Well child visits are more important than you might imagine. In addition to providing you and your child with the perfect opportunity to get to know your doctor (and your doctor to get to know you), they allow your doctor to evaluate your child’s general health, growth, and development.
When children are sick, they do not feel like showing the doctor how well they walk or talk. They do not relate very well either, so their social skills cannot be evaluated. A well child visit requires a well child. A 6-month-old’s appointment for an ear infection cannot be used for the 6-month well child visit.
The American Academy of Pediatrics recommends well child visits at the following times:
At each well child visit, the doctor will ask about:
When your child is a baby, your doctor will ask you questions while you hold your child. By age 4 or 5, your child will probably feel comfortable sitting on the exam table during these questions. By school age, the doctor spends part of the time talking directly with your child. Once your child becomes a teenager, the doctor will talk with and examine your child without you in the room.
Each well child visit includes a height and weight check before the exam. In the first 2 years of life, your baby’s head size is also measured.
In the first months of life, length is measured with your child lying down with legs stretched straight. When your child is older (approximately age 2), height is measured while your child is standing. Many times the first height measured on a child is less than the last recorded length. Your child did not shrink. It is just the difference in the way the height (standing) and length (lying down) are measured.
Unlike height, your child’s weight changes from day to day and from morning to night. In the first few months of life, small differences may seem very important. Do not be surprised if your doctor’s scale weighs your child heavier or lighter than your scale at home. Remember, your doctor follows your child’s weight pattern, which is much more accurate than a single weight.
The head grows faster in the first two years than any other time in life. Both your baby’s head size and the rate at which your baby’s head is growing are important. These measurements help your doctor determine if your child’s skull and brain are developing normally.
At each visit, your child’s height, weight, and head size (in the first two years) are compared to normal values for children of the same age and sex. Your child’s measurements are plotted on growth charts. Your child’s growth tells your doctor about your child’s general health and nutrition. Each child grows at a different rate. Steady growth is what is important. A short child who grows steadily is not a worry. A child who stops growing or who loses weight is a worry. By following the growth pattern over a number of months, the normal spurts and slow periods of growth even out.
Your doctor begins the exam by taking a careful look at your child, checking for a healthy appearance or any signs of health problems. The order of the physical exam changes with the age of the child. With a young child, the doctor usually starts with the parts of the exam requiring cooperation such as listening to the heart and lungs.
Doctors usually begin taking yearly blood pressure measurements at the 3-year well child visit. Normal values for blood pressure change with age and are based on height and gender. Normal blood pressure values for children are lower than normal blood pressure values for adults. A normal blood pressure for a boy of average height is less than:
(Adult values are considered normal if they are less than 120/80.) Coughing, crying, struggling or anxiety can significantly increase the blood pressure in young children. Children can have high blood pressure for a number of reasons, but frequently it is due to a problem with the kidneys.
When examining a child under 2, the physician checks the “soft spots” of the skull. Soft spots, or fontanels, are areas where the skull bones have not yet grown together to form a bony, protective shell over the brain. There are two fontanels that may be open at birth. The fontanel on the back of the head, which is triangular, may be closed at birth, but if not, it closes in the first 4 months of life. The fontanel on the top of the head, which is diamond-shaped, closes by 2 years of age. The closure occurs as the edges of the bones surrounding the fontanel add new bone until the fontanel is finally filled in.
In addition to measuring your child’s head size, your doctor checks the shape of your child’s head. Young babies who lie with their heads in one position too long can have flattening of that part of the skull.
Your child’s doctor checks his or her ears for signs of infection or fluid behind the eardrum. Ear infections are common in young children. Not all children complain of earaches. Untreated ear infections cause problems with speech and hearing. Your doctor checks to make sure a “silent” ear infection is not missed. If you have any concerns about your child’s hearing, be sure to bring them up with your doctor.
Children with normal hearing at birth can develop hearing problems because of ear infections or exposure to very loud noises. Parents are frequently the first to notice a hearing problem. Do not be concerned about ear wax and do not use a cotton swab to clean your child’s ears because the ear canal is easily injured. If the doctor cannot see the eardrum because of ear wax, he or she will take care of the problem very carefully.
Your doctor uses a lighted instrument called an ophthalmoscope to look through the pupil into the back of the eye. The doctor is looking for problems inside the eye like a cataract or a tumor. The doctor also checks your child’s eyes for problems that can be seen from the outside like excessive tearing or eyes that do not move together.
Beginning at age 3, the doctor will probably check your child’s vision. If you have a family history of vision problems, particularly of hereditary eye disease, be sure to tell your doctor. Your child will be referred to an ophthalmologist if your doctor suspects problems.
Nose, Throat, and Mouth
The doctor checks your child’s nose for signs of allergy or chronic infection. Your doctor also checks the back of your child’s throat for enlarged tonsils or signs of infection.
When examining the mouth, he or she looks at the condition of the teeth and gums. Your doctor’s examination of your child’s teeth does not substitute for a visit to the dentist. Children should begin regular dental check-ups by age 2.
Your doctor checks several things with the neck exam. He or she checks to make sure your child’s head moves easily from side to side and up and down. The doctor also feels the neck for “lumps and bumps” – an enlarged thyroid gland or swollen lymph nodes. Swollen lymph nodes in the back of the neck may suggest an infection of the scalp. Swollen lymph nodes in the front of the neck may suggest an infection in the nose, mouth or neck. Swollen lymph nodes behind the ear may suggest an ear infection.
Chest and Lungs
Your doctor will look, listen, and feel during the chest and lung exam. He or she observes the rate of breathing, deep or shallow breathing and easy or labored breathing. The stethoscope is used to listen for normal or abnormal breathing sounds.
Your doctor can feel the force of your child’s heart beating by feeling the chest wall over the heart. The stethoscope is used to listen for normal or abnormal sounds. Many children have heart murmurs; however, not all of these indicate a problem. If your doctor mentions a murmur, do not be alarmed. If it is serious, your child will be referred to a pediatric heart specialist for further evaluation.
By gently pressing down on the abdominal wall, your doctor learns if your child’s spleen and liver are normal size or enlarged. By pressing deeper, your doctor checks kidney size. Your doctor also checks for any “lumps or bumps” or tenderness in the abdomen.
Using a stethoscope, your doctor can hear the sounds of fluid or food moving through the bowel, which means the intestines are working normally.
The examination of the abdomen can be uncomfortable for ticklish preschoolers and school-age children who frequently start to giggle when the doctor’s hand comes close to the child’s tummy. It is important for the abdominal muscles to be relaxed when your doctor checks for abnormalities.
The doctor routinely checks the genitals for rashes and other signs of infection. With both girls and boys, the doctor uses the genital exam to look for signs of sexual maturation. When examining boys, the doctor checks to make sure the testes have descended into the scrotum and that there are no abnormal masses.
When your child’s reflexes are checked, the doctor is looking for problems with the nervous system. Simple tests of coordination and muscle strength combined with the developmental assessment are also used to look for diseases of the nervous system.
Your doctor checks for different skeletal problems at different ages. At the early well child visits, your doctor checks to make sure your child does not have a problem with abnormal hip joints. It is important to treat hip problems early to avoid the need for surgery. Your doctor also checks your baby’s legs and feet. The baby’s cramped position during pregnancy can cause the legs to appear bowed and may cause incurving of the feet. Such problems are temporary and will be outgrown.
Sports injuries are the most frequent cause of bone and joint problems of older children. The next most common skeletal problem your doctor checks for is scoliosis or “S” curving of the back. Frequently, schools screen for scoliosis, and parents are asked to have a child with a positive screening test further evaluated. Scoliosis can be progressive and needs to be diagnosed early so it can be treated. It is more common in girls than in boys.
At each visit, the doctor will examine your child’s skin for rashes, birthmarks, bruising, infection, or changes in moles. The skin may provide the first clue of an illness such as leukemia or problems with the nervous system. In the teen years, acne will be a primary concern – more for your teenager than for the doctor. There are lots of things to do to make sure your child does not end up with permanent scarring from untreated acne. Be sure to ask your doctor for help or for a referral to a dermatologist if necessary.
Just as your doctor watches over your child’s growth, he or she follows your child’s development. This is done by discussing your child’s behavior, observing your child during the visit, and having you fill out questionnaires on your child’s skills. If you have any concerns about your child’s development be sure to mention them during the visit.
Children are constantly changing, adding new skills in every area: social development, which includes how your child interacts with you and others; language development, which includes everything from cooing to talking in sentences; gross motor skills, which include large muscle movements involving the arms and legs like throwing a ball or walking; and fine motor skills, which include using fingers and hands for drawing or coloring.
By following your child’s development over time, your doctor is able to identify possible problems with development and refer your child for early intervention.