The Well Child Visit (CHDP): Highlights
2-3 day visit
-nurse or physician
-focus on weight change, support breast feeding, screen for jaundice
-prevention: SIDS, shaken baby
2 week visit
-support breast feeding-if returning to work in a few months, introduce bottle at 4-6 wks
-sleep, crying
-prevention: SIDS, shaken baby, plagiocephaly
-screen for maternal depression
-discuss immunizations for next visit
-Vitamin D in form of tri-vi-sol 1 cc daily unless all formula fed
2 month visit (Pediarix, PCV, HIB, RV)
-review nursing-nothing but breast milk/formula needed, even in hot weather
-managing colic (3 wks to 3 months)- aggravators from mom’s diet: chocolate, broccoli, cauliflower, onions,
garlic, +/- caffeine (bummer, huh?)
-childcare plans
-physical: don’t forget plagiocephaly
-Vitamin D in form of tri-vi-sol 1 cc daily unless all formula fed
4 month visit (Pediarix, PCV, HIB, RV)
-discuss starting solids (rice cereal with breastmilk/formula to make paste), then step 1 foods (thin)-wait until
can sit up and doesn’t thrust out food with tongue
-sleep routines-bath, low lights, put in crib awake but drowsy to self-soothe
-physical: plagiocephaly safety: bath/changing tables
-Hct if premature
6 month visit (Pediarix, PCV, HIB, Flu)
-sleep, sleep, sleep (put in bed drowsy but awake, consistent methods for sleep training)
-introduce new foods, can start sippy with water
-baby proofing-choking/falling off changing table
-start reading to baby
-Rx: formula fed Flouride 0.55 mg/ml or 0.125 mg fluoride/drop 2 drops daily with refills (to age 3) OR….
Breastfed: Poly-vi-flor with iron 0.25 mg/ml, 1 ml po daily (has fluoride, iron and vitamin D)
9 month visit (catch up prn, Flu)
-start meal and snack routines, by age 1 they should eat what parents eat (except choking foods)
-start sippy cups, decreasing bottle
-prepare for stranger anxiety
-brush/wipe any new teeth with non-fluoridated toothpaste AM+PM
-Rx: review Fluoride/vitamin rx as in 6 month visit
-Hct, lead levels if at risk (CBC optional)
12 month visit (MMR, HIB, PCV, Hep A, Flu)
-bedtime routine
-wean from bottle, only water in bottle
-check if nursing at night-higher risk for caries
-1 or 2% milk, limit juice (2-4 oz/day)
-should respond to name
-keep car seat facing rear
-Hct, lead levels if not yet done
-Make sure taking fluoride (in poly-vi-flor with iron), discuss first dental visit this next year
15 month visit (Flu, catch up prn or 18 month except Hep A#2)
-wean bottle, none in bed
-introduce 2 choices
-Reminder: read to child every day
-Rx: Poly-vi-flor with iron 0.25 mg/ml, 1 ml po qhs
18 month visit (Varicella, DtaP, Hep A, Flu)
-Autism screen with MCHAT/pre-MCHAT
-at least 7-10 words
-ignore temper tantrums, discuss idea of time outs for discipline
-wait for toilet training readiness (can tell when they have to, can say “pee” and “poop”, can pull
underwear/pull-ups off)
-SHOULD HAVE 7-10 WORDS: Self-refer now to NBRC (569-2000-parent must call) and for audiology
screen/hearing test if ANY speech delay/concern for DD
-Rx: Poly-vi-flor with iron 0.25 mg/ml, 1 ml po qhs
PRE-MCHAT SCREEN @ 18 and 24 MONTHS
Interest ed other children/siblings
Points with index finger
Pretend play/plays with toys
Makes eye contact
Peek-a-boo
Brings objects for show
If any of these are absent, needs M-CHAT (google MCHAT or go to
http://www2.gsu.edu/~psydlr/Site/Official_M-CHAT_Website.html)
2 and 2 ½ year visit (Flu, PCV13 if never before, catch up)
-Repeat the pre-MCHAT above
-Behavior: praise and choices; time outs-1 min for each year of age, discuss toilet training
-Limit TV and make sure off the bottle!
-FIRST BMI MEASUREMENT-check it! If >95%, use the Get Healthy Action Plan
-Hct, Lead level
-Delay: refer to NBRC (up until age 3)
-Rx: Poly-vi-flor with iron 0.25 mg/ml, 1 ml po qhs
3 year visit (Flu, PCV13 if never before, catch up)
-5+ servings (1 serving=1/2 cup) fruits/vegetables daily, no fast food
-limit TV to 1 hr/day
-toilet training-dry during day
-brush teeth AM/PM, help
-first BP measurement, attempt vision and hearing
-Rx Poly-Vit/Fe/Flor 0.5 mg/ml 1 cc po qhs or 0.5 mg chewable tablet qhs
4-6 year visit THE Kindergarten visit (MMRV, Kinrix, Flu, PCV13 if never before)
-K readiness: counts to 10, knows colors, person with 3+ parts, listens to stories, waits in line
-Read to child daily
-breakfast daily , family dinners with TV off, 5+ fruits/veggies daily
-BP/BMI, vision, hearing, K paperwork
-If 6 soon, Rx Poly-vi-flor 1 mg chewable qhs
7-8 year visit (Flu, catch up)
-review nutrition, family meals, limit screen time to 1-2 hours daily, computer filters, no TV in room
-dentist 2x/yr
- Rx Poly-vi-flor 1 mg chewable qhs
9-10 year visit (Flu, catch up)
-review above
-promote independence but supervise, know friends
-can move to normal seatbelt if over 80# and shoulder belt across chest, but still back seat
- Rx Poly-vi-flor 1 mg chewable qhs
11-12 year visit (MCV4/Menactra, TdaP/Adacel, HPV#1, 1 mo #2, 6 mo #3, Flu)
-Family connection and time together, expectations of drugs, dating, sex
-Tanner stage, scoliosis exam
Ages 13-18 THE ADOLESCENT HEALTH VISIT
-Consider questionnaire in waiting area-seated separately from parents
-Talk to teen first. Start with parent in room.
-Before visit starts, clarify expectations (talk with parent/teen first re: FH, concerns,
then teen alone)
-Ask parent to step out into waiting area.
-Discussed confidentiality. Start history with HEADS (do not write during interview)
*HOME
*EDUCATION
*ACTIVITIES
*DRUGS/DEPRESSION
*SEX/SUICIDE
-Get cell phone number.
-Physical: BMI, scoliosis screen, acne, Tanner stage, testicular exam, pelvic exam if
needed
-Labs: Hct if risk factors (hvy menses, nutritional), obesity labs, STI screening yearly if
SA+.
-Confidential labs: no news is good news, put cell phone number in chart/note
-Immunizations: review meningococcal, HPV series, Tdap
-Anticipatory Guidance: Limit TV/computer/texting, warn against smoking, drugs,
sexual activity; encourage family time/family meals, family rules
-Parents: clear rules, give more autonomy, minimize criticizing/nagging, spend time
together
CAR SEATS
Infant Seats
<1
year old
rear
Babies often outgrow them before a year old
Check the fit: http://www.seatcheck.org/
Face
Convertible Seats
Up
to 40 pounds
Must be rear facing until 2 years (new)
Can then face forward
Some convert to booster
Booster
Flat
or high back
Children > 40#
CHP: to age 6, 60#
AAP: to age 8, 80#, 4’9”
Must be used with lap and shoulder belts
Regular seat belt when shoulder belt over chest, not neck/throat. In back until age 13!
Helpful Resources for you and patients:
Caring for Your Baby and Young Child (AAP)
Healthychildren.org (AAP)
The Supernanny (Jo Frost-behavioral)