Physical Examination

Always plot the weight, length, and head circumference on a growth chart. You are looking for trends. Do not just look at the numbers obtained during the visit. How do they compare to the last well visit? Last well visit the weight was at the 25th percentile but this time it is at the 75th percentile….what happened?

Individual Growth Carts from CDC

Your examination is not head to toe but least invasive to most invasive.

Individual Growth Carts from CDC

Table Retrieved from: https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_EarlyChildhoodVisits.pdf

Screening

Universal Screening	Action
Anemia	Hematocrit or hemoglobin
Lead (high prevalence area or insured by Medicaid)	Lead blood test
Oral Health (in the absence of a dental home)	Apply fluoride varnish after first tooth eruption and every 6 months.
Selective Screening	Risk Assessment	Action if Risk Assessment Positive (+)
Blood Pressure	Children with specific risk conditions or change in risk	Blood pressure measurement
Hearing	+ on risk screening questions	Referral for diagnostic audiologic assessment
Lead (low prevalence area and not insured by Medicaid)
Oral Health	Does not have a dental home	Referral to dental home or, if not available, oral health risk assessment
	Primary water source is deficient in fluoride.	Oral fluoride supplementation
Tuberculosis	+ on risk screening questions	Tuberculin skin test
Vision	+ on risk screening questions	Ophthalmology referral

See the Evidence and Rationale chapter for the criteria on which risk screening questions are based.

Immunizations

Anticipatory Guidance

Review the priorities listed in the beginning of the module. These questions will vary from family to family and visit to visit. You can modify the questions to match your communication style.

Assess communication and social development. Encourage language stimulation using reading, singing, and talking. Reach Out and Read is a program supported by the American Academy of Pediatrics (AAP). Encourage parents to speak whatever language they prefer. Children are able to learn more than one language.

Anticipate stranger and separation anxiety recurring. Encourage his independence while keeping consistent limits.

Recognizing signs of toilet training readiness. Set expectations for the parents. Most children potty train during the day by 30 months of age. Discuss plans for potty training. Encourage reading books about potty training and using positive reinforcement when he sits on the toilet, in the beginning with his clothes on. Let him select “big boy” underwear when he is ready.

Establish limits for media. The AAP recommends no television or digital media before 18 months. If parents plan to introduce media, discuss importance of appropriateness.

Nutrition

• The fat in milk is important. Encourage parents to wait until 2 years of age to introduce low-fat and fat-free milk. Child should drink 16-24 ounces of milk each day.
• Continue breastfeeding as child and mother desires.
• Limit juices due to sugar content. Avoid sodas and sports drinks altogether.

Safety

• Assess safety, such as childproofing the home, car seat, close supervision, remove/lock guns with ammunition locked separately. Children should not sit in the front seat until 13 years of age.
• Make sure parents have the telephone number for the national poison help line 800-222-1222. Call the number immediately. Do NOT make the child vomit.
• Discuss dangers in the home, such as hot liquids or food where the child can reach window blind cords, hot water temperature, heaters, medications, laundry products, and cleaning supplies.
• Watch the child closely when climbing up or down stairs.
• Working smoke detector in every level of the house, especially bedrooms.