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POCKET GUIDE
Editors
Joseph F. Hagan, Jr, MD, FAAP
Judith S. Shaw, RN, MPH, EdD
Paula M. Duncan, MD, FAAP
FUNDED BY
US Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health Bureau
PUBLISHED BY
The American Academy of Pediatrics
CITE AS
Hagan JF, Shaw JS, Duncan P, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents, Third Edition. Pocket Guide. Elk Grove Village, IL: American Academy of Pediatrics.
Copyright 2008 by the American Academy of Pediatrics. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photo-
copying, recording, or otherwise, without prior written permission from the publisher.
Library of Congress Catalog Card Number: 2007929964
ISBN-13: 978-1-58110-224-6
ISBN-10: 1-58110-224-0
BF0027
PUBLISHED BY
American Academy of Pediatrics
141 Northwest Point Blvd
Elk Grove Village, IL 60007-1098
USA
847-434-4000
AAP Web site: www.aap.org
Bright Futures Web site: http://brightfutures.aap.org
Additional copies of this publication are available from the American Academy of Pediatrics Online Bookstore at
www.aap.org/bookstore.
This publication has been produced by the American Academy of Pediatrics under its cooperative agreement
(U06MC00002) with the US Department of Health and Human Services, Health Resources and Services Administration
(HRSA), Maternal and Child Health Bureau (MCHB).
TABLE OF CONTENTS
Bright Futures at the American Academy of Pediatrics. . . . . . . . . v 15 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
How to Use This Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 18 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Core Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 2 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Building Effective Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x 2 12 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Fostering Family-Centered Communication . . . . . . . . . . . . . . . . . . . xi 3 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Promoting Health and Preventing Illness. . . . . . . . . . . . . . . . . . . . . . xii 4 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Managing Time for Health Promotion . . . . . . . . . . . . . . . . . . . . . . . xiii 5 and 6 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Educating Families Through Teachable Moments . . . . . . . . . . . . . . xiv 7 and 8 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Advocating for Children, Families, and Communities . . . . . . . . . . . xv 9 and 10 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Supporting Families Successfully . . . . . . . . . . . . . . . . . . . . . . . . . xvii Early Adolescence (11 to 14 Year Visits) . . . . . . . . . . . . . . . . . . . . . 42
Children and Youth With Special Health Care Needs . . . . . . . . . . . xvii Middle Adolescence (15 to 17 Year Visits). . . . . . . . . . . . . . . . . . . . 46
Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Late Adolescence (18 to 21 Year Visits) . . . . . . . . . . . . . . . . . . . . . . 50
Complementary and Alternative Care . . . . . . . . . . . . . . . . . . . . . . xviii Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Bright Futures Themes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Developmental Milestones at a Glance Infancy . . . . . . . . . . . . . 54
Bright Futures Health Supervision Visits . . . . . . . . . . . . . . . . . . . . 1 Developmental Milestones at a Glance Early Childhood . . . . . . 55
Acronyms Used in the Bright Futures Health Supervision Visits. . . . . 1 Social and Emotional Development in Middle Childhood . . . . . . . . 56
Prenatal Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Domains of Adolescent Development . . . . . . . . . . . . . . . . . . . . . . . 57
Newborn Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Recommended Medical Screening Infancy . . . . . . . . . . . . . . . . . 58
First Week Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Recommended Medical Screening Early Childhood . . . . . . . . . . 59
1 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Recommended Medical Screening Middle Childhood . . . . . . . . 60
2 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Recommended Medical Screening Adolescence . . . . . . . . . . . . 61
4 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Tooth Eruption Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
6 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Sexual Maturity Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
9 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Useful Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
iii
12 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Bright Futures at the American What Is Bright Futures?
Bright Futures is a set of principles, strategies, and tools
Academy of Pediatrics that are theory based, evidence driven, and systems
oriented that can be used to improve the health and
F
ounded in 1930, the American Academy of
Pediatrics (AAP) is an organization of 60,000 pedia- well-being of all children through culturally appropriate
tricians who are committed to the attainment of interventions that address their current and emerging
optimal physical, mental, and social health and well- health promotion needs at the family, clinical practice,
being for all infants, children, adolescents, and young community, health system, and policy levels.
adults.
The Bright Futures initiative was launched in 1990 Goals of Bright Futures
n Enhance health care professionals knowledge, skills,
under the leadership of the Federal Maternal and Child
Health Bureau (MCHB) of the Health Resources and and practice of developmentally appropriate health care
Services Administration (HRSA) to improve the quality of in the context of family and community.
n Promote desired social, developmental, and health
health services for children through health promotion and
disease prevention. In 2002, the MCHB selected the AAP outcomes of infants, children, and adolescents.
n Foster partnerships between families, health care pro-
to lead the Bright Futures initiative. With the encourage-
ment and strong support of the MCHB, the AAP and its fessionals, and communities.
n Increase family knowledge, skills, and participation in
many collaborating partners set out to update the Bright
Futures Guidelines as a uniform set of recommendations health-promoting and prevention activities.
n Address the needs of children and youth with special
for health care professionals. The Bright Futures
Guidelines are the cornerstone of the Bright Futures initia- health care needs through enhanced identification and
tive and the foundation for the development of all Bright services.
Futures materials. For more information about Bright Futures and
available materials and resources, visit http://
v
brightfutures.aap.org.
How to Use This Guide Developmental Observation: Includes observation of
parent-child interaction, developmental surveillance, and
T
he Pocket Guide is based on Bright Futures: school performance questions.
Guidelines for Health Supervision of Infants,
Children, and Adolescents, Third Edition. Presenting Physical Exam: Recommends a complete physical exam,
key information from the Guidelines, the Pocket Guide including specific issues for each visit.
serves as a quick reference tool and training resource for Screening: Includes universal and selective screening
health care professionals. procedures and risk assessment.
Sections of the Pocket Guide Immunizations: Provides Centers for Disease Control
Themes: Highlights 10 cross-cutting child health topics and Prevention/National Immunization Program and
that are discussed in depth in the Guidelines. These American Academy of Pediatrics Red Book Web sites for
themes are important to families and health care profes- current schedules.
sionals in their mission to promote the health and well- Anticipatory Guidance: Presents guidance for
being of all children. The Pocket Guide lists these themes; families, organized by the 5 priorities of each visit.
see the Guidelines for the full text. Sample questions also are provided for selected topics.
The Health Visit: Focuses on specific age-appropriate Guidance and questions in black type are intended for
health and developmental issues. the parent; guidance and questions in green type are
intended for the child/adolescent/young adult. These can
Visit Priorities: The Bright Futures Expert Panels be modified to match the health care professionals
acknowledge that the most important priority is to communication style.
attend to the concerns of the parent or youth. In addi-
tion, they have developed 5 priority health supervision
topics for each visit.
vii
Appendices: Includes developmental milestones at-a-
glance charts for infancy and early childhood, a chart on
social and emotional development in middle childhood,
a chart on domains of adolescent development,
recommended medical screening tables, a tooth eruption
chart, a sexual maturity ratings chart, and a list of useful
Web sites.
viii
Core Concepts All 6 core concepts rely on the health care profession-
als skills in using open-ended questions to communicate
I
n todays complex and changing health care system, effectively, partner with and educate children and their
health care professionals can improve the way they families, and serve as their advocates to promote health
carry out each visit by using an innovative health and prevent illness in a time-efficient manner.
promotion curriculum developed specifically to help
professionals integrate Bright Futures principles into Open-ended questions
clinical practice. n Help to start a conversation
This unique curriculum, developed by a health promo- n Ask: Why? How? What?
tion work group supported by the Maternal and Child n Are interpretive
Health Bureau, includes 6 core concepts: n Have a wide range of possible answers
n Partnership n Stimulate thinking
n Communication n Promote problem solving
n Health promotion/illness prevention EXAMPLES:
n Time management
How do you and your partner manage the babys behavior?
What do you do when you disagree?
n Education
(To a child) Tell me about your favorite activities at school.
n Advocacy
xiv
Advocating for Children, Families, and Communities 2. Assess the situation.
Health care professionals can be involved in advocacy n Determine existing community resources.
either at an individual level (eg, obtaining services for a n Learn about existing laws that address the issue.
child or family) or at a local or national level (eg, speaking n Review the data and resources to be sure they support
with the media, community groups, or legislators). the issue.
1. Identify family needs or concerns. n Assess political climate to determine support or
n Use open-ended questions to identify specific needs or opposition.
concerns of the family. EXAMPLE:
EXAMPLE: Is this issue of interest to anyone else (eg, school/early interven-
What are some of the main concerns in your life right now? tion teacher, local policy makers)? Who (or what) might oppose
n Choose a specific area of focus. the advocacy efforts? Why?
EXAMPLE: 3. Develop a strategy.
Obtaining special education services for a child. n Limit efforts to a specific issue.
n Clarify familys beliefs and expectations about the issue. EXAMPLE:
n Determine what has been done to date, and what has Obtaining special education services for one child rather than
(or hasnt) worked. changing the laws for all.
EXAMPLE: n Use existing resources.
Parents may have tried unsuccessfully to obtain services for their n Start with small steps, then build upon successes.
child.
n Obtain data through some initial fact finding. 4. Follow through.
EXAMPLE: n Be passionate about the issue, but willing to negotiate.
Contact board of education or local public health department. n Review the outcome.
n Talk with others; determine progress. n Evaluate your efforts.
EXAMPLE: n Determine next steps with family.
Do any local school coalitions address this issue? n Recognize that health care professionals and families
can learn from one another about effective advocacy.
xv
Supporting Families Successfully The child or youth with special health care needs shares
most health supervision requirements with her peers.
U
nderstanding and building on the strengths of Bright Futures uses screening, ongoing assessment,
families requires health care professionals to com- health supervision, and anticipatory guidance as essential
bine well-honed clinical interview skills with a will- interventions to promote wellness and identify differ-
ingness to learn from families. Families demonstrate a ences in development, physical health, and mental health
wide range of beliefs and priorities in how they structure for all children.
daily routines and rituals for their children and how they
use health care resources. This edition of the Bright Cultural Competence
Futures Guidelines places special emphasis on 3 areas of Cultures form around language, gender, disability, sexual
vital importance to caring for children and families. orientation, religion, or socioeconomic status. Even peo-
ple who have been fully acculturated within mainstream
Children and Youth With Special Health Care Needs society can maintain values, traditions, communication
As of 2000, more than 9 million children in the United patterns, and child-rearing practices of their original cul-
States have special health care needs. This means that 1 ture. Immigrant families, in particular, face many cultural
of every 5 households includes a child with a develop- stressors.
mental delay, chronic health condition, or some form of It is important for health care professionals who serve
disability. Family-centered care that promotes strong children and families from backgrounds other than their
partnerships and honest communication is especially im- own to listen and observe carefully, learn from the family,
portant when caring for children and youth with special and work to build trust and respect. If possible, the pres-
health care needs. These children and youth now live ence of a staff member who is familiar with a familys
normal life spans and tend to require visits with health community and fluent in the familys language is helpful
care professionals more frequently than other children. during discussions with families.
At the same time, the impact of specialness or exten-
sive health care needs should not overshadow the child. xvii
Complementary and Alternative Care
Families must be empowered as care participants. Their
unique ability to choose what is best for their children
must be recognized. The health care professional must
be aware of the disciplines or philosophies that are cho-
sen by the childs family, especially if the family chooses a
therapy that is unfamiliar or outside the scope of stan-
dard care. Such therapies are not necessarily harmful or
without potential benefit. Providers of standard care need
not be threatened by such choices. Therapies can be safe
and effective, safe and ineffective, or unsafe.
The use of complementary and alternative care is par-
ticularly common when a child has a chronic illness or
condition. Parents are often reluctant to tell their health
care professional about such treatments, fearing disap-
proval. Health care professionals should ask parents
directly, in a nonjudgmental manner, about the use of
complementary and alternative care.
Consultation with colleagues who are knowledgeable
about complementary and alternative care might be nec-
essary. Discussion with a complementary and alternative
care therapist also may be useful.
xviii
Bright Futures Themes context of their childs health and support their childs
and familys development.
A
number of themes are of key importance to fam- Because of the overwhelming importance to overall
ilies and health care professionals in their com- health and well-being of mental health and healthy
mon mission to promote the health and weight, and the prevalence of problems in these areas,
well-being of children from birth through adolescence. the Bright Futures authors have designated Promoting
These themes are: Mental Health and Promoting Healthy Weight as
n Promoting Family Support Significant Challenges to Child and Adolescent
n Promoting Child Development Health for this edition.
n Promoting Mental Health
n Promoting Healthy Weight
n Promoting Healthy Nutrition
n Promoting Physical Activity
n Promoting Oral Health
n Promoting Healthy Sexual Development and Sexuality
n Promoting Safety and Injury Prevention
n Promoting Community Relationships and Resources
1
Observation of Parent-Child Interaction: Who asks Screening
questions and who provides responses to questions? Discuss the purpose and importance of the newborn
(Observe parent with partner, other children, other family screening tests (metabolic, hearing) that will be done in
members.) Do the verbal and nonverbal behaviors/ the hospital before the baby is discharged.
communication among family members indicate support
and understanding, or differences of opinion and conflicts? Immunizations
Discuss routine initiation of immunizations.
PA R E N TA L ( M AT E R N A L ) W E L L - B E I N G
Anticipatory Guidance
INFANCY | PRENATAL VISIT
2
Key= Guidance for parents, questions
BREASTFEEDING DECISION Dont use alcohol/drugs.
3
Observation of Parent-Child Interaction: Do parents Assess/Observe pinnae, patency of auditory canals, pits or
recognize and respond to the babys needs? Are they tags; nasal patency, septal deviation; cleft lip or palate,
comfortable when feeding, holding, or caring for the natal teeth, frenulum; heart rate/rhythm/sounds, heart
baby? Do they have visitors or other signs of a support murmurs. Palpate femoral pulses. Examine/Determine
network? umbilical cord/cord vessels; descended testes, penile
anomalies, anal patency. Note back/spine/foot deformi-
Surveillance of Development: Has periods of wakeful-
ties. Perform Ortolani and Barlow maneuvers. Detect
ness, is responsive to parental voice and touch, is able to
primitive reflexes.
be calmed when picked up, looks at parents when
awake, moves in response to visual or auditory stimuli. Screening (See p 58.)
INFANCY | NEWBORN VISIT
Physical Exam. Complete, including: Measure and Universal: Metabolic and Hemoglobinopathy; Hearing
plot length, weight, head circumference; plot weight-for- Selective: Blood Pressure; Vision
length. Assess/Observe alertness, distress, congenital
anomalies; skin lesions or jaundice; head shape/size, Immunizations
fontanelles, signs of birth trauma; eyes/eyelids, ocular CDC: www.cdc.gov/vaccines
mobility. Examine pupils for opacification, red reflexes. AAP: www.aapredbook.org
4 What makes you get upset with the baby? What do you do when Infant capabilities, parent-child relationship, sleep (location,
you get upset? position, crib safety), sleep/wake states (calming)
Key= Guidance for parents, questions
Learn babys temperament, reactions. SAFETY
baby to sleep on back; choose crib with slats <2 83" Car safety seats, tobacco smoke, hot liquids (water
apart, keep sides up; dont use loose, soft bedding; temperature)
have baby sleep in your room, in own crib. Use rear-facing car safety seat in back seat; never put
Help baby wake for feeding by patting/diaper baby in front seat of vehicle with passenger air bag.
change/undressing. Always use safety belt; do not drive under the influence
Calm baby with stroking head or gentle rocking. of alcohol or drugs.
NUTRITIONAL ADEQUACY Dont smoke; keep home/vehicle smoke-free.
Feeding success (weight gain), feeding strategies (holding, Avoid drinking hot liquids while holding baby; set
burping), hydration/jaundice, hunger/satiation cues, feeding home water temperature <120F.
guidance (breastfeeding, formula) NEWBORN CARE
Exclusive breastfeeding during the first 4-6 months pro- When to call (temperature taking), emergency readiness
vides ideal nutrition, supports best growth and develop- (CPR), illness prevention (hand washing, outings), skin care
ment; iron-fortified formula is recommended substitute; (sun exposure)
recognize signs of hunger, fullness; develop feeding Take temperature rectally, not by ear.
routine; adequate weight gain = 6-8 wet diapers a day, What thermometer do you use? Do you know how to use it?
no extra fluids; cultural/family beliefs. Create emergency preparedness plan (first-aid kit, list of
How do you know if your baby is hungry? Had enough to eat?
telephone numbers).
If breastfeeding: Avoid own allergens; wait 1 month Wash hands often; avoid crowds.
before offering pacifier. Avoid sun, use childrens sunscreen; ask if rash is a concern. 7
How is breastfeeding going? What concerns do you have?
Observation of Parent-Child Interaction: Do reflexes, eye color/intensity/clarity, opacities, clouding of
parents appear content, depressed, angry, fatigued, cornea. Ascult for heart murmurs. Palpate femoral pulses.
overwhelmed? Do parents appear uncertain or nervous? Search for abdominal masses. Note umbilicus healing.
How do the parent and infant interact? How do parents Perform Ortolani/Barlow maneuvers. Assess neurologic
respond to the infants cues? Do they appear to be com- tone, attentiveness to visual and auditory stimuli.
fortable with each other and with the baby?
Screening (See p 58.)
Surveillance of Development: Responsive to calming
Universal: Metabolic and Hemoglobinopathy; Hearing
actions when upset; able to follow parents with eyes,
Selective: Blood Pressure; Vision; Tuberculosis
recognizes the parents voices; has started to smile; is
INFANCY | 1 MONTH VISIT
Anticipatory Guidance FA M I LY A D J U S T M E N T
Family resources, family support, parent roles, domestic
PA R E N TA L ( M AT E R N A L ) W E L L - B E I N G
violence, community resources
Health (maternal postpartum checkup, depression, substance
abuse), return to work/school (breastfeeding plans, child care) Contact community resources if needed.
Tell me about your living situation. How are your resources for
Have postpartum checkup; recognize baby blues. caring for your baby (heat, appliances, housing, knowledge, insur-
How are your spirits? What are your best and most difficult times ance, money)? Who helps you with the baby?
of day with the baby? Do you find youre drinking, using herbs, or Take time for self, partner.
taking drugs to help you feel better?
Make back-to-work/school plans; plan for breastfeed-
8
ing, child care.
Key= Guidance for parents, questions
Ask for help with domestic violence. Exclusive breastfeeding during the first 4-6 months is
I N FA N T- FA M I LY S Y N C H R O N Y
Car safety seats, water temperature (hot liquids), choking,
tobacco smoke, drowning, falls (rolling over)
Parent-infant separation (return to work/school), child care
Use rear-facing car safety seat in back seat; never put
Plan for return to school/work. baby in front seat of vehicle with passenger air bag.
Choose quality child care; recognize that separation is Always use safety belt; do not drive under the influence
hard. of alcohol or drugs.
How do you feel about leaving your baby with someone else?
Dont drink hot liquids while holding baby; set home
NUTRITIONAL ADEQUACY water temperature <120F.
Feeding routine, feeding choices (delaying complementary Dont smoke; keep home/vehicle smoke-free.
foods, herbs/vitamins/supplements), hunger/satiation cues, Dont leave baby alone in tub or high places (changing
feeding strategies (holding, burping), feeding guidance tables, beds, sofas); keep hand on baby.
(breastfeeding, formula) Keep small objects, plastic bags away from baby.
11
Observation of Parent-Child Interaction: Are parents Physical Exam. Complete, including: Measure and
and infant responsive to each other? Do parents comfort plot length, weight, head circumference. Plot weight-for-
when infant cries? Are parents attentive to infant? Do length. Assess/Observe rashes, bruising; positional skull
parents and infant demonstrate reciprocal engagement deformities; ocular mobility for lateral gaze, pupil opacifi-
around feeding/eating? Do parents respond to infants cation, red reflexes. Ascult for heart murmurs. Palpate
cues and how does the infant respond? femoral pulses. Assess/Observe developmental hip dyspla-
sia; neurologic tone, strength, and movement symmetry.
Surveillance of Development: Smiles spontaneously,
elicits social interactions, shows solidified self-consolation Screening (See p 58.)
skills; cries in differentiated manner, babbles expressively
Universal: None
INFANCY | 4 MONTH VISIT
Anticipatory Guidance What do you think your baby is trying to tell you when she cries,
looks at you, turns away, smiles?
FA M I LY F U N C T I O N I N G Make quality child care arrangements.
Parent roles/responsibilities, parental responses to infant, I N FA N T D E V E L O P M E N T
child care providers (number, quality)
Consistent daily routines, sleep (crib safety, sleep location),
Take time for self, partner; maintain social contacts; parent-child relationship (play, tummy time), infant self-
spend time with your other children. regulation (social development, infant self-calming)
Hold, cuddle, talk/sing to baby.
Continue regular feeding/sleeping routines; put baby to
Learn babys responses, temperament, likes/dislikes.
12 bed awake but drowsy.
13
Observation of Parent-Child Interaction: Are the length. Assess/Observe rashes, bruising; ocular mobility,
parents and infant responsive to one another? Do the eye alignment, pupil opacification, red reflexes. Ascult for
parents show confidence with infant? Does the parent- heart murmurs. Palpate femoral pulses. Assess/Observe
infant relationship demonstrate comfort, adequate developmental hip dysplasia, neurologic tone, movement
feeding/eating, and response to the infants cues? strength and symmetry.
Do parents/partners support each other?
Screening (See p 58.)
Surveillance of Development: Is socially interactive
with parent, recognizes familiar faces, babbles, enjoys Universal: Oral Health
vocal turn taking, starts to know own name; uses visual Selective: Blood Pressure; Vision; Hearing; Lead;
and oral exploration to learn about environment; rolls Tuberculosis
INFANCY | 6 MONTH VISIT
Anticipatory Guidance I N FA N T D E V E L O P M E N T
Parent expectations (parents as teachers), infant develop-
FA M I LY F U N C T I O N I N G
mental changes (cognitive development/learning, playtime),
Balancing parent roles (health care decision making, parent
communication (babbling, reciprocal activities, early
support systems), child care
intervention), emerging infant independence (infant self-
Use support networks. regulation/behavior management), sleep routine (self-
How are you balancing your roles of partner and parent? Who are calming/putting self to sleep, crib safety)
you able to go to when you need help with your family?
14 Choose responsible, trusted child care providers; Use high chair/upright seat so baby can see you.
consider playgroups.
Key= Guidance for parents, questions
Engage in interactive, reciprocal play. Talk/sing to, O R A L H E A LT H
Anticipatory Guidance Make time for self and partner; time with family; keep
ties with friends.
FA M I LY S U P P O RT Maintain or expand ties to your community; consider
Adjustment to the childs developmental changes and parent-toddler playgroups, parent education, or sup-
behavior, family-work balance, parental agreement/ port group.
disagreement about child issues Who do you talk to about parenting issues?
Anticipatory Guidance How does your child communicate what she wants? Does she
point to something she wants and then watch to see if you see
C O M M U N I C AT I O N A N D S O C I A L D E V E L O P M E N T what shes doing?
Individuation, separation, attention to how child SLEEP ROUTINES AND ISSUES
communicates wants and interests, signs of shared attention Regular bedtime routine, night waking, no bottle in bed
When possible, allow child to choose between 2 Maintain consistent bedtime and nighttime routine;
options acceptable to you. tuck in when drowsy, but still awake.
Stranger anxiety and separation anxiety reflect new If night waking occurs, reassure briefly, give stuffed
cognitive gains; speak reassuringly. animal or blanket for self-consolation.
Use simple, clear words and phrases to promote lan- Do not give bottle in bed.
20 guage development and improve communication.
Key= Guidance for parent, questions
T E M P E R TA N T R U M S A N D D I S C I P L I N E SAFETY
21
Observation of Parent-Child Interaction: How do the movement. Examine for red reflexes. Perform cover/
parent and child communicate? Does child show parent uncover test. Observe for nevi, caf au lait spots, birth-
book? Does parent ask child many questions or give marks, bruising; caries, plaque, demineralization, staining,
many directions? What is the tone of parent-child inter- injury.
actions? How does parent guide child to safe limits?
EARLY CHILDHOOD | 18 MONTH VISIT
Anticipatory Guidance Create family times; spend time with each child; take
actions to ensure own health.
FA M I LY S U P P O RT What activities do you do as a family? Tell me if you have ever
Parental well-being, adjustment to toddlers growing been in a relationship where you have been hurt, threatened, or
independence and occasional negativity, queries about a treated badly? What did you do?
new sibling planned or on the way Support emerging independence but reinforce limits
and appropriate behavior.
Prepare toddler for new sibling by reading books
22 together about a new baby.
Key= Guidance for parent, questions
C H I L D D E V E L O P M E N T A N D B E H AV I O R SAFETY
has at least 50 words, uses 2-word phrases, asks parent Screening (See p 59.)
to read a book; follows 2-step commands, completes
Universal: Autism; Lead (high prevalence/Medicaid)
sentences and rhymes in familiar books; stacks 5 or 6
Selective: Oral Health; Blood Pressure; Vision; Hearing;
blocks, makes or imitates horizontal and circular strokes
Anemia; Lead (low prevalence/no Medicaid); Tuberculosis;
with crayon, turns pages one at a time, imitates food
Dyslipidemia
preparation, throws ball overhand; goes up and down
stairs one step at a time, jumps up. Immunizations
Physical Exam. Complete, including: Measure stand- CDC: www.cdc.gov/vaccines
ing height (preferred) or recumbent length, weight, head AAP: www.aapredbook.org
25
Observation of Parent-Child Interaction: How actively Physical Exam. Complete, including: Measure and
do parent and child communicate? Does the child use plot standing height (preferred) or recumbent length,
questions and phrases at appropriate age level? Do par- weight, head circumference. Calculate and plot BMI, or
ent and child look at book, discuss, and interact? How plot weight-for-length. Examine red reflexes. Perform
well does parent calm child? cover/uncover test. Observe coordination, language
acquisition/clarity, socialization. Assess vocalizations.
EARLY CHILDHOOD | 2 12 YEAR VISIT
P R E S C H O O L C O N S I D E R AT I O N S
Readiness for early childhood programs, playgroups, or
playdates
27
Observation of Parent-Child Interaction: How do Physical Exam. Complete, including: Measure blood
parent and child communicate? Does parent give child pressure. Measure and plot height, weight. Calculate and
choices? Does parent encourage the childs cooperation? plot BMI. Attempt ophthalmoscopic exam of optic nerve
Does unacceptable behavior elicit appropriate responses? and retinal vessels. Observe for caries, plaque, demineral-
ization, staining, injury, gingivitis; language acquisition,
Surveillance of Development: Has self-care skills (eg,
speech clarity; adult-child interaction.
feeding, dressing); imaginative play becomes more
EARLY CHILDHOOD | 3 YEAR VISIT
Anticipatory Guidance Prepare child for school; tour school; attend back-to-
school events.
SCHOOL READINESS What concerns do you have about your childs ability to do well in
Established routines, after-school care and activities, school?
parent-teacher communication, friends, bullying, maturity, Be sure after-school care is safe, positive.
management of disappointments, fears Talk to child about school experiences.
Talk to parents about school, worries.
32 Tell me about your new school. Do kids ever call you mean names
or tease you?
Key= Guidance for parent, questions; Guidance for child, questions
M E N TA L H E A LT H Give fluoride supplement if dentist recommends.
Show affection/respect; model anger management/self- Pedestrian safety, booster seat, safety helmets, swimming
discipline. safety, child sexual abuse prevention, fire escape/drill plan
Use discipline for teaching, not punishing. and smoke detectors, carbon monoxide detectors/alarms,
Solve conflict/anger by talking, going outside and play- guns
ing, walking away. Teach safe street habits (crossing/riding school bus).
What makes you sad, angry? How do you handle it?
Use properly positioned belt-positioning booster seat in
NUTRITION AND PHYSICAL ACTIVITY back seat.
Healthy weight; appropriate well-balanced diet; increased Ensure child uses safety equipment (helmet, pads).
fruit, vegetable, whole-grain consumption; adequate calcium Teach child to swim; supervise around water; use sun-
intake; 60 minutes of exercise a day screen.
Teach rules for how to be safe with adults: (1) no adult
Eat breakfast; eat 5+ servings of fruits/vegetables a day. should tell a child to keep secrets from parents, (2) no
Limit candy/soda/high-fat snacks. adult should express interest in private parts, (3) no
Have at least 2 cups low-fat milk/other dairy a day. adult should ask a child for help with his/her private
Be physically active 60 minutes a day. parts; explain privates.
Limit TV to 2 hours a day; no TV in bedroom. Have you talked to your child about ways to avoid sexual abuse?
O R A L H E A LT H
What would you do if a grown-up made you scared? Who could
you tell? Who would help you?
Regular visits with dentist, daily brushing and flossing, Install smoke detectors/carbon monoxide detector/
adequate fluoride alarms; make fire escape plan.
Help child with brushing if needed. Remove guns from home; if gun necessary, store un-
Visit dentist twice a year. loaded and locked with ammunition locked separately. 33
Observation of Parent-Child Interaction: How do par- Screening (See p 60.)
ent and child interact? Does parent have realistic expecta- 7 Year Visit
MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS
tions about child? How does child interact with adults Universal: None
other than parents? Selective: Vision; Hearing; Anemia; Tuberculosis
Surveillance of Development: 8 Year Visit
Physical, cognitive, emotional, social, moral Universal: Vision; Hearing
competencies Selective: Anemia; Tuberculosis; Dyslipidemia
Caring, supportive relationship with family, other adults,
peers Immunizations
Physical Exam. Complete, including: Measure blood CDC: www.cdc.gov/vaccines
pressure. Measure and plot height, weight. Calculate and AAP: www.aapredbook.org
plot BMI. Observe hip/knee/ankle function. Observe for
caries, gingival inflammation, and malocclusion. Assess
for SMR.
34
Key= Guidance for parent, questions; Guidance for child, questions
Anticipatory Guidance Be aware of pubertal changes; answer questions
Show interest in school and activities. Healthy weight, appropriate food intake, adequate calcium,
How is your child doing in school? How do you help your child water instead of soda, adequate physical activity in organized
solve conflicts? sports/after-school programs/fun activities, limits on screen
How do you like school? Are you picked on by others? time
If concerns, ask teacher about evaluation for special
help/tutoring; help with bullying. Encourage nutritious food choices.
What do you think of your childs weight and growth over the past
D E V E L O P M E N T A N D M E N TA L H E A LT H year?
Independence, self-esteem, establishing rules and Eat 5+ servings of fruits/vegetables a day; eat breakfast.
consequences, temper problems, managing and resolving Limit candy/soda/high-fat snacks.
conflicts, puberty/pubertal development Get at least 2 cups low-fat milk/other dairy a day.
Eat meals as a family.
Encourage competence/independence. Be physically active 60 minutes a day.
What new things have you tried recently? How often do you go outside to play?
Show affection, praise child. Limit screen time to 2 hours a day; no TV/computer in
Be positive role model; do not hit or let others hit. bedroom.
Discuss rules, consequences. How much time do you spend each day with TV or computers?
What types of discipline do you use most often?
Talk about worries.
Who do you talk to about your worries and things that make you 35
mad?
O R A L H E A LT H Use belt-positioning booster seat in back seat until the
Regular visits with dentist, daily brushing and flossing, lab/shoulder belt fits.
MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS
36
Key= Guidance for parent, questions; Guidance for child, questions
Observation of Parent-Child Interaction: Does parent self-inflicted injuries. Note nevi or birthmarks. Examine
MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS
allow child to talk with health care professional directly? back. Assess SMR.
Surveillance of Development: Screening (See p 60.)
Physical, cognitive, emotional, social, and moral compe-
9 Year Visit
tencies
Universal: None
Behaviors that promote wellness and contribute to a
Selective: Vision; Hearing; Anemia; Tuberculosis
healthy lifestyle
Caring, supportive relationship with family, other adults, 10 Year Visit
and peers Universal: Vision; Hearing
Sense of self-confidence and hopefulness Selective: Anemia; Tuberculosis; Dyslipidemia
Increasingly responsible and independent decision
making Immunizations
CDC: www.cdc.gov/vaccines
Physical Exam. Complete, including: Measure blood AAP: www.aapredbook.org
pressure. Measure and plot height, weight. Calculate and
plot BMI. Observe tattoos/piercings/signs of abuse,
38
Key= Guidance for parent, questions; Guidance for child, questions
Anticipatory Guidance Answer questions about puberty/sexuality; counsel to
40
Key= Guidance for parent, questions; Guidance for child, questions
Observation of Parent-Youth Interaction: How com- plot BMI. Inspect for acne, acanthosis nigricans, atypical
EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS
fortably do youth and parent interact? Who asks and nevi, tattoos/piercings, signs of abuse or self-inflicted
answers most questions? Does youth express interest in injury. Examine back. Females: Assess SMR; signs of STIs.
managing his own health? Perform pelvic exam if warranted. Males: Observe for
gynecomastia. Assess SMR, signs of STIs. Examine
Surveillance of Development:
testicles for hydrocele, hernias, varicocele, masses.
Physical, cognitive, emotional, social, and moral
competencies Screening (See p 61.)
Behaviors that contribute to a healthy lifestyle
Universal: Vision (once in early adolescence)
Caring, supportive relationship with family, other adults,
Selective: Vision (when universal screening not per-
and peers
formed); Hearing; Anemia; Tuberculosis; Dyslipidemia;
Positive engagement with community
STIs; Pregnancy; Cervical Dysplasia; Alcohol or Drug Use
Self-confidence, hopefulness, well-being, and resiliency
when confronted with life stressors Immunizations
Increasingly responsible and independent decision CDC: www.cdc.gov/vaccines
making AAP: www.aapredbook.org
Physical Exam. Complete, including: Measure blood
pressure. Measure and plot height, weight. Calculate and
Note: Beginning with the Early Adolescence Visits, many health care professionals conduct the first part of the medical
interview with the parent in the examination room, and then spend time with the adolescent alone. This approach
helps adolescents build a unique relationship with their health care professional, promotes confidence and full
disclosure of health information, and enhances self-management. When explained within the context of healthy
adolescent development, parents usually support this approach.
42
Key= Guidance for parent, questions; Guidance for youth, questions
Anticipatory Guidance Help youth follow their interests to new activities,
get high?
during puberty, including menstruation for girls.
Discuss your expectations/values about dating, relation- Talk about relationships, sex, values; encourage sexual
ships, and sex. abstinence; provide opportunities for safe activities.
How do you plan to help your child deal with pressures to have
Get accurate information about physical development, sex?
sexual feelings, and sexuality; talk to parents/trusted The safest way to prevent pregnancy and STIs is to not
adult/me. have sex, including oral sex.
For females: Have you had your first period? If so, tell me more
(how often, how heavy?) For females and males: Have you talked Plan how to avoid risky situations; if sexually active,
with your parents about dating and sex? protect against STIs/pregnancy.
Have you had sex? Was it wanted or unwanted? Have you ever
RISK REDUCTION been forced or pressured to do something sexual that you havent
Tobacco, alcohol, or other drugs; pregnancy; STIs wanted to do? Were your partners male or female, or have you
had both male and female partners? Were your partners younger,
Know youths friends and activities; clearly discuss rules, older, or your age? Did you use a condom or other contraceptive?
expectations. V I O L E N C E A N D I N J U RY P R E V E N T I O N
Talk with youth about tobacco/alcohol/drugs; praise
him for not using; be a role model. Safety belt and helmet use, substance abuse and riding in a
Consider locking liquor cabinet, putting prescription vehicle, guns, interpersonal violence (fights), bullying
medicines in a place where youth cannot get them. Wear safety belt; dont allow ATV riding.
Do you regularly supervise your childs social and recreational Wear safety belt, helmet, protective gear, life jacket.
activities? What have you and your child discussed about the risk
Help youth make plan for handling situation in which
of using alcohol/tobacco/drugs?
she feels unsafe riding in a car.
Dont smoke, drink, use drugs; avoid situations with
Dont ride in car with driver who has used
drugs/alcohol; support friends who dont use; talk
alcohol/drugs; call parents/trusted adult for help.
with me if concerned about your own, or a family Do you have someone you can call for a ride if you feel unsafe
44 members, use. riding with someone?
Key= Guidance for parent, questions; Guidance for youth, questions
Remove guns from home; if gun necessary, store un-
45
Observation of Parent-Youth Interaction: How plot BMI. Inspect for acne, acanthosis nigricans, atypical
comfortably do youth and parent interact? Who asks and nevi, tattoos, piercings, signs of abuse or self-inflicted
MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS
answers most questions? Does youth express interest in injury. Examine back. Females: Assess SMR, signs of STIs.
managing his own health? Perform pelvic exam if warranted. Males: Observe for
gynecomastia; SMR; signs of STIs. Examine testicles for
Surveillance of Development:
hydrocele, hernias, varicocele, masses.
Physical, cognitive, emotional, social, and moral
competencies Screening (See p 61.)
Behaviors that contribute to a healthy lifestyle
Universal: Vision (once in middle adolescence)
Caring, supportive relationship with family, other adults,
Selective: Vision (when universal screening not per-
and peers
formed); Hearing; Anemia; Tuberculosis; Dyslipidemia;
Positive engagement with community
STIs; Pregnancy; Cervical Dysplasia; Alcohol or Drug Use
Self-confidence, hopefulness, well-being, and resiliency
when confronted with life stressors Immunizations
Increasingly responsible and independent decision CDC: www.cdc.gov/vaccines
making AAP: www.aapredbook.org
Physical Exam. Complete, including: Measure blood
pressure. Measure and plot height, weight. Calculate and
46
Key= Guidance for youth, questions; Guidance for parent, questions
Anticipatory Guidance Explore interests, new activities, including those that
49
Observation of Parent-Young Adult Interaction: plot BMI. Inspect for acne, acanthosis nigricans, atypical
How comfortably do young adult and parent, if present, nevi, tattoos, piercings, signs of abuse or self-inflicted
LATE ADOLESCENCE | 18 TO 21 YEAR VISITS
interact? Is young adult appropriately encouraged to injury. Females: CBE routine after age 20. Assess signs of
manage own health? STIs. Perform pelvic exam if warranted. Males: Assess
SMR; signs of STIs. Examine testicles for hydrocele,
Surveillance of Development:
hernias, varicocele, masses.
Physical, cognitive, emotional, social, and moral
competencies Screening (See p 61.)
Behaviors that contribute to a healthy lifestyle
Universal: Vision (once in late adolescence); Dyslipidemia
Caring, supportive relationship with family, other adults,
(once in late adolescence)
and peers
Selective screening: Vision (when universal screening
Positive engagement with community
not performed); Hearing; Anemia; Tuberculosis;
Self-confidence, hopefulness, well-being, and resiliency
Dyslipidemia (when universal screening not performed);
when confronted with life stressors
STIs; Pregnancy; Cervical Dysplasia; Alcohol or Drug Use
Increasingly responsible and independent decision
making Immunizations
Physical Exam. Complete, including: Measure blood CDC: www.cdc.gov/vaccines
pressure. Measure and plot height, weight. Calculate and AAP: www.aapredbook.org
50
Key= Guidance for young adult, questions
Anticipatory Guidance EMOTIONAL WELL-BEING
51
Think through how to make sure you can carry out Manage conflict nonviolently; avoid risky situations;
your decisions about sex. Considering role of alcohol leave violent relationships; healthy relationships are built
LATE ADOLESCENCE | 18 TO 21 YEAR VISITS
and drug use and avoiding risky places and relation- on respect, concern and mutual interests; saying NO is
ships can help. okay.
If sexually active, protect against STIs/pregnancy; make Do you belong to a gang or know anyone in a gang? Have you
a plan so you can carry out your decisions about sex ever been hit, slapped, or physically hurt while on a date? Have
you ever been forced to have sexual intercourse?
(avoid alcohol/risky situations).
Have you had sex? Was it wanted or unwanted? Were your part-
ners male or female or have you had both male and female part-
ners? Did you use a condom or other contraceptive?
V I O L E N C E A N D I N J U RY P R E V E N T I O N
Safety belt and helmet use, substance abuse and riding in a
vehicle, guns, interpersonal violence (fights), bullying
52
Key= Guidance for young adult, questions
Appendices
APPENDICES
Developmental Milestones at a Glance Infancy
Developmental Milestones at a Glance Early Childhood
Social and Emotional Development in Middle Childhood
Domains of Adolescent Development
Recommended Medical Screening Infancy
Recommended Medical Screening Early Childhood
Recommended Medical Screening Middle Childhood
Recommended Medical Screening Adolescence
Tooth Eruption Chart
Sexual Maturity Ratings
Useful Web Sites
53
Developmental Milestones at a Glance Infancy
AGE GROSS MOTOR FINE MOTOR COGNITIVE, LINGUISTIC, SOCIAL-EMOTIONAL
AND COMMUNICATION
2 Months Head up 45 Follow past midline Laugh Smile spontaneously
Lift head Follow to midline Vocalize Smile responsively
4 Months Roll over Follow to 180 Turn to rattling sound
Sithead steady Grasp rattle Laugh Regard own hand
6 Months Sitno support Look for dropped yarn Turn to voice Feed self
Roll over Reach Turn to rattling sound Work for toy (out of reach)
9 Months Pull to stand Take 2 cubes Dada/Mama, nonspecific Wave bye-bye
Stand holding on Pass cube (transfer) Single syllables Feed self
KEY
Black: 50% to 90% of children pass this item.
Green: More than 90% of children pass this item.
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
54
Developmental Milestones at a Glance Early Childhood
AGE GROSS MOTOR FINE MOTOR COGNITIVE, LINGUISTIC, SOCIAL-EMOTIONAL
AND COMMUNICATION
1 Year Stand alone Put block in cup Imitate vocalizations/sounds Protodeclarative pointing*
Pull to stand Bang 2 cubes held in hands Babbling* Wave bye-bye
1 word Imitate activities
Play pat-a-cake
15 Months Walk backwards Scribble 1 word* Drink from cup
Stoop and recover Put block in cup 3 words Wave bye-bye
Walk well
18 Months Walk up steps Dump raisin, demonstrated Point to at least 1 body part Remove garment
Run Tower of 2 cubes 6 words Help in house
Walk backwards Scribble 3 words
2 Years Throw ball overhand Tower of 6 cubes Name 1 picture Put on clothing
Jump up Tower of 4 cubes Combine words Remove garment
Kick ball forward Point to 2 pictures
Walk up steps
212 Years Throw ball overhand Imitate vertical line Know 2 actions Wash and dry hands
Jump up Tower of 8 cubes Speech half understandable Put on clothing
Tower of 6 cubes Point to 6 body parts
Name 1 picture
3 Years Balance on each foot 1 second Thumb wiggle Speech all understandable Name friend
Broad jump Imitate vertical line Name 1 color Brush teeth with help
Throw ball overhand Tower of 8 cubes Know 2 adjectives
Tower of 6 cubes Name 4 pictures
4 Years Hop Draw a person with 3 parts Define 5 words Copy a cross (+)
Balance on each foot Tower of 8 cubes Name 4 colors Copy a circle
2 seconds Speech all understandable
KEY
Black: 50% to 90% of children pass this item.
Green: More than 90% of children pass this item.
*Absence of this milestone should trigger screening for autism.
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
55
Social and Emotional Development in Middle Childhood
TOPICS KEY AREAS (Key areas in italics are especially important for children with special health care needs.)
Self Self-esteem:
Experiences of success
Reasonable risk-taking behavior
Resilience and ability to handle failure
Supportive family and peer relationships
Self-image:
Body image, celebrating different body images
Prepubertal changes; initiating discussion about sexuality and reproduction; prepubertal changes related to physical care issues
Family What matters at home:
Expectation and limit setting
Family times together
Communication
Family responsibilities
Family transitions
Sibling relationships
Caregiver relationships
Friends Friendships:
Making friends, friendships with peers with and without special health care needs
Family support of friendships, family support to have typical friendship activities, as appropriate
School School:
Expectation for school performance, school performance/defined in the Individualized Education Program
Homework
Child-teacher conflicts, building relationships with teachers
Parent-teacher communication
Ability of schools to address the needs of children from diverse backgrounds
Awareness of aggression, bullying, and victimization
Absenteeism
Community Community strengths:
Community organizations
Religious groups
Cultural groups
High-risk behaviors and environments:
Substance use
Unsafe friendships
56 Unsafe community environments
Particular awareness of risk-taking behaviors and unsafe environments, because children may be easily victimized
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
Domains of Adolescent Development
EARLY ADOLESCENCE MIDDLE ADOLESCENCE LATE ADOLESCENCE
(11 TO 14 YEARS) (15 TO 17 YEARS) (18 TO 21 YEARS)
Physiological Onset of puberty, growth spurt, Ovulation (females), growth spurt (males) Growth completed
menarche (females)
Psychological Concrete thought, preoccupation with Competence in abstract and future thought, Future orientation, emotional
rapid body changes, sexual identity, idealism, sense of invincibility or narcissism, sexual independence, unmasking of psychiatric
questioning independence, parental identity, beginning of cognitive capacity to disorders, capacity for empathy, intimacy,
controls remain strong provide legal consent and reciprocity in interpersonal
relationships, self-identity; recognized as
legally capable of providing consent,
attainment of legal age for some issues
(eg, voting) but not all issues (eg, drinking
alcohol)
Social Search for same-sex peer affiliation, Beginning emotional emancipation, increased Individual over peer relationships; transition
good parental relationships, other adults power of peer group, conflicts over parental in parent-child relationship, transition out
as role models; transition to middle control, interest in sexual relationships, initiation of home; may begin preparation for
school, involvement in extracurricular of driving, risk-taking behavior, transition to high further education, career, marriage, and
activities; sensitivity to differences school, reduced involvement in extracurricular parenting
between home culture and culture activities, possible cultural conflict as adolescent
of others navigates between familys values and values of
broader culture and peer culture
Potential Delayed puberty, acne, orthopedic Experimentation with health risk behaviors (eg, Eating disorders, depression, suicide, auto
Problems problems, school problems, sex, drinking, drug use, smoking), auto crashes, crashes, unintended pregnancy, acne,
psychosomatic concerns, depression, menstrual disorders, unintended pregnancy, smoking, alcohol or drug dependence
unintended pregnancy; initiation of acne, short stature (males), conflicts with
tobacco, alcohol, or other drug use parents, overweight, physical inactivity, poor
eating behaviors, eating disorders (eg, purging,
binge eating, and anorexia nervosa)
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
57
Recommended Medical Screening Infancy
UNIVERSAL ACTION NB 1W 1M 2M 4M 6M 9M
Metabolic and Done according to state law
hemoglobinopathy
Development Structured developmental screen
Oral health Administer OH risk assessment
Hearing All NB before discharge; if not by discharge, in 1st month; verify documentation of
screening results and appropriate rescreening by 2M
SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + NB 1W 1M 2M 4M 6M 9M
Blood pressure Children with specific risk conditions Blood pressure
or change in risk
Vision Prematurity with risk conditions, abnormal Ophthalmology referral
fundoscopic exam, parental concern (all visits);
abnormal eye alignment (4M and 6M);
abnormal cover/uncover test (9M)
Hearing + on risk screening questions Referral for diagnostic audiologic
assessment
Anemia Preterm/LBW; not on iron-fortified formula Hemoglobin or hematocrit
Lead + on risk screening questions Lead screen
Tuberculosis + on risk screening questions Tuberculin skin test
58
Recommended Medical Screening Early Childhood
UNIVERSAL ACTION 12M 15M 18M 2Y 2 12Y 3Y 4Y
Development Structured developmental screen
Autism Autism Specific Screen
Vision Objective measure with age-appropriate visual acuity measurement (using HOTV;
tumbling E tests; Snellen letters; Snellen numbers; or Picture tests, such as Allen
figures or LEA symbols)
Hearing Audiometry
Anemia Hematocrit or hemoglobin
Lead* Lead screen
SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + 12M 15M 18M 2Y 2 12Y 3Y 4Y
Oral health No dental home Referral to dental home; if not available,
oral health risk assessment (12M, 18M,
2Y, 2 12 Y). Referral to dental home (3Y).
Primary water source is deficient Oral fluoride supplementation
in fluoride
Blood Specific risk conditions or Blood pressure
pressure change in risk
Vision Parental concern or abnormal Ophthalmology referral
fundoscopic exam or cover/
uncover test
Hearing + on risk screening questions Referral for diagnostic audiologic assessment
Anemia + on risk screening questions Hematocrit or hemoglobin
Lead + on risk screening questions Lead screen
Lead No previous screen or change in risk Lead screen
No previous screen and + on Lead screen
risk screening questions or
change in risk
Tuberculosis + on risk screening questions Tuberculin skin test
Dyslipidemia + on risk screening questions; not Fasting lipid profile
previously screened with normal
results (4Y) 59
*Universal lead screen = high prevalence area or on Medicaid; Beginning at age 3, blood pressure becomes part of the physical examination; Selective lead screen = low prevalence area and not on Medicaid.
Recommended Medical Screening Middle Childhood
UNIVERSAL ACTION 5Y 6Y 7Y 8Y 9Y 10Y
Vision Objective measure with age-appropriate visual acuity measurement (using HOTV; tumbling
E tests; Snellen letters; Snellen numbers; or Picture tests, such as Allen figures or LEA symbols)
Snellen test
Hearing Audiometry
SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + 5Y 6Y 7Y 8Y 9Y 10Y
Oral health No dental home Referral to dental home
Primary water source deficient in fluoride Oral fluoride supplementation
Vision + on risk screening questions Snellen test
Hearing + on risk screening questions Audiometry
Anemia + on risk screening questions Hemoglobin or hematocrit
Lead No previous screen and + on risk Lead screen
screening questions or change in risk
Tuberculosis + on risk screening questions Tuberculin skin test
Dyslipidemia + on risk screening questions and not Fasting lipid profile
previously screened with normal results
60
Recommended Medical Screening Adolescence
UNIVERSAL ACTION EARLY MIDDLE LATE
(11-14Y) (15-17Y) (18-21Y)
Vision (once during Snellen test
each age stage)
Dyslipidemia (once A fasting lipoprotein profile (total cholesterol, LDL cholesterol high
during Late density lipoprotein [hDL], cholesterol and triglyceride). If the testing
Adolescence) opportunity is non-fasting, only total cholesterol and HDL
cholesterol will be usable.
SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + EARLY MIDDLE LATE
(11-14Y) (15-17Y) (18-21Y)
Vision (when universal + on risk screening questions Snellen test
screening not
performed)
Hearing + on risk screening questions Audiometry
Anemia + on risk screening questions Hemoglobin or hematocrit
Tuberculosis + on risk screening questions Tuberculin skin test
Dyslipidemia (when + on risk screening questions and Lipid screen
universal screening not previously screened with
not performed) normal results
STIs Sexually active Chlamydia and gonorrhea screen; use
tests appropriate to the patient population
and clinical setting
Sexually active and + on risk Syphilis blood test
screening questions HIV*
Pregnancy Sexually active without contraception, Urine hCG
late menses, amenorrhea, or heavy or
irregular bleeding
Cervical dysplasia Sexually active, within 3 years Pap smear, conventional slide or liquid-based
of onset of sexual activity or no later
than age 21
Alcohol or drug use + on risk screening questions Administer alcohol- and drug-screening tool
*The CDC has recently recommended universal voluntary HIV screening for all sexually active people, beginning at age 13. At the time of publication, the AAP and other groups had not yet commented on the CDC recom-
61
mendation, nor recommended screening criteria or techniques. The health care professionals attention is drawn to the voluntary nature of screening and that the CDC allows an opt out in communities where the HIV rate is
<0.1%. The management of positives and false positives must be considered before testing.
Tooth Eruption Chart
62 Source: Reproduced with permission from the Arizona Department of Health Services, Office of Oral Health, courtesy of Don Altman, DDS, MPH.
The assistance of the American Dental Hygienists Association is gratefully acknowledged.
Sexual Maturity Ratings The developmental stages of the adolescents sexual char-
Sexual maturity ratings (SMRs) are widely used to assess acteristics should be rated separately (ie, one stage for
adolescents physical development during puberty in 5 pubic hair and one for breasts in females, one stage for
stages (from preadolescent to adult). Also known as pubic hair and one for genitals in males), because these
Tanner stages, SMRs are a way of assessing the degree characteristics may differ in their degree of maturity.
of maturation of secondary sexual characteristics.
Source: Tables have been adapted with permission from Daniels1(p29) (as drawn from Tanner2); see also Spear.3(p4)
References
1. Daniels WA. Adolescents in Health and Disease. St Louis, MO: Mosby, Inc; 1977
2. Tanner JM. Growth at Adolescence. 2nd ed. Oxford, England: Blackwell Scientific Publications; 1962 63
3. Spear B. Adolescent growth and development. In: Rickert VI, ed. Adolescent Nutrition: Assessment and Management. New York, NY: Chapman and Hall (Aspen Publishers, Inc); 1996:3-24
Useful Web Sites Centers for Disease Control and Prevention
American Academy of Pediatrics National Immunization Information Hotline
www.aap.org (800-CDC-INFO)
www.vaccines.ashastd.org
American Academy of Pediatrics Bright Futures
http://brightfutures.aap.org Centers for Disease Prevention and Control
Physical Activity for Everyone
American Academy of Pediatrics Clinical Guide:
www.cdc.gov/nccdphp/dnpa/physical/recommendations/
Connected Kids
young.htm
www.aap.org/ConnectedKids/ClinicalGuide.pdf
Child Safety Seat Information
American Academy of Pediatrics Red Book Online
(866-SEATCHECK [866-732-8243])
www.aapredbook.org
www.seatcheck.org
American Association of Poison Control Centers
Institute of Medicine of the National Academies
(Poison Control: 800-222-1222 and 911)
www.iom.edu/file.asp?id=21372
www.aapcc.org
Maternal and Child Health Bureau
American College of Obstetricians and Gynecologists
Accurately Weighing & Measuring: Technique
www.acog.org
http://depts.washington.edu/growth/module5/text/
Automotive Safety Program contents.htm
www.preventinjury.org
MyPyramid, US Department of Agriculture
Centers for Disease Control and Prevention www.mypyramid.gov/kids/index.html
Morbidity and Mortality Weekly Report
National Association for Sport & Physical Education
www.cdc.gov/mmwr/pdf/ss/ss5505.pdf
www.aahperd.org/naspe/template.cfm?template=
Centers for Disease Prevention and Control toddlers.html
64 National Immunization Program
www.cdc.gov/vaccines
National Cancer Institute Smoking Cessation Information Olweus Bullying Prevention Program
(1-800-QUITNOW) www.clemson.edu/olweus/index.html
http://1800quitnow.cancer.gov
Reach Out and Read
National Center for Education Statistics www.reachoutandread.org
www.nces.ed.gov
Safe Kids Worldwide
National Center for Health Statistics www.safekids.org/members/unitedStates.html
www.cdc.gov/nchs
Statistical Abstract of the United States
National Center for Health Statistics Growth Charts www.census.gov/prod/www/statistical-abstract.html
www.cdc.gov/growthcharts
The Cochrane Collaboration
National Center for Homeless Education www.cochrane.org
www.serve.org/nche
The National Early Childhood Technical Assistance Center
National Guideline Clearinghouse www.nectac.org/topics/earlyid/partcelig.asp
www.guideline.gov
The Presidents Council on Physical Fitness and Sports
National Institute of Mental Health http://fitness.gov
www.nimh.nih.gov
US Department of Health & Human Services
National Maternal and Child Oral Health Resource Center Guide to Reliable Health Information
www.mchoralhealth.org www.healthfinder.gov
National Society of Genetic Counselors US Department of Labor
www.nsgc.org/consumer/familytree http://jobcorps.doleta.gov
National Youth Violence Prevention Resource Center Web-based Injury Statistics Query and Reporting System
www.safeyouth.org www.cdc.gov/ncipc/wisqars
65