derivative] tuberculin) is the screening test of choice. In accordance with
the National Heart, Lung, and Blood Institute (NHLBI), the American Heart
Association (AHA) and AAP recommend universal screening of high cholesterol
for all children at least one time between the ages of 9 and 11 years and again
between 17 and 21 years. Screening for hyperlipidemia should begin at age 2 in
children with a family history of hyperlipidemia, premature cardiovascular disease,
or other risk factors (see Table 5–4).
Dental Care. Early childhood caries are one of the most prevalent chronic conditions during childhood; therefore, it is important to discuss good oral hygiene and
the establishment of a dental home during well-child visits. At the 4-month visit,
sources of systemic fluoride should be assessed. One of the most effective tools
to prevent teeth decay is systemic fluoride. If there are concerns with the amount
of fluoride in drinking water supplies, especially well water, appropriate testing
should be performed. At 6 months of age, infants should begin to receive appropriate topical (fluoride toothpaste) and systemic fluoride. By the 12-month visit,
each appointment should include a complete dental screening during the physical
examination and reassurance that the child has a regular source of dental care. The
American Academy of Pediatric Dentistry recommends that all children see a dentist by the age of 12 months.
Anticipatory Guidance
A primary feature of the well-child visit should be education of the patient and
family on issues that promote health and prevent illness, injury, or death. This
anticipatory guidance should be focused and age appropriate. The use of preprinted handouts can reinforce topics discussed in the office, address issues that
could not be discussed because of time limitations, and allow for the parent to
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review the information as needed at home. Subjects that should routinely be
addressed include injury prevention, nutrition, development, discipline, exercise, mental health issues, and the need for ongoing care (eg, immunization
schedules, future well-child visits, dental care). During the well-child examination, it is important to evaluate how much time is spent watching television,
using the computer, and playing video games. Screen time should be limited
to 1 to 2 hours or fewer daily. The number of hours and quality of sleep should
be asked at each visit. Abnormalities in sleep should be further investigated and
managed appropriately.
Car Seat Recommendations. Accidents and injuries are the leading cause of death
in children older than age 1 year. Accidents involving motor vehicles, both traffic
and pedestrian accidents, are the leading cause of these accidental deaths. All
states now require the use of car safety seats for children, although the regulations vary from state to state. The general recommendation is that a child should
be in the back seat of the vehicle whenever possible. If there is no back seat, the
child should only ride in the front seat if there is no air bag or if the air bag can
be disabled.
A child should sit in a rear-facing car seat as long as possible, until the child has
reached the maximum height or weight limit of the rear-facing seat. The child should
then be transitioned to a forward-facing car seat. When the child reaches the weight
limit for the forward-facing car seat, they should ride in a booster-type seat along
with the lap and shoulder seatbelts. The child can stop using the booster when the
child can sit with his or her back squarely against the back of the seat with the legs
bent at the knees over the front of the seat. The child usually will need to be at least
4 feet, 9 inches. tall and 8 to 12 years of age to meet these requirements. No child
should ride in the front seat unless they are 13 years of age or older and meet height
and weight requirements.
Sudden Infant Death Syndrome Prevention. According to the CDC, the top three
causes of death in infants younger than 1 year old are congenital abnormalities,
short gestation, and sudden infant death syndrome (SIDS). The “Back to Sleep”
campaign advises parents to place their infant on the infant’s back—not abdomen
or side—when the infant is put down to sleep, as this reduces the risk of dying of
SIDS. In addition, the infant should be placed on a firm mattress with nothing else
in the crib—this includes pillows, positioning devices, and toys. Heavy coverings
and soft mattresses have been associated with an increased risk of SIDS.
Safety in the Home. As children get older, anticipatory guidance on other safety
issues become important. As children learn to crawl and walk, stairwells should
be blocked to reduce the risk of injuries from falling. Cleaning supplies, medications, and other potential poisons need to be stored safely out of reach of children, preferably in locked cabinets. Similarly, firearms should be stored safely,
preferably unloaded and in locked cabinets or safes. Parents should be counseled
on keeping matches and lighters in a safe place out of the reach of children. All
families should be advised to have smoke detectors throughout the home, especially in rooms where people sleep, and to keep the hot water heater set at or
below 120 °F to reduce the risk of scald injuries. The AAFP recommends that all
caregivers be trained in cardiopulmonary resuscitation. When a pool or hot tub
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