The Well Child Visit Schedule

The American Academy of Pediatrics recommends well child visits at the following times:

  • Before your baby is born (for first-time parents)
  • Before your newborn is discharged from the hospital. If your baby is discharged before two full days of life, your baby should be seen again within 48 and 72 hours.
  • During the first year of life – a visit at about 2-4 weeks of age and at 2, 4, 6, 9, and 12 months of age
  • During the second year of life – visits at 15, 18, and 24 months of age
  • In early childhood – yearly visits from 2-5 years of age
  • During early school years – visits at 6, 8, and 10 years of age
  • In adolescence and early adulthood – yearly visits from 11-21 years of age

The Well Child Visit

Well child visits are more important than you might imagine. In addition to providing you and your child with the perfect opportunity to get to know the doctor (and the doctor to get to know the two of you), they allow your doctor to evaluate your child’s general health, growth, and development.

When children are sick, they don’t feel like showing the doctor how well they walk or talk. They don’t relate very well either, so their social skills cannot be evaluated. A well child visit requires a well child. A 6-month-old’s appointment for an ear infection can’t be used for the 6-month well child visit.

The Well Child History

At each well child visit, the doctor will ask about:

  • History of any illnesses since the last visit
  • Daily routine – eating, sleeping, etc.
  • Family relationships/friends
  • Developmental milestones/puberty
  • Child care arrangements
  • School
  • Any other concerns

When your child is a baby, the doctor takes the history while you hold your child. By age 4 or 5, your child will probably feel comfortable sitting on the exam table during the history. By school age, the doctor spends part of the time talking directly with your child. Once your child becomes a teenager, the doctor will talk with and examine your child without you in the room.

The Well Child Physical Examination

Each well child visit includes a height and weight check before the exam. In the first 2 years of life, your baby’s head size is also measured.

Height
In the first months of life, length is measured with your child lying down with legs stretched straight. When your child is older (approximately age 2), height is measured while your child is standing. Many times the first height measured on a child is less than the last recorded length. Your child didn’t shrink. It’s just the difference in the way the height (standing) and length (lying down) are measured.

Weight
Unlike height, your child’s weight changes from day to day and from morning to night. In the first few months of life, small differences may seem very important. Don’t be surprised if your doctor’s scale weighs your child heavier or lighter than your scale at home. Remember, your doctor follows your child’s weight pattern, which is much more accurate than a single weight.

Head Size
The head grows faster in the first two years than any other time in life. Both your baby’s head size and the rate at which your baby’s head is growing are important. These measurements help your doctor determine if your child’s skull and brain are developing normally.

Growth
At each visit, your child’s height, weight, and head size (in the first two years) are compared to normal values for children of the same age and sex. Your child’s measurements are plotted on growth charts from the National Center for Health Statistics like the charts on page 47 of the Growth and Development section.
Your child’s growth tells your doctor about your child’s general health and nutrition. Each child grows differently. Steady growth is important. A short child who grows steadily is not a worry. A child who stops growing or who loses weight is a worry. By following the growth pattern over a number of months, the normal spurts and slow periods of growth even out.

General Appearance
Your doctor begins the exam by taking a careful look at your child, checking for a healthy appearance or any signs of health problems. The order of the physical exam changes with the age of the child. With a young child, the doctor usually starts with the parts of the exam requiring cooperation such as listening to the heart and lungs. As the child becomes older, the doctor starts by taking the blood pressure and the examination proceeds head to toe.

Blood Pressure
Doctors usually begin taking yearly blood pressure measurements at the 3-year well child visit. Normal values for blood pressure change with age and are closely related to height and weight. Normal blood pressure values for children are lower than normal blood pressure values for adults. A normal blood pressure is less than: 105/60 for a 3-year-old; 115/75 for a 10-year-old; and 127/79 for a 15-year-old. (Adult values are considered normal if they are less than 130/85.) Coughing, crying, struggling or anxiety can significantly increase the blood pressure in young children. Children can have high blood pressure for a number of reasons, but frequently it’s due to a kidney problem.

Head
When examining a child under 2, the physician checks the “soft spots” of the skull. Soft spots, or fontanels, are areas where the skull bones have not yet grown together to form a bony, protective shell over the brain.
There are two fontanels that may be open at birth. The fontanel on the back of the head, which is triangular, may be closed at birth, but if not, it closes in the first 4 months of life. The fontanel on the top of the head, which is diamond-shaped, closes by 2 years of age. The closure occurs as the edges of the bones surrounding the fontanel add new bone until the fontanel is finally filled in.

In addition to measuring your child’s head size, your doctor checks the shape of your child’s head. Young babies who lie with their heads in one position too long can have flattening of that part of the skull.

Ears
Your doctor checks your child’s ears for signs of infection or fluid behind the ear drum. Ear infections are common in young children. Not all children complain of earaches. Untreated ear infections cause problems with speech and hearing. Your doctor checks to make sure a “silent” ear infection is not missed. If you have any concerns about your child’s hearing, be sure to bring them up with your doctor. Children with normal hearing at birth can develop hearing problems because of ear infections or exposure to very loud noises. Parents are frequently the first to notice a hearing problem. Don’t be concerned about ear wax and don’t use a cotton swab to clean your child’s ears because the ear canal is easily injured. If the doctor can’t see the ear drum because of ear wax, he or she will take care of the problem very carefully.

Eyes
Your doctor uses a lighted instrument called an ophthalmoscope to look through the pupil into the back of the eye. The doctor is looking for problems inside the eye like a cataract or a tumor. The doctor also checks your child’s eyes for problems that can be seen from the outside like excessive tearing or eyes that don’t move together.

Beginning at age 3, the doctor will probably check your child’s vision. If you have a family history of vision problems, particularly of hereditary eye disease, be sure to tell your doctor. Your child will be referred to an ophthalmologist if your doctor suspects problems.

Nose, Throat, and Mouth
The doctor checks your child’s nose for signs of allergy or chronic infection. Your doctor also checks the back of your child’s throat for enlarged tonsils or signs of infection.

When examining the mouth, he or she looks at the condition of the teeth and gums. Your doctor’s examination of your child’s teeth does not substitute for a visit to the dentist. Children should begin regular dental check-ups between ages 2 and 3.

Neck
Your doctor checks several things with the neck exam. He or she checks to make sure your child’s head moves easily from side to side and up and down. The doctor feels the neck for “lumps and bumps” – an enlarged thyroid gland or swollen lymph nodes. Swollen lymph nodes in the back of the neck suggest an infection of the scalp. Swollen lymph nodes in the front of the neck suggest an infection of the tonsils. Swollen lymph nodes behind the ear suggest an ear infection.

Chest and Lungs
Your doctor will look, listen, and feel during the chest and lung exam. Your doctor observes the rate of breathing, deep or shallow breathing, and easy or labored breathing. The stethoscope is used to listen for normal or abnormal breathing sounds.

Heart
Your doctor can feel the force of your child’s heart beating by feeling the chest wall over the heart. The stethoscope is used to listen for normal or abnormal sounds. Many children have heart murmurs, however, not all of these indicate a problem. If your doctor mentions a murmur, don’t be alarmed. If it is serious, your child will be referred to a pediatric heart specialist for further evaluation.

Abdomen
By gently pressing down on the abdominal wall, your doctor learns if your child’s spleen and liver are normal size or enlarged. By pressing deeper, your doctor checks kidney size. Your doctor also checks for any “lumps or bumps” or tenderness in the abdomen.

Using a stethoscope, your doctor can hear the sounds of fluid or food moving through the bowel, which means the intestines are working normally.

The examination of the abdomen can be uncomfortable for ticklish preschoolers and school-age children who frequently start to giggle when the doctor’s hand comes close to the child’s tummy. It’s important for the tummy muscles to be relaxed when your doctor checks for abnormalities. Very likely, your doctor will try to distract your child during the exam. That sometimes helps with the “giggles.”

Genitals
The doctor routinely checks the genitals for rashes and other signs of infection. With both girls and boys, the doctor uses the genital exam to look for signs of sexual maturation. When examining boys, the doctor checks to make sure the testes have descended into the scrotum and that there are no abnormal masses.

Nervous System
When your child’s reflexes are checked, the doctor is looking for problems with the nervous system. Simple tests of coordination and muscle strength combined with the developmental assessment are also used to look for diseases of the nervous system.

Skeletal System
Your doctor checks for different skeletal problems at different ages. At the early well child visits, your doctor checks to make sure your child does not have a problem with abnormal hip joints. It is important to treat hip problems early to avoid the need for surgery. Your doctor also checks your baby’s legs and feet. The baby’s cramped position during pregnancy can cause the legs to appear bowed and may cause incurving of the feet. Such problems are temporary and will be outgrown.

Sports injuries are the most frequent cause of bone and joint problems of older children. The next most common skeletal problem your doctor checks for is scoliosis or “S” curving of the back. Frequently, schools screen for scoliosis, and parents are asked to have a child with a positive screening test further evaluated. Scoliosis can be progressive and needs to be diagnosed early so it can be treated. It is more common in girls than in boys.

Skin
At each visit, the doctor will examine your child’s skin for rashes, birthmarks, bruising, infection, or changes in moles. The skin may provide the first clue of an illness such as leukemia or problems with the nervous system.
In the teen years, acne will be a primary concern – more for your teenager than for the doctor. There are lots of things to do to make sure your child doesn’t end up with permanent scarring from untreated acne. Be sure to ask your doctor for help or for referral to a dermatologist.

Development
Just as your doctor watches over your child’s growth, he or she follows your child’s development. Children are constantly changing, adding new skills in every area: social development, which includes how your child interacts with you and others; language development, which includes everything from cooing to talking in sentences; gross motor skills, which include large muscle movements involving the arms and legs like throwing a ball or walking; and fine motor skills, which include using fingers and hands for drawing or coloring. By following your child’s development over time, your doctor is able to identify possible problems with development and refer your child for early intervention.

Talking with the Doctor

If the best part of the well child visit is watching your child show off new developmental skills, the second best part is having the opportunity to talk about your child with an expert one-on-one!

You can check out an armload of books from the library, log on to an up-to-the-minute child care Web site, or spend hours trading stories with other parents. However, not one of these valuable resources matches the individualized support and professional expertise available to you at each well child visit.

Take advantage of this golden opportunity. Go prepared. Check out the list below for age-appropriate discussion topics.

1 month

Crying
Colic
Thumb sucking
Pacifiers
Sleep
Tempermant

2 months

Child Care
Returning to work

4 months

Talking to your baby
Teething
Bedtime routine
Age-appropriate toys
Reading to your baby

6 months

Talking to your baby
Daily routine
Self-comfort
Transitional object (stuffed animal)

9 months

Talking to your baby
Safe exploration
Simple rules like "don't touch"
Transitional object
Bedtime routine

1 year

Behavior
Language development
Safe play
Consistent rules
Hitting, biting
Self-quieting

15 months

Curiosity
Power struggles
Negative behavior

18 months

Appropriate language
Power struggles
Praising positive behavior
Night waking, night fears, nightmares
Sharing

2 years

Praising positive behavior
Appropriate language
Parallel play
Limits and structure
Toilet training

3 years

Praising positive behavior
Preschool readiness
Reading
Physical activity
Fears
Genital exploration/masturbation

4 years

Praising positive behavior
School readiness
Family chores

5 years

Health habits
TV limits
Bedtime 7-8 p.m.
Personal care and hygiene
Hand washing

6 years

Team sports
Family chores
Teaching child right and wrong
Self-control
Impulse control
Managing anger
Child's friends
School performance
Discipline

8 years

Healthy habits
Tobacco, alcohol, drug education
Education about pubertal changes
Peer relationships
Reading

10 years

Bedtime 8-9 p.m.
Hobbies
Homework spot
Acceptance of diversity
Opportunities for success
Education about pubertal changes

11-14 years

Sleep
TV and computer limits
Time management
Family time
Team sports
Family rules
Sexuality issues, sex identification, abstinence, protected sex, sexually-transmitted diseases (STDs)
Substance abuse, alcohol, tobacco

15-17 years

Stress
Feelings
Challenges
School work
Life plans
Safe driving
New skills like life saving, peer mentoring
Sexuality issues, STDs, abstinence
Substance abuse, alcohol, tobacco