Health Supervision of the Well Child

Deborah M. Consolini

, MD,

Assistant Professor of Pediatrics
Sidney Kimmel Medical College of Thomas Jefferson University
Chief, Division of Diagnostic Referral
Nemours/Alfred I. duPont Hospital for Children
Staff Pediatrician in Pediatric Liver Transplantation Program
Nemours/Alfred I. duPont Hospital for Children

Last full review/revision Jun 2019| Content last modified Jun 2019

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Topic Resources

Body Mass Index (BMI) percentiles for boys (2 to 20 years)

Body Mass Index (BMI) percentiles for girls (2 to 20 years)

Blood Pressure Percentiles for Boys (2 - 17 years)

Blood Pressure Percentiles for Girls (2 - 17 years)

Recommendations for Preventive Care During Infancy[a]

Recommendations for Preventive Care During Early and Middle Childhood[a]

Recommendations for Preventive Care During Adolescence[a]

Blood Pressure (BP) Levels for the 50th to 99th Percentiles of BP for Boys Aged 1 to 17 Years by Percentiles of Height

Blood Pressure (BP) Levels for the 50th to 99th Percentiles of BP for Girls Aged 1 to 17 Years by Percentiles of Height

Fluoride Supplementation Based on Fluoride Content in Drinking Water

Well-child visits aim to do the following:

Promote health
Prevent disease through routine vaccinations and education
Detect and treat disease early
Guide parents to optimize the child’s emotional and intellectual development

The American Academy of Pediatrics (AAP) has recommended preventive health care schedules (see Table: Recommendations for Preventive Care During Adolescence[a], see Table: Recommendations for Preventive Care During Early and Middle Childhood[a], and see Table: Recommendations for Preventive Care During Adolescence[a] ) for children who have no significant health problems and who are growing and developing satisfactorily. Children who do not meet these criteria should have more frequent and intensive visits. If children come under care for the first time late on the schedule or if any items are not done at the suggested age, children should be brought up to date as soon as possible.

Children who have developmental delay, psychosocial problems, or chronic disease may require more frequent counseling and treatment visits that are separate from preventive care visits.

If the pregnancy is high risk (see Overview of High-Risk Pregnancy) or if the parents are first-time parents or wish to have a conference, a prenatal visit with the pediatrician is appropriate.

In addition to physical examination, practitioners should evaluate the child’s motor, cognitive, and social development and parent-child interactions. These assessments can be made by

Taking a thorough history from parents and child
Making direct observations
Sometimes seeking information from outside sources such as teachers and child care providers

Tools (eg, the Modified Checklist for Autism in Toddlers [M-CHAT-R/F]; 1) are available for office use to facilitate evaluation of cognitive and social development.

Both physical examination and screening are important parts of preventive health care in infants and children. Most parameters, such as weight, are included for all children; others are applicable to selected patients, such as lead screening in 1- and 2-year-olds.

Anticipatory guidance is also important to preventive health care. It includes

Obtaining information about the child and parents (via questionnaire, interview, or evaluation)
Working with parents to promote health (forming a therapeutic alliance)
Teaching parents what to expect in their child’s development, how they can help enhance development (eg, by establishing a healthy lifestyle), and what the benefits of a healthy lifestyle are

Recommendations for Preventive Care During Infancy[a]

Item	Neonate	Age 3–5 days	By age 1 month	Age 2 months	Age 4 months	Age 6 months	Age 9 months
History (initial or interval)
—	X	X	X	X	X	X	X
Measurements
Length or height and weight	X	X	X	X	X	X	X
Head circumference	X	X	X	X	X	X	X
Weight for length	X	X	X	X	X	X	X
Blood pressure[b]	RA	RA	RA	RA	RA	RA	RA
Sensory screening
Vision	RA	RA	RA	RA	RA	RA	RA
Hearing	X	RA	RA	RA	RA	RA	RA
Developmental and behavioral assessment
Developmental surveillance[c]	X	X	X	X	X	X
Developmental screening[d]							X
Psychosocial and behavioral assessment	X	X	X	X	X	X	X
Physical examination
—	X	X	X	X	X	X	X
Laboratory testing[e]
Neonatal metabolic and hemoglobinopathy screening[f]	←––––––––––––––––––X–––––––––––––––––→
Critical congenital heart defect screening[g]	X
Hematocrit or hemoglobin					RA
Lead screening[h]						RA	RA
Tuberculosis screening[i]			RA			RA
Other
Immunization[j] (see Table: Recommended Immunization Schedule for Ages 0–6 Years and see Table: Catch-up Immunization Schedule for Ages 4 Months–18 Years)	X	X	X	X	X	X	X
Oral health[k]						RA	RA
Fluoride varnish[l]						X	X
Anticipatory guidance	X	X	X	X	X	X	X
[a]These guidelines are adapted from the AAP's and Bright Futures' 2019 recommendations for preventive pediatric health care.
[b]If infants and children have certain high-risk conditions, blood pressure should be measured at visits before age 3 years.
[c]Developmental surveillance is an ongoing process. It involves determining what concerns parents have about their child’s development, accurately observing the child, identifying risk and protective factors, and recording the process (eg, child’s developmental history, methods used, findings).
[d]Developmental screening involves using a standardized test and is routinely done at 9, 18, and 30 months. However, screening is also done when risk factors are identified or when developmental surveillance detects a problem; in such cases, screening is focused on the area of concern.
[e]Testing may be modified depending on when the child enters the schedule and what the child’s needs are.
[f]For metabolic and hemoglobinopathy screening, state law should be followed. Clinicians should review results at visits and retest or refer as needed.
[g]Clinicians should screen newborns for critical congenital heart disease using pulse oximetry, waiting at least 24 hours after birth; however, screening should be done before newborns are discharged from the hospital, as recommended in the 2011 AAP endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease.
[h]If children are at risk of lead exposure, clinicians should consult the Council on Environmental Health/AAP's Prevention of Childhood Lead Toxicity statement and should screen children according to state law where applicable.
[i]For tuberculosis screening, recommendations published in the current edition of Red Book: 2018–2021 Report of the Committee on Infectious Diseases, 31st ed., should be followed. As soon as high-risk children are identified by questionnaire, they should be tested.
[j]Clinicians should follow schedules recommended by the Committee on Infectious Diseases, which are published annually in the January issue of Pediatrics. Every visit should be used as an opportunity to update and complete a child’s immunizations (see also CDC: Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2019).
[k]Children should be referred to a dentist, if available. Otherwise, clinicians should assess oral health risk. If the primary water source is fluoride-deficient, oral fluoride supplementation should be considered.
[l]Once teeth are present, fluoride varnish may be applied to all children every 3 to 6 months in the primary care or dental office. For indications for fluoride use, see the 2014 AAP clinical report Fluoride use in caries prevention in the primary care setting.
AAP = American Academy of Pediatrics; CDC = Centers for Disease Control and Prevention; RA = age at which risk assessment should be done, followed, if results are positive, by appropriate examination or testing; X = age at which evaluation should be done; ←X→ = range during which evaluation may be done, with X indicating the preferred age.

Recommendations for Preventive Care During Early and Middle Childhood[a]

Item	Age 12 months	Age 15 months	Age 18 months	Age 24 months	Age 30 months	Age 3 years	Age 4 years	Age 5 years	Age 6 years	Age 7 years	Age 8 years	Age 9 years	Age 10 years
History (initial or interval)
—	X	X	X	X	X	X	X	X	X	X	X	X	X
Measurements
Height and weight	X	X	X	X	X	X	X	X	X	X	X	X	X
Head circumference	X	X	X	X
Weight for length/height	X	X	X
Body mass index				X	X	X	X	X	X	X	X	X	X
Blood pressure[b]	RA	RA	RA	RA	RA	X	X	X	X	X	X	X	X
Sensory screening
Vision	RA	RA	RA	RA	RA	X[c]	X	X	X	RA	X	RA	X
Hearing	RA	RA	RA	RA	RA	RA	X	X	X	RA	X	RA	X
Developmental and behavioral assessment
Developmental surveillance[d]	X	X		X		X	X	X	X	X	X	X	X
Developmental screening[e]			X		X
Autism[f]			X	X
Psychosocial and behavioral assessment	X	X	X	X	X	X	X	X	X	X	X	X	X
Physical examination
—	X	X	X	X	X	X	X	X	X	X	X	X	X
Laboratory testing[g]
Hematocrit or hemoglobin	X	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA
Lead screening[h]	X or RA		RA	X or RA		RA	RA	RA	RA
Tuberculosis screening[i]	RA			RA		RA	RA	RA	RA	RA	RA	RA	RA
Dyslipidemia screening[j]				RA			RA		RA		RA	←---X---→
Other
Immunization[k] (see Table: Recommended Immunization Schedule for Ages 0–6 Years, see Table: Recommended Immunization Schedule for Ages 7–18 Years, and see Table: Catch-up Immunization Schedule for Ages 4 Months–18 Years)	X	X	X	X	X	X	X	X	X	X	X	X	X
Oral health[l]	X or RA		X or RA	X or RA	X or RA	X			X
Fluoride varnish[m]	←-----------------------------X---------------------------→								RA	RA	RA	RA	RA
Anticipatory guidance	X	X	X	X	X	X	X	X	X	X	X	X	X
[a]These guidelines are adapted from the AAP's and Bright Futures' 2019 recommendations for preventive pediatric health care.
[b]If infants and children have certain high-risk conditions, blood pressure should be measured at visits before age 3 years.
[c]If children are uncooperative, they can be rescreened within 6 months.
[d]Developmental surveillance is an ongoing process. It involves determining what concerns parents have about their child’s development, accurately observing the child, identifying risk and protective factors, and recording the process (eg, child’s developmental history, methods used, findings).
[e]Developmental screening involves using a standardized test and is routinely done at 9, 18, and 30 months. However, screening is also done when risk factors are identified or when developmental surveillance detects a problem; in such cases, screening is focused on the area of concern.
[f]Screening with an autism-specific tool (such as the Modified Checklist for Autism in Toddlers [M-CHAT-R/F]) at age 18 months is recommended. Screening is repeated at age 24 months because parents may not notice problems by age 18 months (the mean age that parents report autistic regression is 20 months). See Johnson CP, Myers SM, American Academy of Pediatrics Council on Children With Disabilities: Identification and evaluation of children with autism spectrum disorders. Pediatrics 120(5):1183–1215, 2007. doi: 10.1542/peds.2007-2361.
[g]Testing may be modified depending on when the child enters the schedule and what the child’s needs are.
[h]If children are at risk of lead exposure, clinicians should consult the Council on Environmental Health/AAP's Prevention of Childhood Lead Toxicity statement and should screen children according to state law where applicable. Risk is assessed or screening is done based on universal screening requirements for patients with Medicaid or in high-prevalence areas.
[j]For tuberculosis screening, recommendations published in the current edition of Red Book: 2018–2021 Report of the Committee on Infectious Diseases, 31st ed, should be followed. As soon as high-risk children are identified, they should be tested.
[j]The AAP recommends screening children between ages 1 year and 8 years and between ages 12 years and 17 years only if they have a family history of high cholesterol or coronary artery disease or risk factors for coronary artery disease (eg, diabetes, obesity, hypertension). Most useful is a fasting lipid profile. A lipid profile is also recommended for all children between ages 9 years and 11 years and again between ages 18 years and 21 years (see the AAP-endorsed 2012 guidelines from the National Heart, Lung, and Blood Institute Integrated guidelines for cardiovascular health and risk reduction in children and adolescents).
[k]Clinicians should follow schedules recommended by the Committee on Infectious Diseases, which are published annually in the January issue of Pediatrics. Every visit should be used as an opportunity to update and complete a child’s immunizations (see also CDC: Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2019).
[l]Children should be referred to a dentist, if available. Otherwise, clinicians should assess oral health risk. If the primary water source is fluoride-deficient, oral fluoride supplementation should be considered. At the 3- and 6-year visits, the clinician should determine whether the child has a dental home and, if not, should refer the child to one.
[m]Once teeth are present, fluoride varnish may be applied to all children every 3 to 6 months in the primary care office. Dentists typically begin seeing children after age 3 years, and after that age, clinicians should assess that appropriate dental care is being received. For indications for fluoride use, see the 2014 AAP clinical report Fluoride use in caries prevention in the primary care setting.
AAP = American Academy of Pediatrics; CDC = Centers for Disease Control and Prevention; RA = age at which risk assessment should be done, followed, if results are positive, by appropriate examination or testing; X = age at which evaluation should be done; ←X→ = range during which evaluation may be done, with X indicating the preferred age.

Recommendations for Preventive Care During Adolescence[a]

Item	Age 11 years	Age 12 years	Age 13 years	Age 14 years	Age 15 years	Age 16 years	Age 17 years	Age 18 years	Age 19 years	Age 20 years	Age 21 years
History (initial or interval)
—	X	X	X	X	X	X	X	X	X	X	X
Measurements
Height and weight	X	X	X	X	X	X	X	X	X	X	X
Body mass index	X	X	X	X	X	X	X	X	X	X	X
Blood pressure	X	X	X	X	X	X	X	X	X	X	X
Sensory screening
Vision	RA	X	RA	RA	X	RA	RA	RA	RA	RA	RA
Hearing	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA
Developmental/behavioral assessment
Developmental surveillance[b]	X	X	X	X	X	X	X	X	X	X	X
Psychosocial and behavioral assessment	X	X	X	X	X	X	X	X	X	X	X
Alcohol and drug use assessment[c]	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA
Depression screening[d]	X	X	X	X	X	X	X	X	X	X	X
Physical examination
—	X	X	X	X	X	X	X	X	X	X	X
Testing[e]
Hematocrit or hemoglobin	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA
Tuberculosis screening[f]	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA
Dyslipidemia screening[g]	X	RA	RA	RA	RA	RA	RA	←–––––------X--------––→
STD/HIV screening[h]	RA	RA	RA	RA	RA	←––––--X-------→			RA	RA	RA
Cervical dysplasia screening[i]											X
Other
Immunization[j] (see Table: Recommended Immunization Schedule for Ages 7–18 Years and see Table: Catch-up Immunization Schedule for Ages 4 Months–18 Years)	X	X	X	X	X	X	X	X	X	X	X
Fluoride varnish[k]	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA	RA
Anticipatory guidance	X	X	X	X	X	X	X	X	X	X	X
[a]These guidelines are adapted from the AAP's and Bright Futures' 2019 recommendations for preventive pediatric health care.
[b]Developmental surveillance is an ongoing process. It involves determining what concerns parents have about their child’s development, accurately observing the child, identifying risk and protective factors, and recording the process (eg, child’s developmental history, methods used, findings).
[c]Validated screening tools for use of alcohol and other drugs in children < 21 years of age are available (see Levy SJ, Williams JF, AAP Committee on Substance Use and Prevention: Substance use screening, brief intervention, and referral to treatment. Pediatrics 138(1):e20161211, 2016. doi: 10.1542/peds.2016-1211).
[d]For a list of available mental health screening tools, see the AAP's Mental health screening and assessment tools for primary care.
[e]Testing may be modified depending on when the child enters the schedule and what the child’s needs are.
[f]For tuberculosis screening, recommendations published in the current edition of the Red Book: 2018–2021 Report of the Committee on Infectious Diseases, 31st ed., should be followed. As soon as high-risk children are identified by questionnaire, they should be tested.
[g]The AAP recommends screening between ages 12 years and 17 years only if they have a family history of high cholesterol or coronary artery disease or risk factors for coronary artery disease (eg, diabetes, obesity, hypertension). Most useful is a fasting lipid profile. A lipid profile is also recommended for all children between ages 9 years and 11 years and again between ages 18 years and 21 years (see the AAP-endorsed 2012 guidelines from the National Heart, Lung, and Blood Institute Integrated guidelines for cardiovascular health and risk reduction in children and adolescents).
[h]All sexually active patients should be screened for STDs as recommended in the current edition of the Red Book: 2018–2021 Report of the Committee on Infectious Diseases, 31st ed. Also, all adolescents should be offered HIV screening in appropriate settings at least once by age 16 to 18 years, as recommended in the 2011 AAP statement Adolescents and HIV infection: The pediatrician's role in promoting routine testing; every effort should be made to preserve the confidentiality of the adolescent. Adolescents at increased risk of HIV infection (because they are sexually active, use injection drugs, or have another STD) should be tested yearly.
[i]Adolescents should not be routinely screened for cervical dysplasia until they are age 21. In certain circumstances, pelvic examinations are indicated before age 21 (see the 2010 AAP statement Gynecologic examination for adolescents in the pediatric office setting).
[j]Clinicians should follow schedules recommended by the Committee on Infectious Diseases, which are published annually in the January issue of Pediatrics. Every visit should be used as an opportunity to update and complete a child’s immunizations (see also CDC: Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2019).
[k]Clinicians should assess that adolescents are receiving appropriate dental care, including fluoride treatment if needed. For indications for fluoride use, see the 2014 AAP clinical report Fluoride use in caries prevention in the primary care setting.
AAP = American Academy of Pediatrics; CDC = Centers for Disease Control and Prevention; HIV = human immunodeficiency virus; RA = age at which risk assessment should be done, followed, if results are positive, by appropriate examination or testing; STDs = sexually transmitted diseases; X = age at which evaluation should be done; ←X→ = range during which evaluation may be done, with X indicating the preferred age.

1. Frankenburg WK, Dodds JB: The Denver Developmental Screening Test. J Pediatr 71(2):181–191, 1967. doi: 10.1016/S0022-3476(67)80070-2.

Length (crown-heel) or height (once children can stand) and weight should be measured at each visit. Head circumference should be measured at each visit through 36 months. Growth rate should be monitored using a growth curve with percentiles; deviations in these parameters should be evaluated (see Physical Growth of Infants and Children).

Starting at 3 years of age, blood pressure (BP) should be routinely checked by using an appropriate-sized cuff. The cuff should cover at least two thirds of the upper arm, and the bladder should encircle 80 to 100% of the circumference of the arm. If no available cuff fits the criteria, using the larger cuff is better.

Systolic and diastolic BPs are considered normal if they are < 90th percentile; actual values for each percentile vary by sex, age, and size (as height percentile), so reference to published tables is essential (see tables for BP levels for the 50th to 99th percentiles for boys and girls, below). Systolic and diastolic BP measurements between the 90th and 95th percentiles should prompt continued observation and assessment of hypertensive risk factors. If measurements are consistently ≥ 95th percentile, children should be considered hypertensive, and a cause should be determined.

Blood Pressure (BP) Levels for the 50th to 99th Percentiles of BP for Boys Aged 1 to 17 Years by Percentiles of Height

		Systolic Blood Pressure (mm Hg)/Percentile of Height							Diastolic Blood Pressure (mm Hg)/Percentile of Height
Age (year)	Blood Pressure Percentile	5th	10th	25th	50th	75th	90th	95th	5th	10th	25th	50th	75th	90th	95th
1	50th	80	81	83	85	87	88	89	34	35	36	37	38	39	39
	90th	94	95	97	99	100	102	103	49	50	51	52	53	53	54
	95th	98	99	101	103	104	106	106	54	54	55	56	57	58	58
	99th	105	106	108	110	112	113	114	61	62	63	64	65	66	66
2	50th	84	85	87	88	90	92	92	39	40	41	42	43	44	44
	90th	97	99	100	102	104	105	106	54	55	56	57	58	58	59
	95th	101	102	104	106	108	109	110	59	59	60	61	62	63	63
	99th	109	110	111	113	115	117	117	66	67	68	69	70	71	71
3	50th	86	87	89	91	93	94	95	44	44	45	46	47	48	48
	90th	100	101	103	105	107	108	109	59	59	60	61	62	63	63
	95th	104	105	107	109	110	112	113	63	63	64	65	66	67	67
	99th	111	112	114	116	118	119	120	71	71	72	73	74	75	75
4	50th	88	89	91	93	95	96	97	47	48	49	50	51	51	52
	90th	102	103	105	107	109	110	111	62	63	64	65	66	66	67
	95th	106	107	109	111	112	114	115	66	67	68	69	70	71	71
	99th	113	114	116	118	120	121	122	74	75	76	77	78	78	79
5	50th	90	91	93	95	96	98	98	50	51	52	53	54	55	55
	90th	104	105	106	108	110	111	112	65	66	67	68	69	69	70
	95th	108	109	110	112	114	115	116	69	70	71	72	73	74	74
	99th	115	116	118	120	121	123	123	77	78	79	80	81	81	82
6	50th	91	92	94	96	98	99	100	53	53	54	55	56	57	57
	90th	105	106	108	110	111	113	113	68	68	69	70	71	72	72
	95th	109	110	112	114	115	117	117	72	72	73	74	75	76	76
	99th	116	117	119	121	123	124	125	80	80	81	82	83	84	84
7	50th	92	94	95	97	99	100	101	55	55	56	57	58	59	59
	90th	106	107	109	111	113	114	115	70	70	71	72	73	74	74
	95th	110	111	113	115	117	118	119	74	74	75	76	77	78	78
	99th	117	118	120	122	124	125	126	82	82	83	84	85	86	86
8	50th	94	95	97	99	100	102	102	56	57	58	59	60	60	61
	90th	107	109	110	112	114	115	116	71	72	72	73	74	75	76
	95th	111	112	114	116	118	119	120	75	76	77	78	79	79	80
	99th	119	120	122	123	125	127	127	83	84	85	86	87	87	88
9	50th	95	96	98	100	102	103	104	57	58	59	60	61	61	62
	90th	109	110	112	114	115	117	118	72	73	74	75	76	76	77
	95th	113	114	116	118	119	121	121	76	77	78	79	80	81	81
	99th	120	121	123	125	127	128	129	84	85	86	87	88	88	89
10	50th	97	98	100	102	103	105	106	58	59	60	61	61	62	63
	90th	111	112	114	115	117	119	119	73	73	74	75	76	77	78
	95th	115	116	117	119	121	122	123	77	78	79	80	81	81	82
	99th	122	123	125	127	128	130	130	85	86	86	88	88	89	90
11	50th	99	100	102	104	105	107	107	59	59	60	61	62	63	63
	90th	113	114	115	117	119	120	121	74	74	75	76	77	78	78
	95th	117	118	119	121	123	124	125	78	78	79	80	81	82	82
	99th	124	125	127	129	130	132	132	86	86	87	88	89	90	90
12	50th	101	102	104	106	108	109	110	59	60	61	62	63	63	64
	90th	115	116	118	120	121	123	123	74	75	75	76	77	78	79
	95th	119	120	122	123	125	127	127	78	79	80	81	82	82	83
	99th	126	127	129	131	133	134	135	86	87	88	89	90	90	91
13	50th	104	105	106	108	110	111	112	60	60	61	62	63	64	64
	90th	117	118	120	122	124	125	126	75	75	76	77	78	79	79
	95th	121	122	124	126	128	129	130	79	79	80	81	82	83	83
	99th	128	130	131	133	135	136	137	87	87	88	89	90	91	91
14	50th	106	107	109	111	113	114	115	60	61	62	63	64	65	65
	90th	120	121	123	125	126	128	128	75	76	77	78	79	79	80
	95th	124	125	127	128	130	132	132	80	80	81	82	83	84	84
	99th	131	132	134	136	138	139	140	87	88	89	90	91	92	92
15	50th	109	110	112	113	115	117	117	61	62	63	64	65	66	66
	90th	122	124	125	127	129	130	131	76	77	78	79	80	80	81
	95th	126	127	129	131	133	134	135	81	81	82	83	84	85	85
	99th	134	135	136	138	140	142	142	88	89	90	91	92	93	93
16	50th	111	112	114	116	118	119	120	63	63	64	65	66	67	67
	90th	125	126	128	130	131	133	134	78	78	79	80	81	82	82
	95th	129	130	132	134	135	137	137	82	83	83	84	85	86	87
	99th	136	137	139	141	143	144	145	90	90	91	92	93	94	94
17	50th	114	115	116	118	120	121	122	65	66	66	67	68	69	70
	90th	127	128	130	132	134	135	136	80	80	81	82	83	84	84
	95th	131	132	134	136	138	139	140	84	85	86	87	87	88	89
	99th	139	140	141	143	145	146	147	92	93	93	94	95	96	97
The 90th percentile is 1.28 standard deviations (SDs), the 95th percentile is 1.645 SDs, and the 99th percentile is 2.326 SDs over the mean.

Blood Pressure (BP) Levels for the 50th to 99th Percentiles of BP for Girls Aged 1 to 17 Years by Percentiles of Height

		Systolic Blood Pressure (mm Hg)/Percentile of Height							Diastolic Blood Pressure (mm Hg)/Percentile of Height
Age (year)	Blood Pressure Percentile	5th	10th	25th	50th	75th	90th	95th	5th	10th	25th	50th	75th	90th	95th
1	50th	83	84	85	86	88	89	90	38	39	39	40	41	41	42
	90th	97	97	98	100	101	102	103	52	53	53	54	55	55	56
	95th	100	101	102	104	105	106	107	56	57	57	58	59	59	60
	99th	108	108	109	111	112	113	114	64	64	65	65	66	67	67
2	50th	85	85	87	88	89	91	91	43	44	44	45	46	46	47
	90th	98	99	100	101	103	104	105	57	58	58	59	60	61	61
	95th	102	103	104	105	107	108	109	61	62	62	63	64	65	65
	99th	109	110	111	112	114	115	116	69	69	70	70	71	72	72
3	50th	86	87	88	89	91	92	93	47	48	48	49	50	50	51
	90th	100	100	102	103	104	106	106	61	62	62	63	64	64	65
	95th	104	104	105	107	108	109	110	65	66	66	67	68	68	69
	99th	111	111	113	114	115	116	117	73	73	74	74	75	76	76
4	50th	88	88	90	91	92	94	94	50	50	51	52	52	53	54
	90th	101	102	103	104	106	107	108	64	64	65	66	67	67	68
	95th	105	106	107	108	110	111	112	68	68	69	70	71	71	72
	99th	112	113	114	115	117	118	119	76	76	76	77	78	79	79
5	50th	89	90	91	93	94	95	96	52	53	53	54	55	55	56
	90th	103	103	105	106	107	109	109	66	67	67	68	69	69	70
	95th	107	107	108	110	111	112	113	70	71	71	72	73	73	74
	99th	114	114	116	117	118	120	120	78	78	79	79	80	81	81
6	50th	91	92	93	94	96	97	98	54	54	55	56	56	57	58
	90th	104	105	106	108	109	110	111	68	68	69	70	70	71	72
	95th	108	109	110	111	113	114	115	72	72	73	74	74	75	76
	99th	115	116	117	119	120	121	122	80	80	80	81	82	83	83
7	50th	93	93	95	96	97	99	99	55	56	56	57	58	58	59
	90th	106	107	108	109	111	112	113	69	70	70	71	72	72	73
	95th	110	111	112	113	115	116	116	73	74	74	75	76	76	77
	99th	117	118	119	120	122	123	124	81	81	82	82	83	84	84
8	50th	95	95	96	98	99	100	101	57	57	57	58	59	60	60
	90th	108	109	110	111	113	114	114	71	71	71	72	73	74	74
	95th	112	112	114	115	116	118	118	75	75	75	76	77	78	78
	99th	119	120	121	122	123	125	125	82	82	83	83	84	85	86
9	50th	96	97	98	100	101	102	103	58	58	58	59	60	61	61
	90th	110	110	112	113	114	116	116	72	72	72	73	74	75	75
	95th	114	114	115	117	118	119	120	76	76	76	77	78	79	79
	99th	121	121	123	124	125	127	127	83	83	84	84	85	86	87
10	50th	98	99	100	102	103	104	105	59	59	59	60	61	62	62
	90th	112	112	114	115	116	118	118	73	73	73	74	75	76	76
	95th	116	116	117	119	120	121	122	77	77	77	78	79	80	80
	99th	123	123	125	126	127	129	129	84	84	85	86	86	87	88
11	50th	100	101	102	103	105	106	107	60	60	60	61	62	63	63
	90th	114	114	116	117	118	119	120	74	74	74	75	76	77	77
	95th	118	118	119	121	122	123	124	78	78	78	79	80	81	81
	99th	125	125	126	128	129	130	131	85	85	86	87	87	88	89
12	50th	102	103	104	105	107	108	109	61	61	61	62	63	64	64
	90th	116	116	117	119	120	121	122	75	75	75	76	77	78	78
	95th	119	120	121	123	124	125	126	79	79	79	80	81	82	82
	99th	127	127	128	130	131	132	133	86	86	87	88	88	89	90
13	50th	104	105	106	107	109	110	110	62	62	62	63	64	65	65
	90th	117	118	119	121	122	123	124	76	76	76	77	78	79	79
	95th	121	122	123	124	126	127	128	80	80	80	81	82	83	83
	99th	128	129	130	132	133	134	135	87	87	88	89	89	90	91
14	50th	106	106	107	109	110	111	112	63	63	63	64	65	66	66
	90th	119	120	121	122	124	125	125	77	77	77	78	79	80	80
	95th	123	123	125	126	127	129	129	81	81	81	82	83	84	84
	99th	130	131	132	133	135	136	136	88	88	89	90	90	91	92
15	50th	107	108	109	110	111	113	113	64	64	64	65	66	67	67
	90th	120	121	122	123	125	126	127	78	78	78	79	80	81	81
	95th	124	125	126	127	129	130	131	82	82	82	83	84	85	85
	99th	131	132	133	134	136	137	138	89	89	90	91	91	92	93
16	50th	108	108	110	111	112	114	114	64	64	65	66	66	67	68
	90th	121	122	123	124	126	127	128	78	78	79	80	81	81	82
	95th	125	126	127	128	130	131	132	82	82	83	84	85	85	86
	99th	132	133	134	135	137	138	139	90	90	90	91	92	93	93
17	50th	108	109	110	111	113	114	115	64	65	65	66	67	67	68
	90th	122	122	123	125	126	127	128	78	79	79	80	81	81	82
	95th	125	126	127	129	130	131	132	82	83	83	84	85	85	86
	99th	133	133	134	136	137	138	139	90	90	91	91	92	93	93
The 90th percentile is 1.28 standard deviations (SDs), the 95th percentile is 1.645 SDs, and the 99th percentile is 2.326 SDs over the mean.

The most common abnormality is fluid in the middle ear (otitis media with effusion), manifesting as a change in the appearance of the tympanic membrane. Clinicians should screen for hearing deficits.

Eyes should be assessed at each visit. Clinicians should check for all of the following:

Esotropia or exotropia
Abnormalities in globe size: Suggesting congenital glaucoma
A difference in pupil size, iris color, or both: Suggesting Horner syndrome, trauma, or neuroblastoma (asymmetric pupils may be normal or represent an ocular, autonomic, or intracranial disorder)
Absence or distortion of the red reflex: Suggesting cataract or retinoblastoma

Ptosis and eyelid hemangioma obscure vision and require attention. Infants born at < 32 weeks gestation should be assessed by an ophthalmologist for evidence of retinopathy of prematurity and for refractive errors, which are more common. By age 3 or 4 years, vision testing by Snellen charts or newer testing machines can be used. E charts are better than pictures; visual acuity of < 20/30 should be evaluated by an ophthalmologist.

Detection of dental caries is important, and referral to a dentist should be made if cavities are present, even in children who have only deciduous teeth. If the primary water source is deficient in fluoride, oral fluoride supplementation should begin when a child is 6 months old and be continued daily until the child is 16 years old (see Table: Fluoride Supplementation Based on Fluoride Content in Drinking Water). Brushing with fluoride toothpaste in the appropriate dosage for age should be recommended. Once teeth are present, fluoride varnish may be applied to all children every 3 to 6 months in the primary care setting or until a dental home is established. Dentists typically begin seeing children at about age 3; after this time, clinicians may simply assess that adolescents are receiving appropriate dental care, including fluoride treatment if needed.

Fluoride Supplementation Based on Fluoride Content in Drinking Water

Age	Fluoride < 0.3 ppm	Fluoride 0.3–0.6 ppm	Fluoride > 0.6 ppm
6 months–3 years	0.25 mg once a day	None	None
3–6 years	0.5 mg once a day	0.25 mg once a day	None
6–16 years	1.0 mg once a day	0.5 mg once a day	None

Thrush is common among infants and not usually a sign of immunosuppression.

Auscultation is done to identify new murmurs, heart rate abnormalities, or rhythm disturbances; benign flow murmurs are common and need to be distinguished from pathologic murmurs. The chest wall is palpated for the apical impulse to check for cardiomegaly; femoral pulses are palpated to check for asymmetry, which suggests aortic coarctation.

Palpation is repeated at every visit because many masses, particularly Wilms tumor and neuroblastoma, may be apparent only as children grow.

Stool is often palpable in the left lower quadrant.

Children old enough to stand should be screened for scoliosis by observing posture, shoulder tip and scapular symmetry, torso list, and especially paraspinal asymmetry when children bend forward.

At each visit before children start to walk, evaluation for developmental dysplasia of the hip should be done. The Barlow and Ortolani maneuvers are used until about age 4 months. After that, dysplasia may be suggested by unequal leg length, adductor tightness, or asymmetry of abduction or leg creases.

Toeing-in can result from adduction of the forefoot, tibial torsion, or femoral torsion. Only pronounced cases require therapy and referral to an orthopedist. Asymmetric toeing (toeing-in on one side and toeing-out on the other—windswept appearance) typically requires orthopedic evaluation.

Girls should be offered a pelvic examination and Papanicolaou (Pap) testing at age 21. All sexually active patients should be screened for sexually transmitted diseases.

Testicular and inguinal evaluation should be done at every visit, specifically looking for undescended testes in infants and young boys, testicular masses in older adolescents, and inguinal hernia in boys of all ages. Adolescent boys should be taught how to do testicular self-examination to check for masses, and adolescent girls should be taught how to do breast self-examination.

Preventive counseling is part of every well-child visit and covers a broad spectrum of topics, such as recommendations to have infants sleep on their back, injury prevention, nutritional and exercise advice, and discussions of violence, firearms, and substance abuse.

Recommendations for injury prevention vary by age. Some examples follow.

For infants from birth to 6 months:

Using a rear-facing car seat
Reducing home water temperature to < 49° C (<120° F)
Preventing falls
Using sleeping precautions: Placing infants on their back, not sharing a bed, using a firm mattress, and not allowing stuffed animals, pillows, and blankets in the crib
Avoiding foods and objects that children can aspirate

For infants from 6 to 12 months:

Continuing to use a rear-facing car seat
Continuing to place infants on their back to sleep
Not using baby walkers
Using safety latches on cabinets
Preventing falls from changing tables and around stairs
Vigilantly supervising children when in bathtubs and while learning to walk

For children aged 1 to 4 years:

Using an age- and weight-appropriate car seat (infants and toddlers should use a rear-facing car seat until they exceed the rear-facing weight or height limits for their convertible child safety seat; most convertible car seats have limits that will allow children to ride rear-facing for ≥ 2 years)
Reviewing automobile safety both as passenger and pedestrian
Tying window cords
Using safety caps and latches
Preventing falls
Removing handguns from the home

For children ≥ 5 years:

All of the recommendations for children aged 1 to 4 years
Using a bicycle helmet and protective sports gear
Instructing children about safe street crossing
Closely supervising swimming and sometimes requiring the use of life jackets during swimming

Excessive caloric intake underlies the epidemic of obesity in children. Recommendations for calorie intake vary by age; for children up to age 2 years, see Nutrition in Infants.

As children grow older, parents can allow them some discretion in food choices, while keeping the diet within healthy parameters. Children should be guided away from frequent snacking and foods that are high in calories, salt, and sugar. Soda and excessive fruit juice consumption have been implicated as major contributors to obesity.

Physical inactivity also underlies the epidemic of obesity in children, and the benefits of exercise in maintaining good physical and emotional health should induce parents to make sure their children develop good habits early in life. During infancy and early childhood, children should be allowed to roam and explore in a safe environment under close supervision. Outdoor play should be encouraged from infancy.

As children grow older, play becomes more complex, often evolving to formal school-based athletics. Parents should set good examples and encourage both informal and formal play, always keeping safety issues in mind and promoting healthy attitudes about sportsmanship and competition. Participation in sports and activities as a family provides children with exercise and has important psychologic and developmental benefits. Screening of children before sports participation is recommended.

Limits to television watching, which is linked directly to inactivity and obesity, should start at birth and be maintained throughout adolescence. Similar limits should be set for video games and noneducational computer time as children grow older.

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General reference

Physical Examination

Prevention

OTHER TOPICS IN THIS CHAPTER

ADDITIONAL CONTENT

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Health Supervision of the Well Child

Recommendations for Preventive Care During Infancy[a]

Recommendations for Preventive Care During Early and Middle Childhood[a]

Recommendations for Preventive Care During Adolescence[a]

General reference

Physical Examination

Growth

Blood pressure

Blood Pressure (BP) Levels for the 50th to 99th Percentiles of BP for Boys Aged 1 to 17 Years by Percentiles of Height

Blood Pressure (BP) Levels for the 50th to 99th Percentiles of BP for Girls Aged 1 to 17 Years by Percentiles of Height

Head

Fluoride Supplementation Based on Fluoride Content in Drinking Water

Heart

Abdomen

Spine and extremities

Genital examination

Prevention

Safety

Nutrition

Exercise

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