What immunizations would be recommended at this visit?A 6-month-old male child 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. Your patient was born via an uncomplicated pregnancy to a 23-year-old G1P1 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 he is noted to babble frequently.
What immunizations would be recommended at this visit?
By what age should an infant say “mama” and “dada”?
The child’s mother asks when she can place him in front-facing car seat. What is your recommendation?
Summary: A 6-month-old healthy child is brought in for a routine well-child examination.
• Recommended immunizations for a 6-month well-child visit (in a child who is up-to-date on routine immunizations): Diphtheria, tetanus, and acellular pertussis (DTaP) no. 3, hepatitis B no. 3, Haemophilus influenzae type b (Hib) no. 3, and rotavirus no. 3; inactivated polio vaccine no. 3 can be given between 6 and 15 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 12 months.
• Recommendations for continuing in a rear-facing car seat: A child should stay in a rear-facing car seat until the child weighs at least 20 lb and is at least 1 year old.
1. Learn the basic components of a well-child examination.
2. Know the routine immunization schedule for children.
3. Know common developmental milestones for young children.
The pediatric well-child examination serves many valuable purposes. It provides an opportunity for parents, especially first-time parents, to ask questions about, and for the physician to address specific concerns regarding, their child. It allows the physician 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 doctor-patient-family relationship, which can promote health and serve as an effective tool in the management of illness.
AMBLYOPIA: Reduction or loss of vision in one eye from lack of use. Strabismus is the most common cause of amblyopia.
STRABISMUS: Ocular misalignment.
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 physician will help to engender a positive physician-patient-family relationship and improve the parent’s satisfaction with their child’s care.
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, any medications taken, 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.
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, including 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.
Efforts should be made to obtain old medical records, if any are 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.
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 growth that deviates from predicted growth curves, may warrant further evaluation. 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.
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. Table 5–1 summarizes many of the important motor, language, and social developmental milestones of early childhood.
Table 5–1 • DEVELOPMENTAL MILESTONES
There are a variety of screening tests 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.
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 congenital hypothyroidism, as early treatment can prevent the development of profound mental retardation. 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.
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. Universal screening for lead poisoning is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics for children at 12 months and again at 2 years of age in communities where 27% or more of homes were built before 1950 or where 12% or more of children have a venous lead concentration more than 10 μg/dL. In other communities, screening should be targeted to high-risk children (Table 5–2).
Table 5–2 • 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. New York, NY: McGraw-Hill; 2004:39-40.
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 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 are at higher risk. Iron deficiency can be evaluated by a hemoglobin or hematocrit measurement, usually taken between 6 and 12 months of age. Repeat testing can be considered annually, especially in high-risk children, through adolescence. An anemic child can empirically be given a trial of an iron supplement and dietary modification. Failure to respond to iron therapy should warrant further evaluation of other causes of anemia.
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 (such as neurofibromatosis), or infections associated with hearing loss (such as 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. Office-based 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 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 3 years, 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 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 tuberculin) is the screening test of choice; the multiple puncture tine test is no longer recommended. First-time screening for hyperlipidemia is recommended in children first between the ages of 2 and 10 if they meet criteria listed below (Table 5–3). Screening is performed with a serum fasting lipid panel. If fasting lipid panel is within normal limits, retesting should be performed within 3 to 5 years.
Table 5–3 • FIRST TIME LIPID SCREENING RECOMMENDATIONS
Perform first-time lipid screening in children ages 2-10 years if:
• Family history of dyslipidemia
• Family history of premature (men ≤55 years or women ≤65 years) cardiovascular disease or dyslipidemia
• Unknown family history
• 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 Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122(1): 198-202.
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 issues discussed in the office, address issues that could not be discussed because of time limitations, and allow for the parent to 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).
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 until the child is both 1 year old and weighs at least 20 lb. A child older than 1 year and between 20 and 40 lb should use a forward-facing car seat. When the child weighs more than 40 lb, the child may use 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 ft 9 in. in height 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.
The leading cause of death of infants younger than 1 year of age is 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.
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. Older children should be advised regarding the importance of wearing a helmet while riding a bicycle, skateboard, scooter, or other similar vehicle. 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.
Nutrition is another important area of anticipatory guidance. Infants younger than 1 year old should be breast-fed or receive an iron-containing formula. Cereals, other baby foods, and water can be introduced between 4 and 6 months of age. Whole cow’s milk is introduced at 12 months and continued until at least the age of 2 years, before considering changing to reduced fat milk.
Ensuring that each child has received the child’s age-appropriate immunizations is a key component of each well-child visit. The child’s immunization status also should be reviewed at acute care visits. Minor illnesses, even those causing low-grade fevers, are not contraindications to vaccinating children, allowing an acute care visit to be an excellent opportunity to provide this service. True contraindications to providing a vaccination include a history of an anaphylactic reaction to a specific vaccine or vaccine component or a severe illness, with or without a fever. The recommended childhood vaccination schedule (Figure 5–1) and catch-up schedules for children who are either completely unimmunized or who have missed doses of the recommended vaccines are published by the Centers for Disease Control and Prevention.
Figure 5–1. Recommended immunization schedule for persons aged 0 through 18 years—United States • 2011. (Available at: http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm. Accessed February 11, 2011.)
5.1 A 7-month-old baby boy is brought into the office for a possible ear infection. In assessing the infant’s posture, you note that he is not able to sit very well without support. You also observe other fine motor skills and speech. Which of the following is the most accurate statement?
A. By 3 months of age, a child should be able to sit up without support.
B. By 6 months of age, a child should be able to transfer objects from one hand to another.
C. By 9 months of age, a child should be able to walk.
D. By 12 months of age, a child should be able to put two words together.
5.2 A 5-year-old presents to your clinic for a school physical. The child weighs 42 lb and is up-to-date on his immunizations. Which of the following anticipatory guidances is most appropriate for a child at this age?
A. He should ride in a rear-facing car seat in the back seat of the vehicle.
B. He should ride in a forward-facing car seat in the back seat of the vehicle.
C. He should ride in a forward-facing car seat in the front seat of the vehicle.
D. He should ride in a booster seat in the back seat of the vehicle.
5.3 A 4-month-old infant is brought into the family physician’s office for routine checkup and immunizations. Which of the following vaccines is routinely recommended at this time?
A. Diphtheria, tetanus, acellular pertussis (DTaP)
B. Oral polio vaccine (OPV)
C. Measles, mumps, rubella (MMR)
D. Varicella
5.4 A 5-year-old child is brought into the pediatrician’s office for immunization and physical examination. The mother is concerned that her child is a little “under the weather.” Which of the following is a contraindication to vaccinating the child?
A. Acute otitis media with a temperature of 100°F requiring antibiotic therapy
B. Previous vaccination reaction that consisted of fever and fussiness that lasted for 2 days
C. History of an allergic reaction to penicillin
D. Previous vaccination reaction that consisted of wheezing and hypotension
5.1 B. It is critical to understand the normal milestones for gross motor, fine motor, speech and social categories. Delay in one or more areas can indicate problems which if addressed can alleviate long-term issues. Most 6-month-old children would be expected to sit without support. Six-month-old children would also be expected to transfer objects from one hand to the other, roll from a prone to supine position, babble, and recognize strangers.
5.2 D. A child who weighs more than 20 lb and is older than 1 year of age may sit in a forward-facing car seat in the back seat of the car. A child who weighs more than 40 lb is usually big enough to use a booster seat, also in the back seat of the car.
5.3 A. DTaP is routinely recommended at ages 2, 4, 6, and 12 to 18 months, and at 4 to 6 years of age. Oral polio vaccination is no longer routinely recommended in children; the inactivated, injectable polio vaccine is recommended in its place and is recommended at ages 2, 4, 6 to 18 months and 4 to 6 years. MMR and varicella vaccination are recommended at ages 12 to 15 months and 4 to 6 years.
5.4 D. A previous anaphylactic reaction is a true contraindication to vaccination. Minor illnesses or vaccination reactions, even with fever, are not contraindications. Penicillin is not a component of vaccines and history of allergy to this medication is not a contraindication.
True contraindications to providing vaccinations are rare; acute care visits are an excellent opportunity to provide childhood vaccinations.
SIDS is the leading cause of death in infants younger than age 1 year. Parents should place their children on their “Back-to-Sleep.”
American Academy of Pediatrics. Recommendations for preventive pediatric healthcare, 2008. Available at: http://practice.aap.org/popup.aspx?aID=1625&language=. Assessed February 11, 2011.
American Academy of Pediatrics. Screening for elevated blood lead levels. Pediatrics. 1998;101(6):1072.
Brayden RM. Office pediatrics. In: Hay WW, Levin MJ, Sondheimer JM, et al (eds). Current Pediatric Diagnosis and Treatment. 15th ed. New York, NY: McGraw-Hill; 2001:203.
Broderick P. Pediatric vision screening for the family physician. Am Fam Physician. 1998;58(3):691-700, 703-704.
Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122(1): 198-202.
DeMichele AM, Ruth RA. Newborn hearing screening, June 15, 2010. Available at: www.emedicine.com/ent/topic576.htm. Accessed February 11, 2011.
Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, PA: WB Saunders; 2002:610.
