BRIGHT FUTURES Guidelines for Health Supervision of Infants, Children, and Adolescents

THIRD EDITION

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 1 Building Effective Partnerships ...... x 2 2 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 Useful Web Sites ...... 64 9 Month Visit...... 16 iii 12 Month Visit ...... 18

What Is Bright Futures? Bright Futures at the American Bright Futures is a set of principles, strategies, and tools Academy of Pediatrics that are theory based, evidence driven, and systems ounded in 1930, the American Academy of oriented that can be used to improve the health and 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 F health promotion needs at the family, clinical practice, optimal physical, mental, and social health and well- 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 under the leadership of the Federal Maternal and Child Ⅲ Enhance health care professionals’ knowledge, skills, 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. health services for children through health promotion and Ⅲ Promote desired social, developmental, and health disease prevention. In 2002, the MCHB selected the AAP outcomes of infants, children, and adolescents. to lead the Bright Futures initiative. With the encourage- Ⅲ Foster partnerships between families, health care pro- ment and strong support of the MCHB, the AAP and its fessionals, and communities. many collaborating partners set out to update the Bright Ⅲ Increase family knowledge, skills, and participation in Futures Guidelines as a uniform set of recommendations health-promoting and prevention activities. for health care professionals. The Bright Futures Ⅲ Address the needs of children and youth with special 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.

Developmental Observation: Includes observation of How to Use This Guide parent-child interaction, developmental surveillance, and he Pocket Guide is based on Bright Futures: school performance questions. Guidelines for Health Supervision of Infants, TChildren, 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 professional’s 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 All 6 core concepts rely on the health care profession- Core Concepts als’ skills in using open-ended questions to communicate n today’s 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 Icarry 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. Ⅲ Help to start a conversation This unique curriculum, developed by a health promo- Ⅲ Ask: “Why?” “How?” “What?” tion work group supported by the Maternal and Child Ⅲ Are interpretive Health Bureau, includes 6 core concepts: Ⅲ Have a wide range of possible answers Ⅲ Partnership Ⅲ Stimulate thinking Ⅲ Communication Ⅲ Promote problem solving Ⅲ Health promotion/illness prevention EXAMPLES: • How do you and your partner manage the baby’s behavior? Ⅲ Time management What do you do when you disagree? Ⅲ Education • (To a child) Tell me about your favorite activities at school. Ⅲ Advocacy A summary of each of these core concepts is present- Techniques ed on the following pages to help all professionals, both Ⅲ Begin with affirming questions. those in training and experienced practitioners, bring EXAMPLE: Bright Futures alive and make it happen for children and •“What are some games you’re really good at?” families. For more information about this unique health Ⅲ Wait at least 3 seconds to allow the family to respond promotion curriculum, visit www.pediatricsinpractice.org. to the question. Ⅲ Ask questions in a supportive way to encourage ix communication. Building Effective Partnerships 4. Identify shared goals. A clinical partnership is a relationship in which participants Ⅲ Promote view of health supervision as partnership join together to ensure health care delivery in a way that between child, family, health care professional, and recognizes the critical roles and contributions of each part- community. ner (child, family, health care professional, and communi- Ⅲ Summarize mutual goals. ty) in promoting health and preventing illness. Following Ⅲ Provide links between stated goals, health issues, and are 6 steps for building effective health partnerships: available resources in community. 1. Model and encourage open, supporting commu- 5. Develop joint plan of action based on stated nication with child and family. goals. Ⅲ Integrate family-centered communication strategies. Ⅲ Be sure that each partner has a role in developing the Ⅲ Use communication skills to build trust, respect, and plan. empathy. Ⅲ Keep plan simple and achievable. Ⅲ Set measurable goals and specific timeline. 2. Identify health issues through active listening and Ⅲ Use family-friendly negotiation skills to ensure “fact finding.” agreement. Ⅲ Selectively choose Bright Futures Anticipatory Guidance Ⅲ Build in mechanism and time for follow-up. questions. Ⅲ Ask open-ended questions to encourage more com- 6. Follow up to sustain the partnership. plete sharing of information. Ⅲ Share progress, successes, and challenges. Ⅲ Communicate understanding of the issues and provide Ⅲ Evaluate and adjust plan. feedback. Ⅲ Provide ongoing support and resources. 3. Affirm strengths of child and family. Ⅲ Recognize what each person brings to the partnership. Ⅲ Acknowledge and respect each person’s contributions. Ⅲ Commend family for specific health and developmental x achievements. Fostering Family-Centered Communication Ⅲ Offer supportive comments. Effective Behaviors Ⅲ Restate in the parent’s or child’s words. Ⅲ Greet each family member and introduce self. Ⅲ Offer information or explanations. Ⅲ Use names of family members. Active Listening Skills: Nonverbal Behaviors Ⅲ Incorporate social talk in the beginning of the interview. Ⅲ Nod in agreement. Ⅲ Show interest and attention. Ⅲ Sit down at the level of the child and make eye contact. Ⅲ Demonstrate empathy. Ⅲ Interact with or play with the child. Ⅲ Appear patient and unhurried. Ⅲ Show expression, attention, concern, or interest. Ⅲ Acknowledge concerns, fears, and feelings of child and Ⅲ Convey understanding and empathy. family. Ⅲ Touch child or parent (if appropriate). Ⅲ Use ordinary language, not medical jargon. Ⅲ Draw pictures to clarify. Ⅲ Use Bright Futures Anticipatory Guidance questions. Ⅲ Demonstrate techniques. Ⅲ Give information clearly. Ⅲ Query level of understanding and allow sufficient time for response. Ⅲ Encourage additional questions. Ⅲ Discuss family life, community, and school. Active Listening Skills: Verbal Behaviors Ⅲ Allow child and parents to state concerns without interruption. Ⅲ Encourage questions and answer them completely. Ⅲ Clarify statements with follow-up questions. Ⅲ Ask about feelings. Ⅲ Acknowledge stress or difficulties. Ⅲ Allow sufficient time for a response (wait time >3 seconds). xi Promoting Health and Preventing Illness EXAMPLES: Because families often hesitate to begin discussion, it is • Take time for self and partner for leisure and exercise. essential that health care professionals identify and focus • Encourage partner to help care for child. on the individual needs of the child and family. • Accept support from friends, family. 1. Identify relevant health promotion topics. 3. Incorporate family and community resources. Ⅲ Ask open-ended, nonjudgmental questions to obtain Ⅲ Approach child within context of family and information and identify appropriate guidance. community. Ⅲ Ask specific follow-up questions to communicate Ⅲ Identify each family member’s role. understanding and focus the discussion. EXAMPLES: EXAMPLE: • “Tell me about your child’s bedtime routine.” • “How often and for how long do you breastfeed the baby? How • “Who’s responsible for household chores?” do you know when he wants to be fed?” Ⅲ Identify community resources, such as a lactation Ⅲ Listen for verbal, and observe nonverbal, cues to consultant or local recreation centers. discover underlying or unidentified concerns. Ⅲ Develop working relationships with community profes- EXAMPLE: sionals and establish lines of referral. • “How do you balance your roles of partner and parent? When Ⅲ Create a list of local resources with contact information. do you make time for yourself?” 4. Come to closure. Note: Ⅲ Be sure that the health message is understood. Ⅲ If parent hesitates with an answer, try to determine the EXAMPLES: reason. • “Have I addressed your question?” Ⅲ If parent brings in child multiple times for minor • “Do you have any other concerns about your teen’s health?” problems, explore the possibility of another unresolved Ⅲ Identify possible barriers. concern. EXAMPLE: 2. Give personalized guidance. • “What problems do you think you might have in following through with what we discussed today?” Ⅲ Introduce new information and reinforce healthy xii practices. Managing Time for Health Promotion 4. Work with the family to prioritize goals for the 1. Maximize time for health promotion. visit. Ⅲ Use accurate methods that minimize documentation Ⅲ Explain purpose of visit (identify and address specific time. concerns and overall health and development). Ⅲ Ask family to complete forms in waiting area. Ⅲ Identify family’s and health care professional’s shared Ⅲ Organize chart in consistent manner. goals. Ⅲ Scan chart before meeting with child and family. Ⅲ Prioritize needs through family-friendly negotiation. Ⅲ Train staff to elicit information and provide follow-up EXAMPLE: with family. • “I appreciate your concerns about _____. While you are here, I would also like to talk about ____.” 2. Clarify health care professional’s goals for visit. Ⅲ Review screening forms and other basic health data. 5. Suggest other options for addressing unmet Ⅲ Observe parent-child interaction. goals. Ⅲ Identify needs, then rank them in order of importance. Ⅲ Acknowledge importance of issues that could not be Ⅲ Clarify visit priorities. fully addressed during the visit. Ⅲ Offer additional resources (handouts, CDs, videotapes/ Note: DVDs, Web-based materials). The Pocket Guide organizes each visit’s Anticipatory Ⅲ Suggest a follow-up visit or phone call. Guidance by designated priorities. Ⅲ Provide referral to professional or community resource. 3. Identify family’s needs and concerns for visit. Ⅲ Selectively use Bright Futures Anticipatory Guidance sample questions. Ⅲ Include open-ended questions to draw family into visit. EXAMPLE: • “Tell me about the baby’s sleeping habits. What position does she sleep in? (Elicits more than yes/no answer and presents “teach- able moment” on “back to sleep” and sudden infant death syn- xiii drome.) Educating Families Through Teachable Moments 5. Seek and provide feedback. Teachable moments occur multiple times each day, but 6. Evaluate effectiveness of teaching. often go unrecognized. Health supervision visits present opportunities for the health care professional to teach Four characteristics of the teachable moment the child and family. Ⅲ Provides “information bites” (small amounts of informa- 1. Recognize teachable moments in health visit. tion) 2. Clarify learning needs of child and family. Ⅲ Is directed to the child’s or family’s specific needs 3. Set a limited agenda and prioritize needs together. Ⅲ Is brief (eg, a few seconds) 4. Select teaching strategy. Ⅲ Requires no preparation time

TEACHING STRATEGIES ADVANTAGES •Telling (explain, provide information, give direction) Works well when giving initial explanations or clarifying concepts •Showing (demonstrate, model, draw) Illustrates concepts for visual learners •Providing resources (handouts, videos/DVDs, Web sites) Serves as a reference after family leaves the office/clinic •Questioning (ask open-ended questions, allow time for response) Promotes problem solving, critical thinking; elicits better information; stimulates recall •Practicing (apply new information) Reinforces new concepts •Giving constructive feedback (seek family’s perspective, restate, clarify) Affirms family’s knowledge; corrects misunderstandings

xiv Advocating for Children, Families, and Communities 2. Assess the situation. Health care professionals can be involved in advocacy Ⅲ Determine existing community resources. either at an individual level (eg, obtaining services for a Ⅲ Learn about existing laws that address the issue. child or family) or at a local or national level (eg, speaking Ⅲ 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. Ⅲ Assess political climate to determine support or Ⅲ 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 the advocacy efforts? Why? Ⅲ Choose a specific area of focus. EXAMPLE: 3. Develop a strategy. • Obtaining special education services for a child. Ⅲ Limit efforts to a specific issue. Ⅲ Clarify family’s beliefs and expectations about the issue. EXAMPLE: Ⅲ Determine what has been done to date, and what has • Obtaining special education services for one child rather than (or hasn’t) worked. changing the laws for all. EXAMPLE: Ⅲ Use existing resources. • Parents may have tried unsuccessfully to obtain services for their Ⅲ Start with small steps, then build upon successes. child. Ⅲ Obtain data through some initial “fact finding.” 4. Follow through. EXAMPLE: Ⅲ Be passionate about the issue, but willing to negotiate. • Contact board of education or local public health department. Ⅲ Review the outcome. Ⅲ Talk with others; determine progress. Ⅲ Evaluate your efforts. EXAMPLE: Ⅲ Determine next steps with family. • Do any local school coalitions address this issue? Ⅲ Recognize that health care professionals and families can learn from one another about effective advocacy. xv

The child or youth with special health care needs shares Supporting Families Successfully most health supervision requirements with her peers. 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 Ubine 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 family’s normal life spans and tend to require visits with health community and fluent in the family’s 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 child’s 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 context of their child’s health and support their child’s Bright Futures Themes and family’s development. 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 Amon 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 Ⅲ Promoting Family Support Significant Challenges to Child and Adolescent Ⅲ Promoting Child Development Health for this edition. Ⅲ Promoting Mental Health Ⅲ Promoting Healthy Weight Ⅲ Promoting Healthy Nutrition Ⅲ Promoting Physical Activity Ⅲ Promoting Oral Health Ⅲ Promoting Healthy Sexual Development and Sexuality Ⅲ Promoting Safety and Injury Prevention Ⅲ Promoting Community Relationships and Resources The Bright Futures Guidelines provide an in-depth, state-of-the-art discussion of these themes, with evidence regarding effectiveness of health promotion interventions at specific developmental stages from birth to early adult- hood. Health care professionals can use these compre- hensive discussions to help families understand the xix

Bright Futures Health Supervision Visits his section presents all the Bright Futures Visits from the Prenatal Visit to the 21 Year Visit. The Table Tbelow lists the acronyms used in this section.

ACRONYMS USED IN THE BRIGHT FUTURES HEALTH SUPERVISION VISITS

AAP American Academy of Pediatrics ATV All-terrain vehicle BMI Body mass index CBE Clinical breast examination CDC Centers for Disease Control and Prevention CPR Cardiopulmonary resuscitation DVD Digital Versatile Disc HIV Human immunodeficiency virus IEP Individualized Education Program OTC Over-the-counter SMR Sexual maturity rating STI Sexually transmitted infection TV Television WIC The Special Supplemental Nutrition Program for Women, Infants, and Children

1 2 INFANCY | PRENATAL VISIT Observation of Parent-Child Interaction: and understanding, or differences of opinion and conflicts? and opinion differencesof or understanding, and support indicate members family among communication behaviors/ nonverbal and verbal the Do members.) family partner,other with children,parent other (Observe questions? to responsesprovides who and questions • • • • Guidance Anticipatory Key= discharge), family resources, use of community resourcesFamily support systems, transition home (assistance after RESOURCES FAMILY Contact community r Ensur Anticipate challenges of caring for new baby. tant to the health of your baby. Your family’s health values/beliefs/practices are impor- caring for the baby? T What health practices do you follow to keep your family healthy? ell me about your living situation. How are your resources for Guidance for parents, e support systems at home (friends, r questions esour ces for help, if needed. elatives). Who asks Who screening tests (metabolic, hearing) that willDiscuss be done the in purpose and importance of the newborn Screening Discuss routine initiation of immunizations. Immunizations the hospital before the baby is discharged. • • • use; pregnancy risks Physical/mental/oralWELL-BEING health; nutritional status;(MATERNAL) medication PARENTAL Consider your feelings about the pr Know your HIV status. diet, sleep, exercise, personal safety). Maintain your health (medical appointments, vitamins, What works for communicating with each other/makingHow do decisions? you, your family, the father feel about your pregnancy? help? information on where to go or who to contact if youhealthy? ever need Do you always feel safe with your partner?What W have you been doing to keep yourself and your baby egnancy . ould you like INFANCY | PRENATAL VISIT 3 " 3 8 2 oom, in own crib. own in oom, Do you keep guns at home? Are there guns in homes you visit you homes in guns there Are home? at guns keep you Do friends)? relatives, (grandparents, apart; have baby sleep in your r your in sleep baby have apart; Don’t use alcohol/drugs. use Don’t lead, for home check smoke-free; home/vehicle Keep mold. store necessary, gun if home; from guns Remove separate. ammunition with locked and unloaded smoke install <120°F; temperature water home Set detector/alarm. monoxide carbon detectors, Put baby to sleep on back; choose crib with slats < slats with crib choose back; on sleep to baby Put Ask for information about practice. about information for Ask Limit baby’s exposure to others. to exposure baby’s Limit Wash hands frequently (diaper changes, feeding). changes, (diaper frequently hands Wash sleep, crib safety, sleep location), newborn health risks (hand (hand risks health newborn location), sleep safety, crib sleep, outings) washing, NEWBORN CARE to (back sleep prevention, illness practice, the to Introduction • • • • • • • • onmental health risks (smoking, lead, mold), mold), lead, (smoking, risks health onmental -facing car safety seat in back seat. back in seat safety car -facing ear Do you have pets at home? If you have cats, have you been tested been you have cats, have you If home? at pets have you Do antibodies? toxoplasmosis for Are you concerned about having enough money to buy food or food buy to money enough having about would concerned that you Are resources in interested be you Would formula? infant baby? your and you for care to afford you help What are your plans for feeding your baby? baby? your feeding for plans your are What Learn about pet risks. risks. pet about Learn Use safety belt. safety Use r Install Contact WIC/community resources if needed. needed. if resources WIC/community Contact Choose breastfeeding if possible; use iron-fortified iron-fortified use possible; if breastfeeding Choose feeding. formula if formula use. supplement/OTC about me Tell carbon monoxide detectors/alarms monoxide carbon SAFETY effects, (fetal use alcohol/substance pets, seats, safety Car envir driving), detectors), smoke setting, heater (water fire/burns guns, Breastfeeding plans, breastfeeding concerns (past experi- (past concerns breastfeeding plans, Breastfeeding medications/drugs, nonprescription or prescription ences, support breastfeeding breastfeeding), of support family feeding infant for resources financial systems, BREASTFEEDING BREASTFEEDING DECISION • • • • • • 4 INFANCY | NEWBORN VISIT awake, moves in response to visual or auditory stimuli.be calmed when picked up, looks at par ness, is responsive to parental voice and touch, is able to mobility fontanelles, signs of birth trauma; eyes/eyelids,anomalies; ocular skin lesions or jaundice; head shape/size,length. Assess/Observe alertness, distress,plot congenital length, weight, head circumference; plotPhysical weight-for- Exam. Surveillance of Development: Observation of Parent-Child Interaction: network? baby? Do they have visitors or other signs of a supportcomfortable when feeding, holding, or caring forrecognize the and respond to the baby’s needs? Are they • • Guidance Anticipatory Key= r Family support, maternal wellness, transition, sibling READINESS FAMILY elationships, family r Never hit or shake baby. Accept help from family, friends. you get upset? What makes you get upset with the baby? What do you do when Guidance for parents, . Examine pupils for opacification, r Complete, including: esour questions ces Has periods of wakeful- Measur ents when ed r Do parents eflexes. e and natal teeth, frenulum; heart rate/rhythm/sounds,tags; heart nasal patency, septal deviation; cleftAssess/Observe lip or palate, pinnae, patency of auditory canals, pits or AAP: CDC: Immunizations Selective: Universal: 58.) p (See Screening primitive reflexes. ties. Perform Ortolani and Barlow maneuvers. Detectanomalies, anal patency. Note back/spine/footumbilical deformi- cord/cord vessels; descended testes,murmurs. penile Palpate femoral pulses. Examine/Determine • • • position, crib safety), sleep/wake states (calming) Infant capabilities, parent-child relationship, sleep (location,INF normal. If it continues, r Feeling tired, blue, or overwhelmed in first weeks is Community agencies can help. Take care of yourself; make time for yourself, partner. caring for the baby? T ell me about your living situation. What are your resources for ANT BEHAVIORSANT www.cdc.gov/vaccines www Blood Pressure; Vision .aapr Metabolic and Hemoglobinopathy; Hearing edbook.org esour ces are available for help. INFANCY | NEWBORN VISIT 5 om the area. the om equently to prevent diaper rash. diaper prevent to equently edness, fluid fr fluid edness, ont seat of vehicle with passenger air bag. Baby bag. air passenger with vehicle of seat ont alcohol or drugs. or alcohol void others with colds/flu. with others void What changes have you made in your home to ensure your baby's your ensure to home your in made you have changes What safety? keep to do can you things about heard you have suggestions What healthy? baby your A Use fragrance-free soap/lotion, avoid powders; avoid powders; avoid soap/lotion, fragrance-free Use sunlight. direct fr if diaper call Change below; diaper keeping by drying” “air care: Cord r smell, bad Rear-facing car safety seat in back seat; never put baby put never seat; back in seat safety car Rear-facing fr travel. in during times all at seat safety car in remain must influence the under drive not do belt; safety use Always of smoke-free. home/vehicle Keep diaper/clothes. changing when baby on hand Keep baby. for safe home Keep Wash your hands often. often. hands your Wash ROUTINE BABY CARE to introduction prevention, illness care, skin supplies, Infant referrals intervention practice/early SAFETY of (review safety home falls, smoke, tobacco seats, safety Car conducted) was visit prenatal no if items priority • • • • • • • • • • - owth and develop and owth formula safely; feed safely; formula ces if needed. needed. if ces e esour e/stor epar Pr 8-12 feedings in 24 hours; continue continue hours; 24 in feedings 8-12 enatal vitamin; avoid alcohol. avoid vitamin; enatal Are you concerned about having enough money to buy food for food buy to money enough having about concerned you Are formula? infant or yourself pr If formula feeding: formula If If breastfeeding: If Exclusive breastfeeding during the first 4-6 months pro- months 4-6 first the during breastfeeding Exclusive gr best supports nutrition, ideal vides carrying, rocking) helps baby feel secure. feel baby helps rocking) carrying, soft loose, use don’t back; on sleep to baby Put crib. own in room, your in sleep baby have bedding; Create nurturing routines; physical contact (holding, contact physical routines; nurturing Create routine; adequate weight gain = 6-8 wet diapers a day, a diapers wet 6-8 = gain weight adequate routine; beliefs. cultural/family fluids; extra no ment; iron-fortified formula is recommended substitute; recommended is formula iron-fortified feeding ment; develop fullness; hunger, of signs recognize Learn baby’s temperament, reactions. reactions. temperament, baby’s Learn every 2-3 hours; hold baby semi-upright; don’t prop don’t semi-upright; baby hold hours; 2-3 every bottle. r WIC/community Contact FEEDING hydration/jaundice, cues, hunger/satiation initiation, Feeding guidance feeding burping), (holding, strategies feeding formula) (breastfeeding, • • • • • • • 6 INFANCY | FIRST WEEK VISIT is able to suck/swallow/br to fix briefly on faces or objects, follows faceneeds to midline; through behaviors, has undifferentiatednight); cry; is turns able and calms to parent’s voice,able communicates to establish longer stretch of sleep (4-5 hoursods of at wakefulness for feeding, will gradually become Surveillance of Development: Observation of Parent-Child Interaction: port each other? dressing/changing diapers, and feeding? Do parentsparents’ sup- and newborn’s interactions aroundappear comforting, confident in caring for newborn? What areparents the responsive to newborn’s distress?content, Do the parents depressed, angry, fatigued, overwhelmed?and newborn Are respond to each other? Do parents appear reflexes, lifts head briefly in the prone position. • A Key= roles Health and depression, family stress, uninvited advice, parent P ARENT baby sleeps. Recognize fatigue, “baby blues.” Rest and sleep when nt Guidance for parents, icipat AL (MA AL TERNAL) WELL-BEING TERNAL) o r y questions G eathe, shows str uidanc Is able to sustain peri- e ong primitive Do parents length. Assess/Observe rashes, jaundice, dysmorphicplot length, fea- weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: AAP: CDC: Immunizations Selective: Universal: 58.) p (See Screening symmetry of movement, state regulation. Assess/Observe posture, neurologic tone, activitycord/cord level, vessels. Perform Ortolani/Barlowheart maneuvers. murmurs. Palpate femoral pulses. Inspectopacification, umbilical red reflexes. Assess dacryocystitis.tures; eyes/eyelids, Ascult for ocular mobility. Examine pupils for • • • Accept help from partner, family, friends. changing subject. Handle unwanted advice by acknowledging, then children. Maintain family r when you feel sad, hopeless, or overwhelmed? How is the adjustment to the new baby going? Are there times www www.aapredbook.org Blood Pressure; Vision .cdc.gov/vaccines Metabolic and Hemoglobinopathy; Hearing outines; spend time with your other Measure and INFANCY | FIRST WEEK VISIT 7 Prepare/store formula safely; feed 2 feed safely; formula Prepare/store e) e) smoke; keep home/vehicle smoke-free. home/vehicle keep smoke; t alcohol or drugs. or alcohol void drinking hot liquids while holding baby; set baby; holding while liquids hot drinking void What thermometer do you use? Do you know how to use it? it? use to how know you Do use? you do thermometer What Don’ ear. by not rectally, temperature Take of list kit, (first-aid plan preparedness emergency Create numbers). telephone Avoid sun, use children’s sunscreen; ask if rash is a concern. If formula feeding: formula hold If hungry; seems still if more and hours 2-3 every oz bottle. prop don’t semi-upright; baby put never seat; back in seat safety car rear-facing bag. Use air passenger with vehicle of seat front in baby influence the under drive not do belt; safety use Always of A <120ºF. temperature water home Contact WIC/lactation consultant if needed. needed. if consultant WIC/lactation Contact Wash hands often; avoid crowds. avoid often; hands Wash NEWBORN CARE readiness emergency taking), (temperature call to care When skin outings), washing, (hand prevention illness (CPR), exposur (sun SAFETY (water liquids hot smoke, tobacco seats, safety Car temperatur • • • • • • • • • • " 3 8 2 ecommended substitute; ecommended void own allergens; wait 1 month 1 wait allergens; own void A on-fortified formula is r is formula on-fortified How is breastfeeding going? What concerns do you have? you do concerns What going? breastfeeding is How How do you know if your baby is hungry? Had enough to eat? to enough Had hungry? is baby your if know you do How change/undressing. apart, keep sides up; don’t use loose, soft bedding; soft loose, use don’t up; sides keep apart, crib. own in room, your in sleep baby have patting/diaper by feeding for wake baby Help If breastfeeding: If vides ideal nutrition, supports best growth and develop- and growth best supports nutrition, ideal vides ir ment; Exclusive breastfeeding during the first 4-6 months pro- months 4-6 first the during breastfeeding Exclusive baby to sleep on back; choose crib with slats < slats with crib choose back; on sleep to baby Help baby to develop sleep and feeding routines. Put routines. feeding and sleep develop to baby Help before offering pacifier. pacifier. offering before Calm baby with stroking head or gentle rocking. gentle or head stroking with baby Calm no extra fluids; cultural/family beliefs. beliefs. cultural/family fluids; extra no recognize signs of hunger, fullness; develop feeding develop fullness; hunger, of signs day, a recognize diapers wet 6-8 = gain weight adequate routine; burping), hydration/jaundice, hunger/satiation cues, feeding feeding cues, hunger/satiation hydration/jaundice, burping), formula) (breastfeeding, guidance NUTRITIONAL ADEQUACY (holding, strategies feeding gain), (weight success Feeding Daily routines, sleep (location, position, crib safety), state state safety), crib position, (location, sleep routines, Daily early relationship, parent-child (calming), modulation referrals developmental NEWBORN NEWBORN TRANSITION • • • • • 8 INFANCY | 1 MONTH VISIT able to lift his head when on tummy. recognizes the parents’ voices; has started toactions smile; when is upset; able to follow par Physical Exam. Complete, including: Surveillance of Development: Observation of Parent-Child Interaction: length. Assess/Observe positional skull deformities;plot length, red weight, head circumference. Plot weight-for- fortable with each other and with the baby? respond to the infant’s cues? Do they appearHow to do be the com- parent and infant interact? How do parentsoverwhelmed? Do parents appear uncertain or nervous?parents appear content, depressed, angry, fatigued, • • Guidance Anticipatory Key= abuse), return to work/school (breastfeeding plans, childHealth care) (mater WELL-BEING (MATERNAL) PARENTAL ing, child care. Make back-to-work/school plans; plan for breastfeed- Have postpartum checkup; recognize “baby blues.” taking drugs to help you feel better? of day with the baby? Do you find you’re drinking,How using are herbs, your spirits? or What are your best and most difficult times Guidance for parents, nal postpartum checkup, depr questions Responsive to calming ents with eyes, Measure and ession, substance Do AAP: CDC: I Selective: Universal: 58.) p (See Screening Search for abdominal masses. Note umbilicus healing.cornea. Ascult for heart murmurs. Palpate femoralreflexes, pulses. eye color/intensity/clarity, opacities, clouding of tone, attentiveness to visual and auditory stimuli.Perform Ortolani/Barlow maneuvers. Assess neurologic • • violence, community resources Family r F mmunizations mmunizations AMIL Take time for self, partner. Contact community resources if needed. ance, money)? Who helps you with the baby? caring for your baby (heat, appliances, housing,Tell knowledge, me about insur- your living situation. How are your resources for www www.aapredbook.org Y esour ADJUSTMENT Blood Pressure; Vision; Tuberculosis .cdc.gov/vaccines Metabolic and Hemoglobinopathy; Hearing ces, family support, par ent r oles, domestic INFANCY | 1 MONTH VISIT 9 ds away away ds op bottle. op pr t Prepare/store formula safely; feed 2 feed safely; formula Prepare/store Continue prenatal vitamin; wait until wait vitamin; prenatal Continue ont seat of vehicle with passenger air bag. air passenger with vehicle of seat ont smoke; keep home/vehicle smoke-free. home/vehicle keep smoke; t alcohol or drugs. or alcohol How do you know if your baby is hungry? is baby your if know you do How Use rear-facing car safety seat in back seat; never put never seat; back in seat safety car rear-facing Use fr in baby influence the under drive not do belt; safety use Always of diaper/clothes; changing when baby on hand Keep strings/cor loops, with toys bracelets, keep baby. from Don’ Exclusive breastfeeding during the first 4-6 months is months 4-6 first the during breastfeeding substitute; Exclusive recommended is formula iron-fortified feeding ideal; develop fullness; hunger, of signs day, a recognize diapers wet 5-8 = gain weight adequate fluids, routine; extra no breaks; natural at burp day; a stools 3-4 spurts. growth recognize food; breastfeeding: If pacifier/bottle. offering before weeks 4-6 feeding: formula hold If hungry; seems still if more and hours 2-3 every oz don’ semi-upright; baby SAFETY tobacco falls, strings, and loops with toys seats, safety Car smoke • • • • • • • " 3 8 2 < . eferrals ocking; never shake baby shake never ocking; oking, r oking, "; never leave baby in with drop side down. down. side drop with in baby leave never "; 1 4 equency (growth spurts), feeding choices (types of of (types choices feeding spurts), (growth equency partner ever hit you? Are you scared that you or other caretakers other or you that scared you Are you? hit go ever to where partner on information like you Would baby? the hurt may help? for contact to who and Do you always feel safe in your home? Has your partner or ex- or partner your Has home? your in safe feel always you Do Hold, cuddle, talk to baby often; calm baby by talking, by baby calm often; baby to talk cuddle, Hold, str patting, Develop consistent sleep/feeding routines. sleep/feeding consistent Develop apart; don’t use loose, soft bedding; have baby sleep in sleep baby have bedding; soft loose, use don’t apart; with playpen mesh choose crib; own in room, your < weave Put baby to sleep on back; choose crib with slats slats with crib choose back; on sleep to baby Put emergency telephone numbers; wash hands often. hands wash numbers; telephone emergency Learn infant first-aid/CPR/temperature taking; know know taking; first-aid/CPR/temperature infant Learn Ask for help with domestic violence. violence. domestic with help for Ask Start “tummy time” when awake. when time” “tummy Start Feeding fr Feeding (holding, strategies feeding cues, hunger foods/fluids), guidance feeding (cleanliness), use pacifier burping), formula) (breastfeeding, FEEDING ROUTINES baby), developmental changes (bored baby, tummy time), time), tummy baby, (bored changes developmental baby), r developmental early INFANT ADJUSTMENT INFANT location, sleep, to (back position sleep schedule, Sleep/wake shaken consoling, (crying, modulation state safety), crib • • • • • • 10 INFANCY | 2 MONTH VISIT and legs, shows diminishing newbor position, shows symmetrical movements of head,position, arms, has consistent head control in supportedable to sitting hold up head and begins to push up in proneclearer behaviors to indicate needs. Indicatesto boredom; demonstrate is differentiated types of crying,parent, coos, has smiles, is able to console and comfort self; begins Surveillance of Development: Observation of Parent-Child Interaction: fant cues? Do parent and partner support each other?around feeding/eating, comforting, and respondingthe infant? to in- What are the parent-infant interactionswhelmed? Are parents comfortable and confidentparents with appear content, depressed, angry,responsive fatigued, over- are parents and infant to each other? Do • Guidance Anticipatory Key= support, sibling relationships activities, depr Health (maternal postpartum checkup and resumption of P ARENT family planning. Have postpartum checkup; talk with partner about Guidance for parents, AL (MA AL ession), par TERNAL) WELL-BEING TERNAL) questions ent r oles and r Attempts to look at n esponsibilities, family r eflexes. How length. Assess/Observe rashes or bruising, fontanelles;plot length, weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: AAP: CDC: I Selective: Universal: 58.) p (See Screening tone, strength and symmetry of movements. Ortolani/Barlow maneuvers. Assess torticollis,reflexes; neurologic heart murmurs, femoral pulses. Performeyes/eyelids, ocular mobility, pupil opacification, red • • reflexes), communication and calming activity (tummy time, rolling over, diminishing newbornposition, crib safety), developmental changes, physicalPar INFANTBEHAVIOR mm Engage other childr Take time for self, partner; maintain social contacts. ent-child r unizat www.cdc.gov/vaccines www.aapredbook.org Blood Pressure; Vision Metabolic and Hemoglobinopathy; Hearing ions elationship, daily r en in car outines, sleep (location, e of baby , Measure and as appr opriate. INFANCY | 2 MONTH VISIT 11 . (hot liquids), choking, choking, liquids), (hot e olling over) olling Prepare/store formula safely; feed safely; formula Prepare/store Continue with 8-12 feedings in 24 in feedings 8-12 with Continue owning, falls (r falls owning, drink hot liquids while holding baby; set home set baby; holding while liquids hot drink t alcohol or drugs. or alcohol Use rear-facing car safety seat in back seat; never put never seat; back in seat safety car rear-facing bag. Use air passenger with vehicle of seat front in baby influence the under drive not do belt; safety use Always of Don’ <120°F. temperature water smoke-free. home/vehicle keep smoke; Don’t (changing places high or tub in alone baby leave Don’t baby on hand keep sofas); beds, tables, Exclusive breastfeeding during the first 4-6 months is months 4-6 first the during breastfeeding substitute; Exclusive recommended is formula iron-fortified natural at ideal; burp fullness; hunger, of signs recognize food. or fluids extra no breaks; breastfeeding: returning If if milk breast pumping/storing for plan hours; work/school. to feeding: formula prop If don’t semi-upright; baby hold hours; 3-4 every bed. in bottle no bottle; Keep small objects, plastic bags away from baby. from away bags plastic objects, small Keep Car safety seats, water temperatur water seats, safety Car dr smoke, tobacco SAFETY • • • • • • • • • " 3 8 2 ecognize that separation is separation that ecognize e; r e; outine, feeding choices (delaying complementary complementary (delaying choices feeding outine, d. How do you feel about leaving your baby with someone else? someone with baby your leaving about feel you do How How much is your baby crying? What are some ways you have you ways some are What crying? baby your is work? much How doesn’t that if do you do What baby? your calm to found is challenging? is What do you and your partner enjoy most about your baby? What baby? your about most enjoy partner your and you do What Choose quality child car child quality Choose have baby sleep in your room, in own crib. crib. own in room, your in sleep baby have times. fussy for strategies Develop apart, keep sides up; don’t use loose, soft bedding; soft loose, use don’t up; sides keep apart, Put baby to sleep on back; choose crib with slats < slats with crib choose back; on sleep to baby Put Hold, cuddle, talk/sing to baby. baby. to talk/sing cuddle, Hold, Learn baby’s responses, temperament, likes/dislikes. temperament, responses, baby’s Learn Maintain regular sleep/feeding routines. sleep/feeding regular Maintain har Use “tummy time” when awake. when time” “tummy Use Plan for return to school/work. to return for Plan feeding strategies (holding, burping), feeding guidance guidance feeding burping), (holding, strategies feeding formula) (breastfeeding, NUTRITIONAL ADEQUACY r cues, Feeding hunger/satiation herbs/vitamins/supplements), foods, INFANT-FAMILY care child work/school), to (return SYNCHRONY separation Parent-infant • • • • • • • • 12 INFANCY | 4 MONTH VISIT objects. cal movements of arms/legs, begins to roll and reachelbows, for has good head control, demonstrates symmetri-vironment, indicates pleasure/displeasure;and pushes spontaneously; chest to responds to affection/changesskills; in cries en- in differentiated manner, babbleselicits expressively social interactions, shows solidified self-consolation Surveillance of Development: Observation of Parent-Child Interaction: cues and how does the infant respond? around feeding/eating? Do parents respond toparents infant’s and infant demonstrate reciprocal engagementwhen infant cries? Are parents attentive to infant?and infant Do responsive to each other? Do parents comfort • • • A Key= child car Parent roles/responsibilities, parental responses to infant, F AMIL Learn baby’s responses, temperament, likes/dislikes.Hold, cuddle, talk/sing to baby. spend time with your other children. Take time for self, partner; maintain social contacts; nt Guidance for parents, Y icipat e FUNCTIONING pr oviders (number o r y questions Guidance , quality) Smiles spontaneously, Are parents length. Assess/Observe rashes, bruising; positionalplot length, skull weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: AAP: DC: I Selective: Universal: 58.) p (See Screening sia; neurologic tone, strength, and movementfemoral symmetry. pulses. Assess/Observe developmentalcation, hip dyspla- red reflexes. Ascult for heart murmurs.deformities; Palpate ocular mobility for lateral gaze, pupil opacifi- • • regulation (social development, infant self-calming) parent-child relationship (play, tummy time), infantConsistent self- daily r INFANTDEVELOPMENT mm bed awake but drowsy. Continue regular feeding/sleeping routines; put baby to Make quality child care arrangements. looks at you, turns away, smiles? What do you think your baby is trying to tell you when she cries, www.cdc.gov/vaccines unizat www.aapredbook.org Blood Pressure; Vision; Hearing; Anemia None ions outines, sleep (crib safety , Measure and sleep location), INFANCY | 4 MONTH VISIT 13 use t ” -facing car safety seat in back seat; never put never seat; back in seat safety car -facing ear alcohol or drugs. or alcohol Avoid bottle in bed, propping, “grazing. propping, bed, in bottle Avoid baby in front seat of vehicle with passenger air bag. bag. air passenger with vehicle of seat front in baby influence the under drive not do belt; safety use Always of (changing places high tub, in alone baby leave Don’t don’ baby; on hand keep sofas); beds, tables, walker. infant <120°F. temperature water home Set ironing, cooking, liquids, (hot baby to risk burn Avoid smoking). baby. from away bags plastic objects, small Keep home. in lead of sources for Check Don’t share spoon or clean pacifier in your mouth; your in pacifier clean or spoon share Don’t hygiene. dental good maintain r Use ORAL ORAL HEALTH teething/ pacifier, clean of use care, health oral Maternal bed in bottle of avoidance drooling, SAFETY drowning, poisoning, lead walkers, falls, seats, safety Car choking burns, liquids), (hot temperature water • • • • • • • • • prop t "; never leave never "; 1 4 owth spurts; plan for safe for plan spurts; owth east milk. milk. east Prepare/store formula safely; 8 to 12 to 8 safely; formula Prepare/store Recognize gr Recognize eastfeeding during the first 4-6 months is months 4-6 first the during eastfeeding on-fortified formula is recommended substitute. recommended is formula on-fortified What do you do to calm your baby? Do you ever feel that you or you that feel ever you Do baby? your calm to do feel- you do that What handle you do How baby? the hurt may caretakers other ing? bottle; no bottle in bed; consider contacting WIC. WIC. contacting consider bed; in bottle no bottle; times in 24 hours; hold baby semi-upright; don’ semi-upright; baby hold hours; 24 in times child is developmentally ready. developmentally is child ideal; ir ideal; when months, 4-6 between introduced be can Cereal Continue calming strategies when fussy. fussy. when strategies calming Continue baby in with drop side down. down. side drop with in time”) baby (“tummy active and singing) (reading, quiet Use explore. to opportunities safe provide playtime; If breastfeeding: breastfeeding: If feeding: formula If Exclusive br Exclusive choose mesh playpen with weave < weave with playpen mesh choose Put baby to sleep on back; don’t use loose, soft bed- soft loose, use don’t back; on sleep to baby Put up; sit can baby before mattress crib lower ding; pumping/storing of br of pumping/storing NUTRITION ADEQUACY AND GROWTH (complementary choices feeding gain, weight success, Feeding (breastfeeding, guidance feeding allergies), food foods, formula) • • • • • • • 14 INFANCY | 6 MONTH VISIT sitting; will move from sitting to crawling. from prone; rocks back and forth; is learning toover rotate and sits, in stands and bounces; moves to crawlingand oral exploration to lear vocal turn taking, starts to know own name; uses visualwith parent, recognizes familiar faces, babbles, enjoys plot length, weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: Surveillance of Development: Observation of Parent-Child Interaction: Do parents/partners support each other? feeding/eating, and response to the infant’sinfant cues? relationship demonstrate comfort, adequateparents show confidence with infant? Does the parent-parents and infant responsive to one another? Do the • • Guidance Anticipatory Key= support systems), child care Balancing parent roles (health care decision making, parent F AMIL consider playgroups. Choose responsible, trusted child care providers; Use support networks. you able to go to when you need help with your family?How are you balancing your roles of partner and parent? Who are Guidance for parents, Y FUNCTIONING questions n about environment; rolls Is socially interactive Measur Are the e and • AAP: CDC: Immunizations Tuberculosis Selective: Universal: 58.) p (See Screening heart murmurs. Palpate femoral pulses. Assess/Observeeye alignment, pupil opacification, red reflexes.length. Ascult Assess/Observe for rashes, bruising; ocular mobility, strength and symmetry. developmental hip dysplasia, neurologic tone, movement calming/putting self to sleep, crib safety) regulation/behavior management), sleep routine (self-intervention), emerging infant independence (infant self-communication (babbling, r mental changes (cognitive development/learning, playtime),Parent expectations (parents as teachers), infant develop- INFANTDEVELOPMENT Use high chair/upright seat so baby can see you. www.cdc.gov/vaccines www.aapredbook.org Blood Pressure; Vision; Hearing; Lead; Oral Health ecipr ocal activities, early INFANCY | 6 MONTH VISIT 15 ound . ” risk to baby (stoves, heaters). (stoves, baby to risk n -facing car safety seat in back seat until 1 year 1 until seat back in seat safety car -facing leave baby alone in tub, high places (changing places high tub, in alone baby leave ear t void bur void To prevent choking, limit “finger foods” to soft bits. soft to foods” “finger limit choking, prevent To Avoid bottle in bed, propping, “grazing. propping, bed, in bottle Avoid AND 20 pounds; never put in front seat of vehicle with vehicle of seat front in put never pounds; 20 AND bag. air passenger ar barriers gates, (stair check safety home Do products). cleaning heaters, space Don’ walker. infant use don’t sofas); beds, tables, kitchen. in when chair/playpen high in baby Keep Assess fluoride source. fluoride Assess r Use A Keep small objects, plastic bags, away from baby. from away bags, plastic objects, small Keep Set home water temperature <120°F. temperature water home Set Brush with soft toothbrush/cloth and water and toothbrush/cloth soft with Brush ORAL ORAL HEALTH in bottle of avoidance toothbrush, hygiene/soft oral Fluoride, bed SAFETY at (gates falls surfaces), water/hot (hot burns seats, safety Car drowning poisoning, choking, walkers), no and stairs • • • • • • • • • • • " 3 8 ed. 2 "; never "; 1 4 esponsibilities), ovide iron-rich ovide owth. limits, location, r location, limits, , Don’t switch to milk; contact milk; to switch Don’t Continue as long as mutually desir mutually as long as Continue edient foods one at a time; pr time; a at one foods edient ecognize slowing rate of gr of rate slowing ecognize How does your baby communicate or tell you what he wants and wants he what you tell or communicate baby your does How needs? WIC/community resources for help. for resources WIC/community leave baby in with drop side down. down. side drop with in baby leave apart; don’t use loose, soft bedding; lower crib mat- crib lower bedding; soft loose, use don’t apart; < weave with playpen mesh choose tress; If breastfeeding: If feeding: formula If Exclusive breastfeeding during the first 4-6 months is months 4-6 first the during breastfeeding substitute; Exclusive recommended is formula iron-fortified ideal; r Put baby to sleep on back; choose crib with slats < slats with crib choose back; on sleep to baby Put Continue regular daily routines; put baby to bed awake bed to baby put routines; daily regular Continue drowsy. but Engage in interactive, reciprocal play. Talk/sing to, Talk/sing play. reciprocal interactive, in Engage baby. with games read/play Determine whether baby is ready for solids; introduce introduce solids; for ready is baby whether Determine single-ingr foods; respond to baby’s cues. baby’s to respond foods; day). a oz (2-4 juice limit cup; Begin NUTRITION AND FEEDING: ADEQUACY/GROWTH (quantity strategies Feeding fluids/juice), of choices foods, (complementary choices feeding formula) (breastfeeding, guidance feeding • • • • • • • • 16 INFANCY | 9 MONTH VISIT games, explores environment; expands motor skills.objects; develops object permanence, learns interactiverepetitive consonants and vowel sounds, pointsapprehension out with strangers, seeks out parent; uses Surveillance of Development: Observation of Parent-Child Interaction: independent behavior within a safe envir safe a within behavior independent appropriate? How do parents respond to infant’sphysically? Are parents’ developmental expectationsexplore and check back with parent visually andfeeding/eating? Can infant move away from parentinfant to demonstrate reciprocal engagement aroundstimulate the infant with language, play? Do parents and • Guidance Anticipatory Key= functioning, domestic violence management), cultural beliefs about child-rearing, familyDiscipline (parenting expectations, consistency, behaviorADAPTATIONS FAMILY “No,” use distraction, be a role model). Use consistent, positive discipline (limit use of the word Guidance for parents, questions Has developed onment? Do parents length. Assess/Observe positional skull deformities;plot length, ocular weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: AAP: CDC: Immunizations Selective: Universal: 58.) p (See Screening reflex. tone, movement strength and symmetry. ElicitAssess/Observe parachute developmental hip dysplasia;Ascult neurologic for heart murmurs. Palpate femoral pulses.mobility, eye alignment, pupil opacification, red reflexes. • • Make time for self, partner, friends. Ask for help with domestic violence. and who to contact for help? may hurt the baby? Would you like information onpartner where to ever go hit you? Are you scared that you or otherDo you caretakers always feel safe in your home? Has your partner or ex- www.cdc.gov/vaccines www Blood Pressure; Vision; Hearing; Lead .aapr Development; Oral Health edbook.org Measure and INFANCY | 9 MONTH VISIT 17 ds). ont seat of vehicle of seat ont oducts, electrical cor electrical oducts, alcohol or drugs. or alcohol Do home safety check (stair gates, barriers around barriers gates, (stair check safety home Do pr cleaning heaters, space kitchen. in when chair/playpen high in baby Keep higher- and second- on guards window operable Install water, windows. near story supervision”) (“touch reach arm’s within Be bathtubs. pools, Use rear-facing car safety seat in back seat until 1 year 1 until seat back in seat safety car rear-facing Use fr in baby put never pounds; 20 AND bag. air passenger with influence the under drive not do belt; safety use Always of tablecloths. on liquids hot objects, heavy leave Don’t Put Poison Control Center number at each telephone. each at number Center Control Poison Put Encourage use of cup; discuss plans for weaning. for plans discuss cup; of use Encourage Continue breastfeeding if mutually desired. mutually if breastfeeding Continue SAFETY guards, window heaters), stoves, (hot burns seats, safety Car guns locks), (safety poisoning drowning, • • • • • • • • • • fect toys; talk/sing/read together; talk/sing/read toys; fect outines, transition to solids (table- (table- solids to transition outines, oduction), cup drinking (plans for weaning) for (plans drinking cup oduction), es. How do you think the baby is learning? How is he communicating he is How learning? is baby the think you do How you? with How does your baby adapt to new situations, people, and places? and people, situations, new to adapt baby your does How Gradually increase table foods; ensure variety of foods, of variety ensure foods; table increase Gradually textur respond to baby’s cues. cues. baby’s to respond computers. videos, TV, Avoid Recognize new social skills, separation anxiety; be sensi- be anxiety; separation skills, social new Recognize temperament. to tive cause-and-ef with Play Provide opportunities for safe exploration, be realistic be exploration, safe for opportunities Provide abilities. about Keep consistent daily routines. daily consistent Keep Provide 3 meals, 2-3 snacks a day. a snacks 2-3 meals, 3 Provide FEEDING ROUTINE r mealtime Self-feeding, intr food Changing sleep pattern (sleep schedule), developmental developmental schedule), (sleep pattern sleep Changing development cognitive play), exploration, (safe mobility and behavior anxiety, separation permanence, (object visual self-regulation, versus temperament learning, communication effect), and cause exploration, INFANT INDEPENDENCE INFANT • • • • • • • 18 EARLY CHILDHOOD | 12 MONTH VISIT bangs 2 cubes held in hands, stands alone. lows simple directions, identifies people uponspeaks request; 1-2 words; jabbers with normal inflections;protodeclarative fol- pointing; imitates vocalizations/sounds;parent and shows distress on separation; demonstratesstory, waves “bye-bye,” has strong attachmentimitates with activities, hands par Surveillance of Development: Observation of Parent-Child Interaction: toddler? Does parent seem positive about child?by health care professional? How do siblings interactparent? with How does parent react to praise of selfparent or child visually? Does toddler bring an object toparent show interact with toddler? Does child check back with • Guidance Anticipatory Key= disagreement about child issues behavior, family-work balance, parental agreement/Adjustment to the child’s developmental changes and F AMIL praise for good behaviors. Discipline with time-outs and positive distractions; When your child is troublesome, what do you do? Guidance for parent, Y SUPPOR T questions ent a book when wants a Plays interactive games, How does length. Examine for red reflexes. Perform cover/uncoverplot length, weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: AAP: CDC: I Lead (low prevalence/no Medicaid); TuberculosisSelective: Universal: 59.) p (See Screening scended. ing. Observe gait. Determine whether testes fullytest. de- Observe for caries, plaque, demineralization, stain- • • mm port group. parent-toddler playgroups, parent education,Maintain or sup- or expand ties to your community; considerties with friends. Make time for self and partner; time with family; keep Who do you talk to about parenting issues? unizat www.cdc.gov/vaccines www.aapredbook.org Oral Health; Blood Pressure; Vision; Hearing; Anemia; Lead (high prevalence/Medicaid) ions Measure and EARLY CHILDHOOD | 12 MONTH VISIT 19 er; make er; Stay within an arm’s reach (“touch supervision”) when supervision”) (“touch reach arm’s an within Stay immediate- bathtubs pools, buckets, empty water; near use. un- after ly store necessary, gun if home; from guns Remove separately. locked ammunition with locked, and loaded “Childproof” home (medications, cleaning supplies, cleaning (medications, home objects). “Childproof” sharp or small stairs, cords, dangling old year 1 heaters, least at until seat safety car rear-facing a Use pounds. 20 high- least at until AND seat safety car rear-facing a use to best is It manufactur by allowed height or weight est facing; forward to switching when changes of seat necessary front in seat safety car rear-facing place never safest. is seat back bag; air passenger with vehicle SAFETY guns drowning, seats, safety car safety, Home • • • • • e soft , . fer only water only fer ovide nutritious food and healthy snacks. healthy and food nutritious ovide What do you all do together? Tell me about your family’s family’s your about me Tell together? do all you do What traditions. Brush teeth twice a day with plain water plain with day a twice teeth Brush toothbrush. of bottle, using still If caregivers do the same. the do caregivers to tend (toddlers eat to much how decide to child Trust “graze”). Encourage self-feeding; avoid small, hard foods. hard small, avoid self-feeding; Encourage sur be day; a snacks nutritious 2-3 and meals 3 Feed Continue 1 nap a day; nightly bedtime routine with routine bedtime nightly day; a nap 1 Continue toy. favorite a singing, reading, time, quiet Establish family traditions. traditions. family Establish Establish teeth brushing routine. brushing teeth Establish Pr Visit the dentist by 12 months or after first tooth. first after or months 12 by dentist the Visit ESTABLISHING A DENTAL HOME A DENTAL ESTABLISHING hygiene dental checkup, dental First Self-feeding, nutritious foods, choices, “grazing” choices, foods, nutritious Self-feeding, FEEDING AND APPETITE CHANGES Family time, bedtime, teeth brushing, nap times nap brushing, teeth bedtime, time, Family ESTABLISHING ROUTINES ESTABLISHING • • • • • • • • • • 20 EARLY CHILDHOOD | 15 MONTH VISIT block in cup, drinks from cup. walks well, stoops, recovers, can step backwards;ing; understands/follows puts simple commands, scribbles;a pulling/pointing/grunting, brings objects totates show, activities, hands may help in house; indicates wants by Surveillance of Development: Observation of Parent-Child Interaction: sional? How do siblings react to toddler? How does parent react to praise from health carein exam? profes- Does toddler check back with parent visually?parent support toddler’s need for safety andemotional reassurance tone between parent and child? How does • • • Guidance Anticipatory Key= communicates wants and inter Individuation, separation, attention to how child COMMUNICA book when wants a story; says 2-3 words with mean- Use simple, clear wor cognitive gains; speak reassuringly. “Stranger anxiety” and separation anxiety reflectoptions new acceptable to you. When possible, allow child to choose between 2 guage development and improve communication. Guidance for parent, TION AND SOCIAL DEVELOPMENT SOCIAL AND TION questions ds and phrases to pr ests, signs of shar Listens to a story, imi- omote lan- What is the ed attention length. Examine red reflexes. Perform cover/uncoverplot length, test. weight, head circumference. PlotPhysical weight-for- Exam. Complete, including: AAP: CDC: I Selective: Universal: 59.) p (See Screening Observe for stranger avoidance. Observe for caries, plaque, demineralization, staining. • • • Regular bedtime routine, night waking, no bottle in bed ISSUES AND ROUTINES SLEEP mmunizations mmunizations Do not give bottle in bed. animal or blanket for self-consolation. If night waking occurs, reassure briefly,tuck give in stuffed when dr Maintain consistent bedtime and nighttime r what she’s doing? point to something she wants and then watch to seeHow if you does see your child communicate what she wants? Does she www www.aapredbook.org Blood Pressure; Vision; Hearing .cdc.gov/vaccines None owsy , but still awake. Measure and outine; EARLY CHILDHOOD | 15 MONTH VISIT 21 er; make nec- make er; . F ° ont seat of vehicle with passenger air bag; back seat back bag; air passenger with vehicle of seat ont When did you last examine your home to make sure it is safe? is it sure make to home your examine last you did phones? When your near posted have you do numbers emergency What Make sure everyone uses a safety belt. safety a uses everyone sure Make cleaning supplies; use stair gates; install operable win- operable install gates; stair use supplies; cleaning windows). higher-story and second- on guards dow monthly/ test level, every on detector smoke set Install plan; escape fire make annually; batteries change <120 water hot It is best to use rear-facing car safety seat until highest until seat safety car rear-facing use to best is It manufactur by allowed height or to weight seat convertible a switching when in seat changes safety essary car rear-facing place never facing; forward fr safest. is poisons, up lock or (remove safety home Review Keep hot liquids, lighters, matches out of reach. of out matches lighters, liquids, hot Keep SAFETY poison, belts, safety of use parental seats, safety Car safety fire • • • • • . event tooth decay by good family oral health habits health oral family good by decay tooth event How are you and your partner managing your child’s behavior? child’s your managing partner your and you are How disagree? you when do you do What What kinds of things do you find yourself saying “No” about? “No” saying yourself find you do things of kinds What ness, allowing child to choose (when appropriate). appropriate). (when choose to child allowing ness, accomplishments. and behavior good Praise punishing. not teaching/protecting, for discipline Use Some conflict/tantrums can be avoided by “toddler- by avoided be can conflict/tantrums messi- Some accepting distractions, using home, proofing” (brushing, flossing), not sharing utensils or cup. cup. Pr or utensils sharing not flossing), (brushing, only water use bottle, nighttime If Schedule first dental visit if hasn’t seen dentist yet. dentist seen hasn’t if visit dental first Schedule plain and brush soft with day a twice teeth Brush water. HEALTHY TEETH HEALTHY usage bottle teeth, Brushing Conflict predictors, distraction, praise for accomplishments, accomplishments, for praise distraction, predictors, Conflict consistency TEMPER TANTRUMS AND TEMPER DISCIPLINE TANTRUMS • • • • • • • 22 EARLY CHILDHOOD | 18 MONTH VISIT scribbles, uses spoon/cup without spilling. favorite books; walks up steps/runs; stacks 2 orbody 3 blocks, part, follows simple instructions, knowsspeaks names of 6 words, points to indicate wants; pointsalone to 1 but with par friendly/aggressive; laughs in response to others, explores Physical Exam. Complete, including: Surveillance of Development: Observation of Parent-Child Interaction: weight-for plot recumbent length, weight, head circumference. Plot actions? How does parent guide child to safe limits?many directions? What is the tone of parent-childbook? inter- Does parent ask child many questions or giveparent and child communicate? Does child show parent Anticipatory Guidance Anticipatory Key= new sibling planned or on the way independence and occasional negativity, queries aboutPar a SUPPORT FAMILY ental well-being, adjustment to toddler’s growing Guidance for parent, -length. Observe gait, hand contr ent nearby; vocalizes and gestures, questions Is interactive/withdrawn, Measure and ol, arm/spine How do the marks, bruising; caries, plaque, demineralization,uncover staining, test. Observe for nevi, café au lait spots,movement. birth- Examine for red reflexes. Perform cover/ AAP: CDC: I Anemia, Lead, Tuberculosis Selective: Universal: 59.) p (See Screening injury. • • • mmunizations mmunizations together about a new baby Pr and appropriate behavior. Support emerging independence but r actions to ensur Create family times; spend time with each child; take treated badly? What did you do? been in a relationship where you have been hurt, threatened,What activities or do you do as a family? Tell me if you have ever epare toddler for new sibling by reading books www www.aapredbook.org Oral Health, Blood Pressure, Vision, Hearing, .cdc.gov/vaccines Development, Autism e own health. . einfor ce limits EARLY CHILDHOOD | 18 MONTH VISIT 23 er; om 6 om eading aloud at every visit fr visit every at aloud eading ont seat of vehicle with passenger air passenger with vehicle of seat ont Bright Futures recommends anticipatory anticipatory recommends Futures Bright Note: r on guidance months to 5 years and encourages giving a book book a giving encourages and years 5 to months visit information, more For visits. these at www.reachoutandread.org. second- and higher-story windows. higher-story and second- liquids/stove/matches/lighters). (hot burns Prevent detectors. smoke un- Install store necessary, gun if home; from guns Remove separately. locked ammunition with locked, and loaded It is best to use a rear-facing car safety seat until until seat safety car rear-facing a use to best is It manufactur by allowed height or weight highest convertible a switching when changes car necessary make rear-facing place never facing; forward to seat fr in seat safety safest. is seat back bag; belt. safety a uses everyone sure on Make guards window operable install gates, stair Use SAFETY and fires, falls, belts; safety of use parental seats; safety Car guns poisoning; burns; • • • • • es in book. in es praise attempts to attempts praise , ds to describe pictur describe to ds ait until child is ready (dry for periods of about 2 about of periods for (dry ready is child until ait How does your child communicate what she wants? she what communicate child your does How sit on the potty. the on sit W up/down, pants pull can dry, and wet knows hours, movement). bowel indicate can potty the using about books Read singing; talk about what you see. you what about talk singing; Encourage language development by reading and reading by development language Encourage Be consistent with discipline/enforcing limits, share with share limits, discipline/enforcing with consistent Be caregivers. other playtime. daily Enjoy Anticipate anxiety/clinging in new situations. new in anxiety/clinging Anticipate behavior/accomplishments. good Praise Use simple wor simple help Use to emotions and feelings describe that words Use feelings. about learn child TOILET TRAINING READINESS expectations parental readiness, of signs Recognizing Encouragement of language, use of simple words/phrases, words/phrases, simple of use language, of Encouragement reading/singing/talking in engagement LANGUAGE PROMOTION/HEARING Adaptation to nonparental care and anticipation of return to to return of anticipation and care nonparental to Adaptation gains cognitive new with connected changes other clinging, CHILD CHILD DEVELOPMENT AND BEHAVIOR • • • • • • • • • 24 EARLY CHILDHOOD | 2 YEAR VISIT ing height (pr stairs one step at a time, jumps up. preparation, throws ball overhand; goes up andwith down crayon, turns pages one at a time, imitates foodblocks, makes or imitates horizontal and circularsentences strokes and rhymes in familiar books; stacksto 5 or r 6 has at least 50 words, uses 2-word phrases, asksalongside parent other children, refers to self as “I” or “me,” Physical Exam. Complete, including: Surveillance of Development: Observation of Parent-Child Interaction: explore the room? How does the parent set limits?tion and the feelings conveyed? Does child feelent free and to child communicate? What is tone of the interac- • • Guidance Anticipatory Key= How child communicates, expectations for language DEVELOPMENT LANGUAGE OF ASSESSMENT over and over Read together every day; child may love same storyModel appr ead a book; follows 2-step commands, completes Guidance for parent, eferr opriate language. . ed) or r questions ecumbent length, weight, head Imitates adults, plays Measure stand- How do par- uncover test. Observe for caries, plaque, demineraliza-for-length. Examine for red reflexes. Performcircumference. cover/ Calculate and plot BMI, or plot weight- Assess language acquisition/clarity. scribbling, socialization, ability to followtion, commands. staining, injury, gingivitis. Observe running, AAP: CDC: Immunizations Dyslipidemia Anemia; Lead (low prevalence/no Medicaid); Tuberculosis;Selective: Universal: 59.) p (See Screening • • Should be able to follow simple 1 or 2 step commands.talk and question slowly. Recognize that child may struggle to r What do you think your child understands? www.cdc.gov/vaccines www Oral Health; Blood Pressure; Vision; Hearing; .aapr Autism; Lead (high prevalence/Medicaid) edbook.org espond quickly; EARLY CHILDHOOD | 2 YEAR VISIT 25 . ound cars, cars, ound ental use of safety belts, bike helmets, helmets, bike belts, safety of use ental everyone else uses a safety belt. safety a uses else everyone e ogramming per day. per ogramming Make sur Make helmet. bike Use Choose TV alternatives (reading, games, singing). games, (reading, alternatives TV Choose Install car safety seat in back seat. back in seat safety car Install ar especially outside, child Supervise streets. in un- machinery, store necessary, gun if home; from guns Remove separately. locked ammunition with locked, and loaded Limit TV and video to no more than 1-2 hours of of hours 1-2 than more no to video and TV Limit pr quality Encourage physical activity; be active as a family a as active be activity; physical Encourage If you allow TV, watch together and discuss. and together watch TV, allow you If TELEVISION TELEVISION VIEWING of promotion reading, of promotion viewing, on Limits play safe and activity physical SAFETY par seats, safety Car guns safety, outdoor • • • • • • • • • eaks (up to 10 times a day). a times 10 to (up eaks equent toilet br toilet equent How does your child act around other children? children? other around act child your does How Tell me about your child’s typical play. typical child’s your about me Tell Begin when child is ready (dry for periods of 2 hours, 2 of periods for (dry ready is child when indi- Begin can up/down, pants pull can dry, and wet knows movement). bowel cate frustration. self-expression. Encourage people/situations. to reacting of way child’s Learn Praise good behavior/accomplishments; listen to and and to listen behavior/accomplishments; good Praise child. your sadness, respect anger, joy, as feelings such express child Help Encourage child to play with other children. other with play to child Encourage Teach personal hygiene (wash hands, sneeze/cough hands, (wash hygiene personal Teach shoulder). into Plan for fr for Plan TOILET TRAINING hygiene personal techniques, tried, parents have What Sensitivity, approachability, adaptability, intensity adaptability, approachability, Sensitivity, TEMPERAMENT TEMPERAMENT AND BEHAVIOR • • • • • • • • 26 1 EARLY CHILDHOOD | 2 2 YEAR VISIT puts on clothes with help, copies vertical line.place, throws ball overhand, brushes teeth withtalks), help, points to 6 body parts; jumps up and downcorrect in action for animal or person (eg, bird flies,understandable man to others 50% of the time; knowsment/unexpected the events; uses phrases of 3-4 wordren; has fears about unexplained changes in environ- Surveillance of Development: Observation of Parent-Child Interaction: well does parent calm child? ent and child look at book, discuss, and interact?questions How and phrases at appropriate age level?do Do parent par- and child communicate? Does the child use • Guidance Anticipatory Key= family activities Par ROUTINES FAMILY taining consistent limits. to Reach agr your child? How well do you and your family agree on limits and discipline for ental consistency Guidance for parent, support child’s emerging independence while main- eement with all family members on how best , questions day and evening r Play includes other chil- outines, enjoyable How actively ds, is weight, head circumference. Calculate and plotplot BMI, standing or height (preferred) or recumbentPhysical length, Exam. Complete, including: AAP: CDC: Immunizations Selective: Universal: 59.) p (See Screening acquisition/clarity, socialization. Assesscover/uncover vocalizations. test. Observe coordination, languageplot weight-for-length. Examine red reflexes. Perform • • • • Interactive communication through song, play, and reading COMMUNICATIONAND PROMOTION LANGUAGE Maintain r monitor what child watches. Limit TV and video to no more than 1-2 hours a day; Read together every day; go to the library Encourage family exercise (walking, swimming, biking). rhymes, and games with you? Does he enjoy having stories read to him? Does he enjoy songs, Tell me how you have fun with your family. www.cdc.gov/vaccines www.aapredbook.org Oral Health; Blood Pressure; Vision; Hearing Development egular family r outines (meals, daily r Measure and . eading). 1 EARLY CHILDHOOD | 2 2 YEAR VISIT 27 een. bathtubs, pools, toilet. pools, bathtubs, , Stay within an arm’s reach (“touch supervision”) near supervision”) (“touch reach arm’s an within Stay water seat. back in seat safety car install machin- Properly cars, around especially outside, child Supervise sunscr use sun, limit helmet; bike and use ery; monthly test level, every on detectors smoke keep Install plan; escape fire make annually; batteries change sight. of out matches SAFETY safety and health outdoor seats, safety car safety, Water burns and fires pets, exposure), sun areas, play (pools, • • • • oups, or oups, outine, place on place outine, essing child in child essing ograms, playgr ograms, TIONS eading/singing. emove clothes, establish daily r daily establish clothes, emove What are your plans for child care or preschool in the year ahead? ahead? year the in preschool or care child for plans your are What Does your child enjoy making independent decisions? What are What decisions? independent making enjoy child your Does doing? is child your things new the of some Is your child speaking in sentences? sentences? in speaking child your Is potty every 1-2 hours, praise, maintain relaxed environ- relaxed maintain praise, hours, 1-2 every potty r by ment easy-to-r ized playdates or playgroups. playgroups. or playdates ized dr by success toilet-training Encourage Consider group child care, preschool program, organ- program, preschool care, child group Consider acceptable alternatives. alternatives. acceptable Encourage play with other children, but supervise supervise but children, other with play Encourage cooperatively. share/play to yet ready not child 2 because between choices offering by independence Build Listen when child speaks; repeat, using correct correct using repeat, speaks; child when Listen grammar. Readiness for early childhood pr childhood early for Readiness playdates PRESCHOOL CONSIDERA others, choices others, Play with other children, limited reciprocal play, imitation of PROMOTING of SOCIAL DEVELOPMENT imitation play, reciprocal limited children, other with Play • • • • • 28 EARLY CHILDHOOD | 3 YEAR VISIT bladder. with 2 body parts; day toilet trained for bowel andup stairs alternating feet; copies a circle, drawsbuilds person tower of 6-8 cubes, throws ball overhand,names walks a friend; knows name, identifies self as girl/boy;sentences, understandable to others 75% of theelaborate, time, enjoys interactive play; conversesfeeding, in 2-3 dressing); imaginative play becomes more Surveillance of Development: Observation of Parent-Child Interaction: Does unacceptable behavior elicit appropriatechoices? responses? Does parent encourage the child’sparent cooperation? and child communicate? Does parent give child • • A Key= Family decisions, sibling rivalry SUPPORT FAMILY limits/appropriate behavior. Show af style and that of your parents. Be awar nt Guidance for parent, icipatory Guidance icipatory e fection; handle anger constructively; reinforce of differences/similarities in your parenting questions; Guidance for child, , work balance Has self-care skills (eg, questions How do plot BMI. Attempt ophthalmoscopic exam of opticpressure. nerve Measure and plot height, weight. CalculatePhysical and Exam. Complete, including: AAP: CDC: I Tuberculosis Selective: Universal: 59.) p (See Screening speech clarity; adult-child interaction. ization, staining, injury, gingivitis; languageand retinal acquisition, vessels. Observe for caries, plaque, demineral- • • mm partner T spend time with each child. Help children develop good relations with each other; What do you like to do best with your brothers and sisters?How do your children get along together? your family does together. Tell me how family members show affection, anger? Describe what ake time for yourself; spend time alone with your unizat www.cdc.gov/vaccines www.aapredbook.org . Oral Health; Hearing; Anemia; Lead; Visual Acuity ions Measure blood EARLY CHILDHOOD | 3 YEAR VISIT 29 child plays. child e Remove guns from home; if gun necessary, store un- store necessary, gun if home; from guns Remove separately; locked ammunition with locked, and loaded wher home in guns if ask Use forward-facing car safety seat, properly installed in installed properly seat, safety car forward-facing Use seat. back child when seat booster belt-positioning to Switch manufacturer by allowed weight/height highest reaches harness. with seat allow forward-facing not of do streets/driveways; near play all Supervise alone. street cross to child operable install windows; from away furniture Move windows. higher-story and second- on guards window SAFETY guns windows, from falls safety, pedestrian seats, safety Car • • • • • or e . TV/DVD player in bedroom; monitor programs monitor bedroom; in player TV/DVD omote daily physical activity at home, in child car child in home, at activity physical daily omote Tell me about your child’s typical play. play. typical child’s your about me Tell How does your child tell you what he wants? How well does the does well How wants? he what you tell child your does How speech? his understand family in preschool. day; in a hours 1-2 than more no to time screen all Limit no watched. Create opportunities for family to share time and exer- and time share to family for opportunities Create together. cise Pr Encourage play with appropriate toys and safe explo- safe and toys appropriate with play Encourage play fantasy ration; Encourage child to talk about friends, experiences. experiences. friends, about talk to child Encourage Read, sing, play rhyme games together. games rhyme play to sing, have Read, always (don’t books in pictures about Talk story. “tell” child let read); Encourage interactive games with peers; taking turns. taking peers; with games interactive Encourage PROMOTING PHYSICAL ACTIVITY inactivity on Limits Interactive games, play opportunities play games, Interactive PLAYING WITH PEERS PLAYING Singing, talking, describing, observing, reading observing, describing, talking, Singing, ENCOURAGING ENCOURAGING LITERACY ACTIVITIES • • • • • • • • 30 EARLY CHILDHOOD | 4 YEAR VISIT teeth, dresses self. builds tower of 8 blocks, copies a cross; brusheshops own on one foot, balances on one foot for 2 seconds,plays board/card games, draws a person with 3 parts;most speech clearly understandable; names 4 colors,first/last name, knows what to do if cold/tired/hungry,self; listens to stories, engages in fantasy play; gives Surveillance of Development: Observation of Parent-Child Interaction: parent let child choose? parent, child, siblings interact? If offeredduring books, exam? does Does child dress and undress self?to How answer do questions? Does child separate from parentparent and child communicate? Does parent allow child • A Key= with other childr Structured learning experiences, opportunities to socialize READINESS SCHOOL others. praise when demonstrates sensitivity to feelingsmodel of r Childr nticipatory Guidance nticipatory Guidance for parent, en ar espectful behavior and apologize if wrong; e very sensitive, easily encouraged or hurt; en, fears, friends, fluency questions; Guidance for child, Describes features of questions How do plot BMI. Observe fine/gross motor skills. Assesspressure. language Measure and plot height, weight. CalculatePhysical and Exam. Complete, including: AAP: CDC: I Selective: Universal: 59.) p (See Screening abstraction. acquisition, speech fluency/clarity, thought content/ • • • mmunizations mmunizations ready for school. Reading is important to help child like reading and be community program); visit parks, museums, libraries.Consider structur Provide opportunities to play with other children. seem happy to go? How happy are you with your child care arrangements? Does she Do you have a favorite friend? she socially and emotionally? How interested is your child in other children? How confident is www www.aapredbook.org Anemia; Lead; Tuberculosis; Dyslipidemia .cdc.gov/vaccines Visual Acuity; Hearing ed lear ning (pr eschool, Head Start, or Measure blood EARLY CHILDHOOD | 4 YEAR VISIT 31 d-facing seat with seat d-facing child plays. child e Are you scared that your partner or partner your that scared you Are . er of forwar of er om home; if gun necessary, store un- store necessary, gun if home; om in homes wher homes in e Where do you sit when you ride in the car? Do you have a special a have you Do car? the in ride you when sit you do Where seat? Many children I see have parents who have been hurt by someone by hurt been have who parents have see I children Many routinely it about ask I so else, child? your or you hurt to try may else someone Use a forward-facing car safety seat installed in back in installed seat safety car forward-facing a al- Use height or weight highest reaches child until seat manufactur by seat. lowed booster belt-positioning to switch Then harness. alone child leave never play, outdoor all Supervise alone. street cross to child allow not do outside; fr guns Remove separately. locked ammunition with locked, and loaded ar guns if Ask keep secrets from parents, (2) no adult should express should adult no (2) parents, from secrets child a keep ask should adult no (3) parts, private in interest parts. private his/her with help a for is safety personal if available is help that Know concern. SAFETY safety, outdoor supervision, seats, booster Belt-positioning guns • • • • AMILY INVOLVEMENT AND SAFETY IN INVOLVEMENT THE COMMUNITY AMILY elating to peers and adults, domestic violence domestic adults, and peers to elating . family each your child rules for how to be safe with adults, with safe be to how for rules child your each ograms, r ograms, How does your child communicate what she wants and knows? knows? and wants she what communicate child your does How Expect curiosity about the body; use correct terms, terms, correct use body; the about curiosity Expect questions. answer to T child a tell should adult no (1) principles: 3 using Maintain or expand participation in community community in participation expand or Maintain activities. Make opportunities for daily play; be physically active as active physically be play; daily for opportunities Make a Limit TV and video to 1-2 hours a day; no TV in bed- in TV no day; a hours 1-2 to video and TV Limit discuss. and together programs watch room; Create calm bedtime ritual, mealtimes without TV, without mealtimes ritual, bedtime calm Create toothpaste. pea-sized with day a twice toothbrushing Give child time to finish sentences; encourage speaking encourage sentences; finish to time child Give together. reading/talking by skills Activities outside the home, community projects, educational educational projects, community home, the outside Activities pr CHILD AND F Limits on viewing, promotion of physical activity and safe safe and activity physical of promotion viewing, on Limits play TELEVISION/MEDIA DEVELOPING HEALTHY PERSONAL HABITS DEVELOPING HEALTHY health promote that routines Daily • • • • • • • 32 MIDDLE CHILDHOOD | 5 AND 6 YEAR VISITS tion, malocclusion; fine/gross motor skills, gait. Assess colors, follows simple directions, listens andarticulation/language attends. skills, counts to 10, namesnumbers, 4+ is able to copy squares and triangles,with has good at least 6 body parts, prints some letters andness skills: has mature pencil grasp, can draw ahops, person and skips; able to tie a knot. Shows school readi- Physical Exam. Complete, including: Surveillance of Development: Observation of Parent-Child Interaction: and r plot BMI. Attempt ophthalmoscopic exam of opticpressure. nerve Measure and plot height, weight. Calculate and expectations about child? do parent and child interact? Does parent haveent realistic and child interact with health care professional? How Anticipatory Guidance Anticipatory Key= management of disappointments, fears parent-teacher communication, friends, bullying, maturity,Established routines, after-school care and activities, READINESS SCHOOL Guidance for parent, etinal vessels. Observe for caries, gingival inflamma questions; Guidance for child, Balances on one foot, Measure blood questions How do par- - content, ability to understand abstract thinking.language acquisition, speech fluency/clarity, thought Screening (See p 60.) p (See Screening AAP: CDC: I Dyslipidemia Selective: Universal: 6 Selective: Universal: 5 • • • • mm Be sure after-school care is safe, positive. school events. Pr Talk to parents about school, worries. Talk to child about school experiences. Year Visit Year Visit or tease you? Tell me about your new school. Do kids ever call you mean names school? What concerns do you have about your child’ epar unizat www.cdc.gov/vaccines www.aapredbook.org e child for school; tour school; attend back-to- Oral Health; Anemia; Lead; Tuberculosis; Anemia; Lead; Tuberculosis Vision; Hearing Vision; Hearing ions s ability to do well in MIDDLE CHILDHOOD | 5 AND 6 YEAR VISITS 33 . est in private parts, (3) no (3) parts, private in est ess inter ess een. Have you talked to your child about ways to avoid sexual abuse? abuse? sexual avoid to ways about child your to talked you Have could Who scared? you made grown-up a if do you would What you? help would Who tell? you Teach safe street habits (crossing/riding school bus). school (crossing/riding habits street safe Teach Give fluoride supplement if dentist recommends. dentist if supplement fluoride Give once. floss day; a twice teeth Brush adult should ask a child for help with his/her private his/her with help for child a ask should adult “privates.” explain parts; Teach child to swim; supervise around water; use sun- use water; around supervise swim; to child Teach adult no scr (1) adults: with safe be to how for rules no (2) Teach parents, from secrets keep to child a tell should expr should adult detector/ monoxide detectors/carbon smoke Install plan. escape fire make un- alarms; store necessary, gun if home; from guns Remove separately locked ammunition with locked and loaded Use properly positioned belt-positioning booster seat in seat booster belt-positioning positioned properly Use seat. back Ensure child uses safety equipment (helmet, pads). (helmet, equipment safety uses child Ensure SAFETY swimming helmets, safety seat, booster safety, plan Pedestrian escape/drill fire prevention, abuse sexual child safety, detectors/alarms, monoxide carbon detectors, smoke and guns • • • • • • • • • . TH isit dentist twice a year a twice dentist isit What makes you sad, angry? How do you handle it? handle you do How angry? sad, you makes What Help child with brushing if needed. if brushing with child Help Use discipline for teaching, not punishing. not teaching, for play- discipline and Use outside going talking, by conflict/anger Solve away. walking ing, Show affection/respect; model anger management/self- anger model affection/respect; Show discipline. Continue family routines; assign household chores. household assign routines; family Continue Be physically active 60 minutes a day. a minutes 60 active physically Be bedroom. in TV no day; a hours 2 to TV Limit Eat breakfast; eat 5+ servings of fruits/vegetables a day. a fruits/vegetables of servings 5+ eat breakfast; Eat snacks. candy/soda/high-fat Limit V Have at least 2 cups low-fat milk/other dairy a day. adequate fluoride adequate ORAL HEAL flossing, and brushing daily dentist, with visits Regular NUTRITION AND PHYSICAL ACTIVITY increased diet; well-balanced appropriate weight; Healthy calcium adequate consumption; whole-grain vegetable, fruit, day a exercise of minutes 60 intake; Family time, routines, temper problems, social interactions social problems, temper routines, time, Family MENTAL HEALTH MENTAL • • • • • • • • • • • 34 MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS Physical Exam. Complete, including: • • Surveillance of Development: Observation of Parent-Child Interaction: for SMR. caries, gingival inflammation, and malocclusion.plot BMI. Assess Observe hip/knee/ankle function. Observepressure. for Measure and plot height, weight. Calculate and other than parents? tions about child? How does child interact withent adults and child interact? Does parent have realistic expecta- Key= peers Caring, supportive relationship with family,competencies other adults, Physical, cognitive, emotional, social, moral Guidance for parent, questions; Guidance for child, Measur questions How do par- e blood Universal: 7 60.) p (See Screening AAP: CDC: Immunizations Selective: Universal: 8 Selective: Year Visit Year Visit www www.aapredbook.org Anemia; Tuberculosis; Dyslipidemia Vision; Hearing; Anemia; Tuberculosis .cdc.gov/vaccines Vision; Hearing None MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS 35 oom. What do you think of your child’s weight and growth over the past the over growth and weight child’s your of think you do What year? play? to outside go you do often How computers? or TV with day each spend you do time much How What have you told your child about how to care for his changing his for care to how about child your told you have What body? about you with talked anyone Has is? puberty what know you Do puberty? during change will body your how Eat 5+ servings of fruits/vegetables a day; eat breakfast. eat day; a fruits/vegetables of servings 5+ Eat family. a as meals Eat day. a minutes 60 active physically Be in TV/computer no day; a hours 2 to time screen Limit bedr Be aware of pubertal changes; answer questions questions answer changes; pubertal of aware Be simply. Encourage nutritious food choices. food nutritious Encourage Limit candy/soda/high-fat snacks. candy/soda/high-fat Limit day. a dairy milk/other low-fat cups 2 least at Get NUTRITION AND PHYSICAL ACTIVITY calcium, adequate intake, food appropriate weight, Healthy organized in activity physical adequate soda, of instead screen on water limits activities, programs/fun sports/after-school time • • • • • • • • esolving TH AL HEAL oblems, managing and r and managing oblems, -school programs, bullying, parental parental bullying, programs, -school ole model; do not hit or let others hit. others let or hit not do model; ole concerns, ask teacher about evaluation for special for evaluation about teacher ask concerns, mad? What types of discipline do you use most often? most use you do discipline of types What you make that things and worries your about to talk you do Who What new things have you tried recently? tried you have things new What How do you like school? Are you picked on by others? others? by on picked you Are school? like you do How How is your child doing in school? How do you help your child your help you do How school? in doing child your is How conflicts? solve Discuss rules, consequences. consequences. rules, Discuss worries. about Talk Encourage competence/independence. competence/independence. Encourage child. praise affection, Show r positive Be If bullying. with help help/tutoring; Show interest in school and activities. activities. and school in interest Show DEVELOPMENT AND MENT and rules establishing self-esteem, Independence, pr temper consequences, development puberty/pubertal conflicts, involvement, IEP or special education services education special or IEP involvement, SCHOOL learning or (behavior problems school school, to school Adaptation in involvement performance/progress, school issues), after and activities • • • • • • • Anticipatory Guidance 36 MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS • • • • • Key= (games, Internet, e-mail) home/vehicles, guns, careful monitoring of computer usesafety, sports safety, swimming safety, sunscreen,friends, smoke-free safety belts/booster seats, helmets, playgroundKnowing child’s friends and their families, supervision with SAFETY adequate fluoride Regular visits with dentist, daily brushing and flossing, HEALTHORAL Wear mouth guard during sports. Brush teeth twice a day; floss once. Give fluoride supplement if dentist recommends. with his/her private parts. private parts, (3) no adult should ask a child for help fr Know child’ adults: (1) no adult should tell a child to keep secremergencies; teach rules for how to be safe with Take child to dentist twice a year. not there? What would you do if you felt unsafe at aDo friend’ you know what to do if you get home and Mom or Dad are uncomfortable? house? Has anyone touched you in a way that made you feel om par Guidance for parent, ents, (2) no adult should expr s friends; teach home safety rules for fir questions; Guidance for child, ess inter questions est in ets s e/ • • • • • • Keep home/vehicle smoke-free. Ensure child uses safety equipment (helmet, pads). Monitor computer use; install safety filter.loaded and locked with ammunition locked separately.Remove guns from home; if gun necessary, store un- sunscreen. Teach child to swim; supervise around water; use lab/shoulder belt fits. Use belt-positioning booster seat in back seat until the What would you do if you came to a site that scared you? have rules for the Internet? How much do you know about your child’s Internet use? Do you

38 MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS Physical Exam. Complete, including: • • • • • Surveillance of Development: Observation of Parent-Child Interaction: plot BMI. Observe tattoos/pier pressure. Measure and plot height, weight. Calculate and allow child to talk with health care professional directly? Key= making Increasingly responsible and independent decisionSense of self-confidence and hopefulness and peers Caring, supportive relationship with family,healthy other lifestyle adults, Behaviors that promote wellness and contributetencies to a Physical, cognitive, emotional, social, and moral compe- Guidance for parent, questions; Guidance for child, cings/signs of abuse, Measure blood questions Does parent Screening (See p 60.) p (See Screening AAP: CDC: Immunizations Selective: Universal: 10 Year Visit Selective: Universal: 9 back. Assess SMR. self-inflicted injuries. Note nevi or birthmarks. Examine Year Visit www.cdc.gov/vaccines www.aapredbook.org Anemia; Tuberculosis; Dyslipidemia Vision; Hearing; Anemia; Tuberculosis Vision; Hearing None MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS 39 . weight and growth over the past the over growth and weight day? How do you feel about how about feel you do How day? s y een time to 2 hours a day a hours 2 to time een physical activity physical , you look? How often have you cut back on how much you eat or eat you much how on back cut you have often How look? you weight? lose to dieted What do you think of your child’ your of think you do What or 5 year? eat to able you Are today? breakfast for eat you did What ever vegetables and fruits more play? and outside go you do often How How well do you and your partner agree on how to talk with your with talk to how on agree partner your and you you do well would How How sexuality? and development sexual about child homosexuality? about you asked child your if respond is body your way the about have you do questions What developing? Encourage nutritious food choices. choices. food nutritious Encourage non- limit day; a minutes 60 active physically Be scr academic Answer questions about puberty/sexuality; counsel to counsel puberty/sexuality; about questions safe Answer be to how for rules teach activity; sexual se- avoid keep to child a tell should adult no (1) adults: interest with express should adult no (2) parents, from help for crets child a ask should adult no (3) parts, private in parts. private his/her with Weight concerns, body image, importance of breakfast, limits limits breakfast, of importance image, body concerns, a as Weight eating juice, or soda than rather water foods, high-fat on family NUTRITION AND PHYSICAL ACTIVITY • • • easonable espect, anger anger espect, AL HEALTH AL HEALTH oblems and setting r setting and oblems ole model; discuss r discuss model; ole friends; supervise activities with peers. peers. with activities supervise friends; s ns, ask teacher about extra help. help. extra about teacher ask ns, owth spurt, menstruation and ejaculation, loss of “baby “baby of loss ejaculation, and menstruation spurt, owth omote independence, self-responsibility; assign self-responsibility; independence, omote What do you and your friends like to do together? What do you do What together? do to like friends your and do? you to do want What don’t you things do to you pressure friends when do What are some things you are good at? at? good are you things some are What management. child’ Know Anticipate new adolescent behaviors, importance of importance behaviors, adolescent new Anticipate peers. chores; provide personal space at home. at space personal provide chores; r positive a Be Pr concer Show interest in school performance and activities; if activities; and performance school in interest Show Get help from teacher/trusted adult if bullied. bullied. if adult teacher/trusted from help Get Create quiet space for homework. for space quiet Create school, sexuality (pubertal onset, personal hygiene, initiation initiation hygiene, personal onset, (pubertal sexuality school, gr of safety) sexual muscle, of accretion and fat” DEVELOPMENT DEVELOPMENT AND MENT communication family self-esteem, and security Emotional pr temper time, family and middle for readiness performance, school friends, limits, SCHOOL bullying homework, performance, School • • • • • • • Anticipatory Guidance 40 MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS • • • • Wear mouth guard during sports. • Brush teeth twice a day; floss once. • Give fluoride supplement if dentist recommends.• Visit dentist twice a year. • • Key= families, supervision of child with friends, guns tobacco/alcohol/drugs, knowing child’s friends andSafety their belts, helmets, bicycle safety, swimming, sunscreen, SAFETY adequate fluoride Regular visits with dentist, daily brushing and flossing, HEALTHORAL Know child’ T Use safety equipment (helmets, pads). belt fits. booster seat to safety belt in rear seat, when theThe safety back seat is the safest place to ride. Switch from Counsel about avoiding tobacco, alcohol, drugs.sunscr one touched you in a way that made you feel uncomfortable? What would you do if you felt unsafe at a friend’ child exposed to substance abuse? Is smoking, alcohol, or drug use a concern in your family? Is your each child to swim, supervise ar Guidance for parent, een. s friends; make plan for personal safety questions; Guidance for child, ound water; use questions s house? Has any- . • loaded and locked with ammunition separate. Remove guns from home; if gun necessary, store un- What have your parents taught you about guns and gun safety?danger to the family? guns. Have you considered not owning a gun becauseHomicide it poses and a completed suicide are more common in homes with

42 EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS pressure. Measure and plot height, weight. Calculate and managing his own health? answers most questions? Does youth express interestfortably in do youth and parent interact? Who asks and Physical Exam. Complete, including: • • • • • • Surveillance of Development: Observation of Parent-Youth Interaction: adolescent development, par disclosur helps adolescents build a unique relationship with their health care professional, promotes confidence and full interview with the par Note: Key= Behaviors that contribute to a healthy lifestyle making Increasingly responsible and independent decisionwhen confronted with life stressors Self-confidence, hopefulness, well-being, andPositive resiliency engagement with community and peers Caring, supportive relationship with family, other adults, competencies Physical, cognitive, emotional, social, and moral Guidance for parent, Beginning with the Early Adolescence V e of health information, and enhances self-management. When explained within the context of healthy questions; ent in the examination r Guidance for youth, ents usually support this appr Measure blood questions How com- oom, and then spend time with the adolescent alone. This appr isits, many health care professionals conduct the first part of the medical oach. injury. Examine back. nevi, tattoos/piercings, signs of abuse or self-inflictedplot BMI. Inspect for acne, acanthosis nigricans, atypical AAP: CDC: Immunizations STIs; Pregnancy; Cervical Dysplasia; Alcoholformed); or Drug Use Hearing; Anemia; Tuberculosis; Dyslipidemia;Selective: Universal: 61.) p (See Screening testicles for hydrocele, hernias, varicocele,gynecomastia. masses. Assess SMR, signs of STIs. ExaminePerform pelvic exam if warranted. www.cdc.gov/vaccines www Vision (when universal screening not per- .aapr Vision (once in early adolescence) edbook.org Females: Assess SMR; signs of STIs. Males: Observe for oach EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS 43 friends, and a and friends, essed, nervous, essed, , ess. feeling sad, depr sad, feeling e ough problems. ough Do you have concerns about your child’s emotional health? emotional child’s your about concerns have you Do Do time? the of most irritable or sad, bored, feeling that been or you alive Have not were you wished you that upset so feel ever you die? to wanted you Help youth follow their interests to new activities, activities, new to interests their follow youth Help issues/needs. community of awareness that those increase including activities, new and interests Explore others. help organization/ with help school; in efforts positive Praise reading. encourage setting; parent/trusted to priority talk schoolwork; for responsibility Take school. at problems about adult to think thr think to behavior, child’s your about concerns your me Tell use. substance or health, mental moods, but disappointments and times difficult has Everyone parents/trusted with Talk temporary. they’re usually ar you you if for hard adult/me it makes it if especially angry, or hopeless, family school, with track on keep to life. toward attitude positive generally Involve youth in family decision making; encourage her encourage making; decision family in youth Involve Find ways to deal with str with deal to ways Find EMOTIONAL EMOTIONAL WELL-BEING sexuality health, mental and regulation mood Coping, • • • • • • • • - esponsi - Stay connected with family; follow family rules and and friends. rules family follow family; with connected Stay curfews. bilities; spend time with your youth, get to know to get youth, your with time spend bilities; academic screen time to 2 hours a day. day. a hours 2 to time screen academic Clearly communicate rules/expectations/family r rules/expectations/family communicate Clearly Be physically active 60 minutes a day; limit non limit day; a minutes 60 active physically Be activities/achievements, not appearance. not activities/achievements, low-fat grains, whole fruits/vegetables, Encourage candy/chips/soda. limit dairy; day; a dairy milk/other fat low servings 3+ Have family. your with eat Visit dentist twice a year; give fluoride supplement if supplement fluoride give year; a twice dentist Visit recommends. dentist praising by self-image healthy Support Brush teeth twice a day, floss once. once. floss day, a twice teeth Brush Connectedness with family, peers, and community; community; and peers, family, with Connectedness performance school relationships; interpersonal SOCIAL AND ACADEMIC COMPETENCE PHYSICAL PHYSICAL GROWTH AND DEVELOPMENT physical eating, healthy image, body health, oral and Physical activity • • • • • • • • Anticipatory Guidance 44 EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS • • • • • • • Key= Tobacco, alcohol, or other drugs; pregnancy; STIs REDUCTION RISK medicines in a place where youth cannot get them. member’s, use. with me if concerned about your own, or a family drugs/alcohol; support friends who don’t use;Don’t talk smoke, drink, use drugs; avoid situations with him for not using; be a r Talk with youth about tobacco/alcohol/drugs;expectations. praise Know youth’s friends and activities; clearly discuss rules, adult/me. sexual feelings, and sexuality; talk to parents/trustedGet accurate information about physical development,ships, and sex. Discuss your expectations/values about dating,during relation- puberty, including menstruation foryour girls. youth about the physical changes that occurYouth go through puberty at different times; talk to Consider locking liquor cabinet, putting pr of using alcohol/tobacco/drugs? activities? What have you and your child discussed about the risk with your parents about dating and sex? Do you regularly super (how often, how heavy?) For females: Guidance for parent, Have you had your first period? If so, tell me more questions; vise your child’ For females and males: ole model. Guidance for youth, s social and recreational questions Have you talked escription • • • • • • • vehicle, guns, interpersonal violence (fights), bullyingSafety belt and helmet use, substance abuse and riding in a INJUR AND VIOLENCE W Wear safety belt; don’t allow ATV riding. alcohol/drugs; call parents/trusted adult forDon’t help. ride in car with driver who has used she feels unsafe riding in a car. Help youth make plan for handling situation in which protect against STIs/pregnancy. Plan how to avoid risky situations; if sexuallyhave active, sex, including oral sex. The safest way to prevent pregnancy and STIs is to not abstinence; provide opportunities for safe activities.Talk about relationships, sex, values; encourage sexual riding with someone? Do you have someone you can call for a ride if you feel unsafe older, or your age? Did you use a condom or otherhad contraceptive? both male and female partners? Were your partnerswanted younger, to do? Were your partners male or female, orbeen have forced you or pressured to do something sexual thatHave you you haven’t had sex? Was it wanted or unwanted? Have you ever sex? How do you plan to help your child deal with pressures to have get high? drugs/steroids? Do you ever sniff, “huff,” or breatheHave you anything ever experimented to with smoking/tobacco/alcohol/ ear safety belt, helmet, protective gear, life jacket. Y PREVENTION • Remove guns from home; if gun necessary, store un- E loaded and locked with ammunition locked separately. A R

Homicide and completed suicide are more common in homes with L guns. Have you considered not owning a gun because it poses a Y danger to the family? A D

Do you ever carry a gun or knife? O L

• Healthy dating relationships are built on respect and E S

concern; saying NO is okay. C

Have you ever been touched in a way that made you feel uncom- E fortable or was unwelcome? Have you ever been touched on your N C

private parts against your wishes? Has anyone ever forced you to E

have sex? | 1

• Teach nonviolent conflict-resolution techniques. 1

• Manage conflict nonviolently; talk to parent/trusted T O adult if bullied, stalked. 1 4 Y E A R V I S I T S

45 46 MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS pressure. Measure and plot height, weight. Calculate and managing his own health? answers most questions? Does youth express interestcomfortably in do youth and parent interact? Who asks and Physical Exam. Complete, including: • • • • • • Surveillance of Development: Observation of Parent-Youth Interaction: Key= Positive engagement with community making Increasingly responsible and independent decisionwhen confronted with life stressors Self-confidence, hopefulness, well-being, and resiliency and peers Caring, supportive relationship with family,Behaviors other adults, that contribute to a healthy lifestylecompetencies Physical, cognitive, emotional, social, and moral Guidance for youth, questions; Guidance for parent, Measure blood questions How injury. Examine back. nevi, tattoos, piercings, signs of abuse or self-inflictedplot BMI. Inspect for acne, acanthosis nigricans, atypical AAP: CDC: Immunizations STIs; Pregnancy; Cervical Dysplasia; Alcoholformed); or Drug Use Hearing; Anemia; Tuberculosis; Dyslipidemia;Selective: Universal: 61.) p (See Screening hydrocele, hernias, varicocele, masses. gynecomastia; SMR; signs of STIs. Examine testiclesPerform for pelvic exam if warranted. www.cdc.gov/vaccines www Vision (when universal screening not per- .aapr Vision (once in middle adolescence) edbook.org Females: Assess SMR, signs of STIs. Males: Observe for MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS 47 EMO ents/trusted ess; talk with par with talk ess; times come and go; talk with with talk go; and come times oblems and practice independent practice and oblems d egulation and mental health, sexuality health, mental and egulation ough pr ough Have you been feeling bored, sad, or irritable most of the time? time? the of most irritable or sad, bored, feeling or been you alive Have not were you wished you that upset so feel ever you Do die? to wanted you that health? emotional youth’s your about concerns have you Do Find ways to deal with str with deal to ways Find her adult. encourage making; decision family in youth Involve thr think to making. decision har that Recognize mental other or anxiety depression, of signs habits, Recognize food/sleep in changes (irritability, issues health abuse). substance rules, to adhering not Explore interests, new activities, including those that those including activities, new interests, Explore others. agree help affection; show youth; with/praise to time Spend interests follow youth help consequences; limits, on community of awareness increase activities, new parent/trusted to issues/needs. talk schoolwork; for responsibility Take school. at problems about with adult help efforts, positive praise school, Emphasize reading. encourage setting, organization/priority parents/trusted adult. adult. parents/trusted Coping, mood r mood Coping, EMOTIONAL EMOTIONAL WELL-BEING • • • • • • • • . peers, and community; community; and peers, , een time to 2 hours a day. a hours 2 to time een Stay connected with family, help at home; get involved get home; at help family, with connected (cars, Stay rules family follow friends; community, with curfews). dairy; eat with your family your with eat dairy; choices/physical activity. choices/physical youth’s praising by self-image healthy Support appearance. not healthy on activities/achievements, focus breakfast; especially day, a meals 3 Eat milk/other low-fat servings daily 3+ have choices; food Maintain healthy weight by balancing food balancing by weight healthy Maintain Encourage physical activity. physical Encourage Encourage healthy eating. healthy Encourage non- limit day; a minutes 60 active physically Be scr academic Brush teeth twice a day; floss once. floss day; a twice teeth Brush Protect your hearing. your Protect Visit dentist twice a year. year. a twice dentist Visit interpersonal relationships; school performance school relationships; interpersonal SOCIAL AND ACADEMIC COMPETENCE family with Connectedness PHYSICAL PHYSICAL GROWTH AND DEVELOPMENT physical eating, healthy image, body health, oral and Physical activity • • • • • • • Anticipatory Guidance • • • 48 MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS • • • • Key= Tobacco, alcohol, or other drugs; pregnancy; STIs REDUCTION RISK medicines in a place where youth can’t find them.consider locking liquor cabinet, putting prescriptionexpectations; praise him for not using; be a roleyouth’s model; friends and activities; clearly discussT rules/ me if you’r drugs/alcohol; support friends who don’t use;Don’t talk with smoke, drink, use drugs; avoid situations with Communicate frequently and share expectations clearly. adult/me. development, sexual feelings; talk to parents/trustedGet accurate information about sexuality, physical or female), or sexual orientation? Have you had sex?cal development, sexuality, gender identityships, (your and identity about sex? as a male Do you have any questions relatedyour parents to physi- about crushes you’ve had, about dating and relation- of using alcohol/tobacco/drugs? activities? What have you and your youth discussedDo you about regularly the risk super get high? drugs/steroids? Do you ever sniff, “huff,” or breatheHave you anything ever experimented to with smoking/tobacco/alcohol/ painful, most recent). For females: alk with youth about tobacco/alcohol/drugs; know Guidance for youth, Tell me about your periods (how often, how heavy, e concer questions; For females and males: vise your youth’s social and recreational ned about family member’ Guidance for parent, Have you talked with questions s use. • • • • • • violence), bullying substance abuse, guns, interpersonal violence (dating Safety belt and helmet use, driving (graduated license) and INJURYPREVENTION AND VIOLENCE Wear safety belt, helmet, protective gear, life jacket. Limit night driving, driving with teen passengers. driving, distracted driving, high-risk situations.limits/expectations about number of passengers,Wear night safety belt; be involved in youth’s driving, set r as she accepts responsibility for her decisionstalk and about your values; have discussions with youthfor resisting pressure; support safe activitiesEncourage at school; sexual abstinence; help youth make a plan If sexually active, protect against STIs/pregnancy.how to avoid sex, risky situations. the safest way to prevent pregnancy and STIs; planAbstaining from sexual intercourse, including oral sex, is values about relationships and sex ? Have you shared with your youth your hopes, expectations, and female partners? Did you use a condom or other contraceptive?your partners male or female or have you had both maleto do? and How many partners have you had in the past year?pressured Were or forced to do something sexual that youHave didn’t you had want sex? Was it wanted or unwanted? Have you ever felt elationships. MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS 49 elationships are built on respect and respect on built are elationships Do you ever carry a gun? Is there a gun at home? at gun a there Is gun? a carry ever you Do Do you have someone you can call for a ride if you feel unsafe unsafe feel you if ride a for call can you someone have you Do someone? with riding Teach nonviolent conflict-resolution techniques. conflict-resolution nonviolent Teach Manage conflict nonviolently; avoid risky situations; risky avoid nonviolently; conflict Manage r dating healthy okay. is NO saying do; to like both you things doing Remove guns from home; if gun necessary, store un- store necessary, gun if home; from guns Remove separately; locked ammunition with locked and loaded youth. to inaccessible key keep and drive. drive. and dangerous. be can weapons carrying Fighting, Don’t ride in car with driver who has used alcohol/ used has who driver with car in ride drink Don’t don’t help; for adult parents/trusted call drugs; • • • • • 50 LATE ADOLESCENCE | 18 TO 21 YEAR VISITS Physical Exam. Complete, including: Complete, Exam. Physical • • • • • • Surveillance of Development: manage own health? interact? Is young adult appropriately encouragedHow comfortably to do young adult and parent, if present,Observation of Parent-Young Adult Interaction: pressure. Measure and plot height, weight. Calculate and Calculate weight. height, plot and Measurepressure. Key= making Increasingly responsible and independent decisionwhen confronted with life stressors Self-confidence, hopefulness, well-being, andPositive resiliency engagement with community and peers Caring, supportive relationship with family,Behaviors other adults, that contribute to a healthy lifestylecompetencies Physical, cognitive, emotional, social, and moral Guidance for young adult, questions Measure blood Measure (once in late adolescence) AAP: CDC: Immunizations STIs; Pregnancy; Cervical Dysplasia; AlcoholDyslipidemia or Drug Use (when universal screening not performed);not performed); Hearing; Anemia; Tuberculosis;Selective screening: Universal: 61.) p (See Screening masses. varicocele, hernias, hydrocele, for testicles Examine STIs. of signs SMR; warranted. if exam pelvic Perform STIs. injury. self-inflicted or abuse of signs piercings, tattoos, nevi, atypical nigricans, acanthosis acne, for Inspect BMI. plot www.cdc.gov/vaccines www.aapredbook.org Females: Vision (once in late adolescence); Dyslipidemia CBE routine after age 20. Assess signs of signs Assess 20. age after routine CBE Vision (when universal screening Males: Assess LATE ADOLESCENCE | 18 TO 21 YEAR VISITS 51 - ell me about your periods (how often, how often, (how periods your about me ell T ents/trusted adult/me. adult/me. ents/trusted For females: For use. painful?). , t ell me about any experiences you’ve had with alcohol, marijuana, alcohol, with had you’ve experiences any about me ell Do you have any questions related to physical development, sexual development, physical to related ori- sexual questions or any have female), you or Do male a as identity (your identity gender ity, entation? heavy T drugs. other or Have you been feeling bored, sad, or irritable most of the time? Do time? the of most irritable or sad, bored, feeling that been or you alive Have not were you wished you that upset so feel ever you die? to wanted you adult. avoid pills; drugs/steroids/diet use drink, smoke, who Don’t friends support drugs/alcohol; with situations don’ Find ways to deal with stress; practice problem solving problem practice stress; with deal to ways Find making. decision are responsible/independent and setbacks and disappointments most that Recognize depressed, sad, so are you that find you if with temporary; track on back get can’t you that angry or nervous, par with talk life, an as development normal to important is Sexuality RISK REDUCTION STIs pregnancy, drugs, other or alcohol, Tobacco, EMOTIONAL EMOTIONAL WELL-BEING sexuality health, mental and regulation mood Coping, • • • • , ecognize some ecognize peers, and community and peers, , What help do you need from me or your parents to help you reach you help to parents your or me from need you do help What goal? your Stay connected with family and friends; r friends; and family with connected Stay servings a day low-fat milk/other dairy. milk/other low-fat day a servings protective use day, a minutes 60 active physically day. Be a hours 2 to time screen nonacademic limit gear; Brush teeth twice a day, floss once; visit dentist twice a twice dentist visit once; floss day, a twice teeth Brush year. hearing. your 3+ Protect vegetables; and fruits day; a meals nutritious 3 Eat friendships change; get involved with community. community. with involved get change; time. on friendships school/work to getting for responsibility Take plans. education/work future Consider Connectedness with family with Connectedness performance school relationships, interpersonal SOCIAL AND ACADEMIC COMPETENCE PHYSICAL PHYSICAL GROWTH AND DEVELOPMENT physical eating, healthy image, body health, oral and Physical activity • • • • • Anticipatory Guidance • • 52 LATE ADOLESCENCE | 18 TO 21 YEAR VISITS • • • • • • Key= vehicle, guns, interpersonal violence (fights), bullyingSafety belt and helmet use, substance abuse and riding in a INJURYPREVENTION AND VIOLENCE Wear safety belt, helmet, protective gear, life jacket. Remove guns fr drugs. Don’t ride in car with driver who has used alcohol/ Don’ (avoid alcohol/risky situations). a If sexually active, protect against STIs/pregnancy;ships can make help. and drug use and avoiding risky places and relation-your decisions about sex. Considering role of alcoholThink through how to make sure you can carry out away from any children. loaded and locked with ammunition separate; keep key Do you ever carry a gun? Is there a gun at home? ners? Did you use a condom or other contraceptive?ners male or female or have you had both male and femaleHave you part- had sex? Was it wanted or unwanted? Were your part- plan so you can carry out your decisions about sex Guidance for young adult, t use alcohol/drugs and drive. om home; if gun necessary questions , stor e un - • okay. on respect, concern and mutual interests; sayingleave NO is violent relationships; healthy relationshipsManage conflict are built nonviolently; avoid risky situations; you ever been forced to have sexual intercourse?ever been hit, slapped, or physically hurt whileDo on you a date? belong Have to a gang or know anyone in a gang? Have you APPENDICES 53 eening — Adolescence — eening eb Sites Sites eb Recommended Medical Scr Medical Recommended Recommended Medical Screening — Infancy — Screening Medical Recommended Childhood Early — Screening Medical Recommended Childhood Middle — Screening Medical Recommended Social and Emotional Development in Middle Childhood Middle in Development Emotional and Social Development Adolescent of Domains Developmental Milestones at a Glance — Infancy — Glance a at Milestones Developmental Childhood Early — Glance a at Milestones Developmental Appendices Useful W Useful Tooth Eruption Chart Eruption Tooth Ratings Maturity Sexual Developmental Milestones at a Glance — Infancy AGE GROSS MOTOR FINE MOTOR COGNITIVE, LINGUISTIC, SOCIAL-EMOTIONAL AND COMMUNICATION 2 Months Head up 45º Follow past midline Laugh Smile spontaneously Lift head Follow to midline Vocalize Smile responsively 4 Months Roll over Follow to 180º Turn to rattling sound Sit—head steady Grasp rattle Laugh Regard own hand 6 Months Sit—no 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 1 22 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 • Unsafe community environments 56 • 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 family’s 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 • •

OH = oral health; NB = newborn; LBW = low birth weight

58 Recommended Medical Screening — Early Childhood

1 UNIVERSAL ACTION 12M 15M 18M 2Y 22Y 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 • •

1 SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + 12M 15M 18M 2Y 22Y 3Y 4Y Oral health No dental home Referral to dental home; if not available, • • • • • oral health risk assessment (12M, 18M, 1 2Y, 2 2Y). 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 professional’s 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

Primary Dentition Permanent Dentition

Upper Teeth Erupt Exfoliate Upper Teeth Erupt Central incisor 8-12 months 6-7 years Central incisor 7-8 years

D.E. F. G. Lateral incisor 9-13 months 7-8 years Lateral incisor 8-9 years H. 7. 8. 9.10. C. Canine (cuspid) 16-22 months 10-12 years 6. 11. Canine (cuspid) 11-12 years 5. B. I. First molar 13-19 months 9-11 years 12. First premolar (first bicuspid) 10-11 years 4. 13. Second molar 25-33 months 10-12 years Second premolar (second bicuspid) 10-12 years A. J. 3. 14. First molar 6-7 years 2. 15. Second molar 12-13 years 1. 16. Third molar (wisdom tooth) 17-21 years Lower Teeth Erupt Exfoliate T. K. Second molar 23-31 months 10-12 years L. Lower Teeth Erupt S. First molar 14-18 months 9-11 years Third molar (wisdom tooth) 17-21 years R. M. Canine (cuspid) 17-23 months 9-12 years 32. 17. Q. P. O.N. Second molar 12-13 years Lateral incisor 10-16 months 7-8 years 31. 18. First molar 6-7 years Central incisor 6-10 months 6-7 years 30. 19. Second premolar (second bicuspid) 10-12 years 29. 20. 28. 21. First premolar (first bicuspid) 10-11 years 27. 24. 22. Canine (cuspid) 11-12 years 26.25.23. Lateral incisor 8-9 years Central incisor 7-8 years

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 adolescent’s 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.

Sexual Maturity Ratings: Males Sexual Maturity Ratings: Females SMR PUBIC HAIR SMR PUBIC HAIR Stage 1 None Stage 1 None Stage 2 Scanty, long, slightly pigmented, primarily at base of penis Stage 2 Sparse, slightly pigmented, straight, at medial border of labia Stage 3 Darker, courser, starts to curl, small amount Stage 3 Darker, beginning to curl, increased amount Stage 4 Course, curly; resembles adult type but covers smaller area Stage 4 Course, curly, abundant, but amount less than in adult Stage 5 Adult quantity and distribution, spread to medial surface of thighs Stage 5 Adult feminine triangle, spread to medial surface of thighs SMR GENITALS SMR BREASTS PENIS TESTES Stage 1 Preadolescent Stage 1 Preadolescent Preadolescent Stage 2 Breast and papilla elevated as small mound; areolar diameter increased Stage 2 Slight enlargement Slight enlargement of testes and scrotum; scrotal skin reddened, Stage 3 Breast and areola enlarged, no contour separation texture altered Stage 4 Areola and papilla form secondary mound Stage 3 Longer Further enlargement of testes and Stage 5 Mature; nipple projects, areola part of general breast contour scrotum Stage 4 Larger in breadth, Further enlargement of testes and glans penis develops scrotum Stage 5 Adult Adult

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 President’s 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