Well-child care - Overview

Diseases

Overview

Introduction

The goals of well-child care are to maximize development, detect treatable diseases at an early stage, and prevent injury and disease through education. The main components are an age-appropriate history, physical exam, screening tests, and counseling. Much of the assessment can be done while taking the history from the parent and by observing the child's behavior, gait, speech, and interactions with people in the room. Well-child visits from age 12 months to 10 years are considered here.

Recommendations and evidence

Several US organizations make recommendations on preventive care for children, including the American Academy of Pediatrics (AAP) in its Bright Futures guidelines, the American Academy of Family Physicians (AAFP), and the Centers for Disease Control and Prevention (CDC).[1] The US Preventive Services Task Force (USPSTF) and the Cochrane Library databases synthesize evidence about preventive-care practices.

With the exception of vaccines, many common and recommended practices for well-child care have not been well studied, and more studied practices often lack evidence showing benefit.[2] The recommended practices nonetheless have the potential benefit of preventing a condition or diagnosing a treatable condition early. Notably, many practices can cause harm in some circumstances. For example, screening often uncovers mildly abnormal laboratory values or physical findings that cause no symptoms. Families may experience undue worry, and children may experience adverse effects from diagnostic workup or treatment when no true pathologic condition is present. Generally, guidelines are written with these effects in mind; some guidelines (e.g., USPSTF) may state that evidence is inconclusive when there are not enough data regarding harms to make a definitive statement that benefits outweigh harms. Thus, AAP guidelines or best practice statements are often relied upon when the evidence of harms is inconclusive.

Healthcare providers should note that some aspects of well-child care, such as a complete physical exam and certain screening tests, may be required for school entry or for payment with some insurance plans, such as Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Several types of primary care interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appear effective in improving screening quality.[3] Families may also have expectations for a well-child visit, such as a thorough physical exam, although there is no direct evidence of benefit for repeated routine exams.[1] [2]

The priorities for a well-child visit are vaccinations and addressing concerns raised by the family or the child. Healthcare providers should determine which of the additional recommendations discussed in this topic are appropriate for an individual child. For example, in certain children, such as children in immigrant families or children with medical complexity, other screening or needs will often take priority over the items listed in this topic.[4] [5] As healthcare providers make assessments about risks and priorities in individual children, they should be aware of the role of racism as a social determinant of health and of the potential for implicit biases to inappropriately influence clinician decision-making.[6]

The priorities and recommendations included here are primarily from the AAP's Bright Futures health supervision guidance, which generally recommends the most comprehensive screening and counseling at each visit.[1] Recommendations from the AAP, the USPSTF, and the AAFP, and the evidence behind them, are also discussed.

Outline for well-child visits

12 months:

Priorities for history if no family concerns: discussing diet through transition to whole milk and primarily solid diet; oral health; family support
Priorities for physical if no family concerns: growth/weight for length; eyes (eye motility, red reflexes); teeth (for signs of decay); abdominal masses; gait if walking; strength; checking testicles descended/labia open; skin (café au lait spots, birthmarks, bruising); blood pressure (if high risk)
Consider anticipatory guidance regarding: childproofing as child's mobility continues to increase; car seats; poisoning; water and sun safety; establishing routines; feeding and appetite changes; oral health counseling; dental referral
Vaccines: healthcare providers should refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age

Screening and surveillance: anemia screen; lead risk assessment, hearing risk assessment, vision risk assessment and tuberculosis risk assessment; psychosocial and behavioral screening; fluoride supplementation if needed; fluoride varnish if dental home is not established

15 months:

Priorities for history if no family concerns: child's increasing communication skills; stranger avoidance; sleep issues
Priorities for physical if no family concerns: growth/weight for length; eyes (eye movement, red reflexes); teeth (for signs of decay); abdominal masses; gait; skin (café au lait spots, birthmarks, bruising); blood pressure (if high risk)
Consider anticipatory guidance regarding: stranger and separation anxiety, temper tantrums, and discipline (encourage distractions for bad behavior and praise for good behavior); sleep routines and issues (such as maintaining consistent bedtime routine, reassurance with night-time awakenings, not allowing a bottle in bed); car seats; poisoning; water and sun safety; oral health counseling
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: anemia risk assessment; vision risk assessment; hearing risk assessment; developmental surveillance; psychosocial and behavioral screening; fluoride supplementation if needed; fluoride varnish if dental home is not established

18 months:

Priorities for history if no family concerns: child's development and behavior; family adjustment to child
Priorities for physical if no family concerns: growth/weight for length; eyes (eye movement, red reflexes, eye contact); gums and teeth (for signs of gingival inflammation and decay); abdominal masses; gait; skin (for birthmarks and bruising); parent child interaction; speech and language; blood pressure (if high risk)
Consider anticipatory guidance regarding: language promotion (such as encouraging reading and use of simple words and phrases); oral health counseling; bathroom training; falls; car seats; poisoning; firearms; water and sun safety; media use; healthy nutrition
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision risk assessment; hearing risk assessment; developmental and autism screening; psychosocial and behavioral screening; anemia risk assessment; lead risk assessment; fluoride supplementation if needed; fluoride varnish if dental home is not established

24 months:

Priorities for history if no family concerns: assessment of language
Priorities for physical if no family concerns: growth/body mass index (BMI) (if standing height); eyes (eye movement, red reflexes); abdominal masses; gums and teeth (for signs of gingival inflammation and decay); skin (café au lait spots, birthmarks, bruising); neurologic (e.g., coordination, speech); socialization; blood pressure (if high risk)
Consider anticipatory guidance regarding: promotion of reading, temperament and behavior; bathroom training; media use (e.g., screen time); safety counseling; oral health counseling
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision risk assessment; hearing risk assessment; autism screening; developmental surveillance; psychosocial and behavioral screening; anemia risk assessment; lead risk assessment; tuberculosis risk assessment; dyslipidemia risk assessment; fluoride supplementation if needed; fluoride varnish if dental home is not established

30 months:

Priorities for history if no family concerns: family routines
Priorities for physical if no family concerns: growth/BMI; eyes (eye movement, red reflexes); gums and teeth (for signs of gingival inflammation and decay); abdominal masses; skin (café au lait spots, birthmarks, bruising); neurologic (e.g., coordination, speech); socialization; blood pressure (if high risk)
Consider anticipatory guidance regarding: promoting language and social development; preschool considerations; safety in cars and outdoors; oral health counseling
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: anemia risk assessment; vision risk assessment; hearing risk assessment; developmental screening; psychosocial and behavioral screening; fluoride supplementation if needed; fluoride varnish if dental home is not established

3 years:

Priorities for history if no family concerns: family support
Priorities for physical if no family concerns: growth/BMI; blood pressure; eyes (eye movement, red reflexes); gums and teeth (for signs of gingival inflammation and decay); abdominal masses; skin (café au lait spots, birthmarks, bruising); speech and language
Consider anticipatory guidance regarding: encouraging literacy activities; promoting physical activity and play; promoting healthy nutrition; pedestrian safety; falls; water, sun, and firearm safety; oral health counseling
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision screening; hearing risk assessment; developmental surveillance; psychosocial and behavioral screening; anemia risk assessment; lead risk assessment; tuberculosis risk assessment; fluoride supplementation if needed; fluoride varnish if dental home is not established

4 years:

Priorities for history if no family concerns: television and other screen use
Priorities for physical if no family concerns: growth/BMI; blood pressure; eyes (eye movement, red reflexes), gums and teeth (for signs of gingival inflammation and decay); abdominal masses; skin (rashes, bruises); fine and gross motor skills; speech and language
Consider anticipatory guidance regarding: school readiness; healthy nutrition and personal habits; limits on television; promoting physical activity and play; involvement in the community; booster seats; water, sun, and firearm safety; oral health counseling
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision screening; hearing screening; developmental surveillance; psychosocial and behavioral screening; anemia risk assessment; lead risk assessment; tuberculosis risk assessment; dyslipidemia risk assessment; fluoride supplementation if needed; fluoride varnish if dental home is not established

5 and 6 years:

Priorities for history if no family concerns: diet; mental health
Priorities for physical if no family concerns: growth/BMI; blood pressure; eyes; gums and teeth (malocclusion, for signs of gingival inflammation and decay); fine and gross motor skills; speech and language; gait
Consider anticipatory guidance regarding: school readiness; nutrition; physical activity; oral health counseling; pedestrian safety; bike helmets; water, sun, and firearm safety; smoke and carbon monoxide detectors; sexual abuse prevention
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision screening; hearing screening; developmental surveillance; psychosocial and behavioral screening; anemia risk assessment; lead risk assessment; tuberculosis risk assessment; dyslipidemia risk assessment (age 6 years only); fluoride supplementation if needed; fluoride varnish if dental home is not established (age 5 years only)

7 and 8 years:

Priorities for history if no family concerns: school performance; mental health concerns; diet
Priorities for physical if no family concerns: growth/BMI; blood pressure; lower extremity joints; gums and teeth (malocclusion, signs of gingival inflammation and decay); Tanner staging
Consider anticipatory guidance regarding: adapting to school; development/puberty; nutrition and physical activity; oral health; booster seats; water, sun ,and firearm safety; monitoring media use; knowing child's friends
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision (risk assessment at 7 years, screening at 8); hearing (risk assessment at 7, screening at 8); developmental surveillance; psychosocial and behavioral screening; anemia risk assessment; tuberculosis risk assessment; dyslipidemia risk assessment (at 8 only); fluoride supplementation if needed

9 and 10 years:

Priorities for history if no family concerns: school performance; mental health; diet
Priorities for physical if no family concerns: growth/BMI; blood pressure; skin (birthmarks and injuries); back (visual inspection for scoliosis); Tanner staging
Consider anticipatory guidance regarding: development; nutrition and physical activity; oral health; seatbelts; bicycle safety; sunscreen; water safety; tobacco, alcohol and drugs; firearms
Vaccines: refer to recommended and catch-up schedulesCDC: child and adult immunization schedule by age
Screening and surveillance: vision (risk assessment at 9 years, screening at 10); hearing (risk assessment at 9, screening at 10); developmental surveillance; psychosocial and behavioral screening; anemia risk assessment; tuberculosis risk assessment; dyslipidemia screen (once between ages 9 and 11); fluoride supplementation if needed

Anticipatory guidance

The American Academy of Pediatrics provides extensive suggestions for anticipatory guidance and recommends it at each well-child visit, for injury prevention and promotion of healthy growth and development.[1] [7] Unintentional injury is the leading cause of death in children ages 1 to 10 years.[8] Some anticipatory guidance may be provided through brochures or through digital media in waiting rooms or other venues; the relative effectiveness of anticipatory guidance for the issues below is not known.

Recommendations:

Suggestions for counseling aimed at preventing injury include: car seats and booster seats; seatbelt use by whole family; childproofing to reduce poisoning, fall, burn, and choking dangers; smoke and carbon monoxide detectors; safety around water in and out of the home; firearms awareness; pedestrian and bicycle safety; sun safety; and sexual abuse prevention.[1]
Suggestions for counseling on other issues include: forming secure and stable nurturing relationships; language and literacy promotion including regular reading to children; establishing routines; dealing with temper tantrums; temperament and behavior; appropriate discipline practices; sleep issues; bathroom training; the importance of developmentally appropriate play, encouraging physical activity; limiting screen time including computer; preschool and school issues; healthy eating; oral health advice; and tobacco, alcohol, and drug-use prevention.[1] [9] [10] [11] [12]

Evidence:

There is very limited evidence for most brief, office-based counseling. Some benefits have been found for certain injury-prevention counseling (seatbelt and car seat use, bicycle helmet use, safe road-crossing behavior, smoke alarm use, safe water temperature), although the most effective methods have involved repeated and intense interventions.[2]
Of the studies that are available, many involve repeated interventions or multiple components. A randomized trial of four videos shown at well-child visits designed to improve parental understanding of development resulted in increased behaviors fostering cognitive growth at age six months.[13] One randomized controlled trial studied office-based, multicomponent interventions for increasing seatbelt and bicycle helmet use, keeping firearms in locked storage, and decreasing alcohol and tobacco use.[14] A significant improvement was seen only for bicycle helmet use.
Evidence to support the importance of play and regular reading in promoting cognitive, language, self-regulation, and social-emotional skills in children is accumulating in a number of areas: enhancing parent engagement; encouraging safe, stable, and nurturing relationships; facilitating the development of a variety of competencies, including executive functioning; and improving the directions children take in life.[15] [16] [17] Reach Out and Read, which combines anticipatory guidance with provision of a book to young children, was shown to improve receptive and expressive language in young children.[18] Reach Out and Read

Vaccines

While the prevalence of vaccine-preventable diseases is decreasing, there is increasing concern among the public about the safety of vaccines. Benefits of vaccination include: complete or partial immunity against various infectious diseases; lower healthcare costs related to treatment of vaccine-preventable diseases; community immunity; and reduced risk of disease outbreaks. Vaccine risks range from common, minor, and local reactions to extremely rare, potentially life-threatening adverse effects.

Recommendations:

The American Academy of Pediatrics (AAP) and American Academy of Family Physicians recommend that health providers should support and implement standards for child and adolescent immunization practices. These practices, derived from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), represent expert opinion on scientific evidence of the balance of benefits and harms from immunizations.[19] [20]
The recommended childhood immunization schedule is revised annually.CDC: child and adult immunization schedule by age
Healthcare providers should follow the most up-to-date schedules available from the CDC.[21]CDC: child and adult immunization schedule by age Current vaccine-preventable diseases include: diphtheria; tetanus; pertussis; polio; hepatitis A and B; pneumococcal disease; Haemophilus influenzae type B (Hib); rotavirus; measles; mumps; rubella; varicella; influenza; human papillomavirus (HPV); meningococcal disease; respiratory syncytial virus (RSV); and coronavirus disease 2019 (COVID-19).
The ACIP recommends simultaneous administration of all vaccines for which a child is eligible.[22] Providers should not delay vaccination due to mild upper respiratory tract infections, as this practice can lead to missed opportunities. National standards for pediatric vaccination practices have been established and include true contraindications (e.g., severe allergy to previous dose of vaccine) and precautions (e.g., moderate to severe acute disease with or without fever) to vaccination.
In all 50 states, the District of Columbia, and Puerto Rico, proof of immunization is required for a child to attend school or a childcare setting. The AAP supports these regulations and agrees with the exemptions to immunizations based on specific medical reasons.[23] The AAP does not support nonmedical exemptions to school-required immunizations.

Evidence

Evidence from systematic reviews of clinical trials report that influenza vaccination in children age over 2 years, Hib vaccination, acellular pertussis vaccination, rotavirus vaccination, and measles, mumps, and rubella (MMR) vaccination are all safe and effective, but that hepatitis B vaccination lacks sufficient evidence of effectiveness in previously unexposed people.[24] [25] [26] [27] [28]

Citations

Key Articles

Hagan JF, Shaw JS, Duncan PM. Bright Futures: guidelines for health supervision of infants, children, and adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
Bright Futures/American Academy of Pediatrics. Recommendations for preventive pediatric health care. Feb 2025 [internet publication].[Full Text]

Other Online Resources

CDC: child and adult immunization schedule by age
Reach Out and Read

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