18-MONTH WELL-BABY VISIT
Resident Author: Gina Yip, MD
Faculty Advisor: Louisa Huband, MD, CCFP
Created: October 2011
Introduction
The 18-month well-baby visit (WBV) is a pivotal primary care visit. In addition to a regular check-up visit, the visit is an opportunity for early identification and
intervention for developmental issues in young children.1,2 Speech and language development, as well as literacy and social interaction, progress rapidly at this
age. Physicians should offer interventions when they are any concerns regarding development or socialization. To facilitate the 18-month WBV, parents/caregivers
are requested to complete a standardized assessment tool, the Nipissing District Developmental Screen (NDDS), prior to or at the time of the visit. Physicians are
recommended to discuss the NDDS results and conduct a consistent, focused evaluation using an evidence-based tool, the Ontario Rourke Baby Record.3 If there is
a concern with communication or socialization, physicians should also include the Checklist for Autism in Toddlers (CHAT) to assess toddlers. An excellent resource
for parents can be found at the Canadian Pediatric Society Website for parents: www.caringforkids.cps.ca
General History2,4,5
Tips:
1. Parental concerns
• Consider asking general question: “do you have any issues you wish to discuss?”
2. Nutrition
• Breast milk with complementary foods may be offered to children for up to two years and beyond
• Homogenized milk (no > than 500-750mL/day) should be offered to ensure high-fat infant diet
• Avoid bottle feeding for healthy dentition
3. Injury Prevention
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4. Discipline
• Screen for maternal depression (risk factor for poor socio-emotional and cognitive development)
5. Parental emotional state
• Screen for maternal depression (risk factor for poor socio-emotional and cognitive development)
6. High-risk children
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7. Pacifier use
• Patient should be weaned from pacifier use at age 12 months: see www.cps.ca
8. Dental care
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9. Toilet-training
• Recommend a child-centred approach with individualized timing and methodology
10. Reading
• Encourage limitation of TV, video and computer games to provide more opportunities for reading
11. Sleep
• Ideal amount of sleep at this age: 10 to 13 hours in a 24-hour period
• Napping needs vary among children and may change during this age
• Keep bedtime routine and sleep time consistent
Forward-facing child car seats only when child is > 1 year and > 10 kg (22lbs)
Children should always be supervised and never left alone in the bath
Infant bath rings or bath seats should not be used to decrease risk of drowning
Avoid hard, small and round, smooth and sticky solid foods until age 3 years
Decrease risk of choking by using safe toys, follow minimum age recommendations, and remove loose parts and broken toys
Assess risk factors for physical abuse: low SES, young maternal age, single parent family, parental experience of childhood
physical abuse, spousal violence, lack of social support, unplanned pregnancy, -ve parental attitude towards pregnancy
Assess risk factors for sexual abuse: living in a family without a natural parent, poor marital relations, presence of a stepfather, poor child-parent relationships, unhappy family life
Confirm appropriate range of local fluoride content in drinking water of: 0.3-0.7ppm
Assess each child for dental caries risk: inadequate fluoride exposure, caries in siblings or parents, frequent/prolonged carbohydrate exposure, lower socio-economic status
Brush the child’s teeth with a soft toothbrush using pea-size of fluoridated toothpaste BID
Parents/caregivers should brush the child’s teeth to prevent excessive swallowing of toothpaste which may result in dental fluorosis
Prescribe fluoride supplementation (0.25mg/day) only if a) fluoride is <0.3ppm in water supply, b) child is not brushing twice daily, and c) child is at high risk for dental caries
Developmental History2,4,5
Tips:
1. Development
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The NDDS is not a diagnostic tool, and serves only as a guide to determine any areas that may require extra attention
List NDDS items not yet attained
-One “no” suggests lack of stimulation in a particular area and the need for further follow-up and evaluation
-Two “no’s” indicate a high suspicion of developmental delay
Perform an enhanced inquiry following the NDDS on social/emotional development, communication skills, motor skills, and adaptive skills with items listed on the Rourke Record
2. Early signs of autism
spectrum disorder
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Lack of response to name
Lack of response to social overtones/reciprocity
No seeking of parents' attention, no pointing
Behavioural irritability, hard to soothe
Lack of interest in toys, lack of mimicking behaviour
Sensory fascination or hypersensitivity
Any regression in social or language skills at any age
Dr. Michael Evans developed the One-Pager concept to provide clinicians with useful clinical information on primary care topics.
18-MONTH WELL-BABY VISIT
Physical Examination2,4,5
Items:
Tips:
1. Height
• Improve accuracy by:
• Measure twice, record results immediately, calculate exact age, and plotting findings on the chart
2. Weight
3. Head circ.
4. Fontanelles
• Fontanelles should be closed
5. Red reflex
• Absence of red reflex may be caused by retinoblastoma or cataract
• Refer for complete visual screening if testing is abnormal
6. Corneal light reflex / cover- uncover test
• Abnormal results may indicate amblyopia
• Refer for complete visual screening if testing is abnormal
7. Hearing inquiry
• Refer positive parental concern of hearing loss for formal hearing assessment
• Refer all children with normal newborn hearing screening who are at high risk of hearing loss for formal audiology/infant hearing assessment
8. Teeth
• Lift the lip for inspection of the teeth for dental caries (white spots or lines on tooth surface are early signs of tooth decay)
• Upper teeth: central incisors, lateral incisors, ±first molars, ± canines
• Lower teeth: central incisors, lateral incisors, first molars, ± canines
Management Considerations
A) Developmental Concerns1,4
Developmental Concern:
Referral:
Speech and language delay/difficulty only
• Preschool Speech and Language Program
• Infant Development Program
• Or continue to monitor closely as needed
Symptoms of social difficulty/autism
• CHAT screening tool
• Refer for paediatric assessment
• Preschool Speech and Language Program
• Infant Development Program
• Preschool Autism Services
• Or continue to monitor closely as needed
Delay with motor development + global developmental delay
• Paediatric assessment
• Developmental Paediatrician
• Infant Development Program
• Children’s Treatment Centre
• Healthy Babies Healthy Children
Social/emotional parent and family issues
• Children’s Mental Health Services
• Healthy Babies Healthy Children
• Infant Development Program
B) Immunization6
1. DTap-IPV-Hib (diphtheria, tetanus, and acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b vaccine) – Pediacel®/ Pentacel®
2. Verify all other previous vaccinations are up to date
Resources for Parents and Physicians
18-month well-baby visit web portal
http://public.machealth.ca/programs/18-month/default.aspx
18 Month Visit Flowchart
http://www.ocfp.on.ca/docs/cme/18-month-well-baby-visit-flow-sheet.
pdf
Nipissing District Developmental ScreenTM
www.ndds.ca
Rourke Baby Record
www.rourkebabyrecord.ca
www.cfpc.ca
Ontario College of Family Physicians
www.ocfp.on.ca
Canadian Paediatric Society
For physicians: www.cps.ca
For parents/caregivers: http://www.caringforkids.cps.ca/
Ontario Early Years Centres
www.ontario.ca/earlyyears
Ministry of Children and Youth Services
www.ontario.ca/child
Ministry of Health Promotion
www.ontario.ca/mhp
Ministry of Health and Long-term Care
www.ontario.ca/health
References can be found online at http://www.dfcm.utoronto.ca/programs/postgraduateprograme/One_Pager_Project_References.htm