What Happens at a Well-Child Visit?

You can expect a well-child visit, also called a “health supervision visit,” to include the following things:

Your child’s doctor will ask about your child’s and your family’s health history. The family history may be discussed before your baby is born, if you have a prenatal visit, or at an early checkup. This can help the doctor determine whether your child should have certain screening tests because he might be at increased risk for genetic, infectious, or environmental health problems. Other information, such as heights of parents and other close relatives, can help the doctor diagnose a growth problem in your child more readily. At each well-child visit, you should tell the doctor about any health problems your child has had since the last visit and about any new developments in your family medical history.

Monitoring of Growth

At each well-child visit, your child’s weight and length or height should be recorded and plotted on a standard growth chart for comparison. Head circumference, which reflects the growth of the brain, is also usually measured at each routine visit until age 24 months.

Assessment of Development

Children who show delays in their physical, emotional, behavioral, or social development may have treatable medical conditions that need attention. That’s why your child’s doctor will check for these things during routine checkups.

Screening for Developmental Progress

Many types of developmental screening tests are available. The most commonly used in a primary care office is called the Denver-II. It includes questions for the parent about the child’s skills, knowledge, and behavior. Parents may be asked to fill out prescreening forms to answer some of these questions. The doctor or nurse will also observe as your child performs certain tasks (hopping on one foot, drawing, etc.) or responds to questions (“Which line is longer?”).

It is important to remember that none of these screening tests is perfect. A child may “fail” an item on the test just because he is tired or uncooperative that day. Your child’s performance on these tests over time is a much more reliable indicator of developmental health than the findings at one visit. And many children who show a delay in one or more developmental areas on the screening test turn out to have no significant problem on subsequent follow-up. On the other hand, even if your child shows no abnormalities on the screening tests, you should be sure to let the doctor know if you have any specific concerns about your child’s development or behavior. Your observation or sense that “something isn’t right” with your child can prove to be more accurate than a screening test.

If your child’s doctor feels that your child might have a problem, he or she may refer your child for evaluation by a neurologist, developmentalist, audiologist, ophthalmologist, psychologist, or other specialist, depending on the type of problem suspected.

The elements of the physical exam, and the order in which they are done, will vary based on your child’s age. With infants and young children, observation is particularly important: Your child’s doctor can learn much about your child’s health from her overall appearance, activity, responsiveness, and interactions with her environment.

When it comes to touching your child, the doctor might start by doing the things that are least threatening, such as listening to the heart with a stethoscope. The parts of the exam that tend to be more distressing to young children, such as looking in the ears and throat, are generally saved for last.

With older infants and toddlers, who are naturally somewhat fearful of strangers and too young to understand the need to be cooperative, parents (or others familiar to the child) can be of great assistance. The doctor may wish to perform much of the exam with your child on your lap or in your comforting arms. You may also be asked to help by gently restraining your child as the doctor performs parts of the exam that require the child to be still. Bringing along a favorite toy or other object can help in creating a distraction to make the exam go more smoothly.

Beginning with your newborn’s first examination, your child’s doctor will be looking for signs of existing or potential vision and hearing problems. Share with your child’s doctor any concerns you may have. A parent’s observations in this regard can be extremely helpful in diagnosing a problem early. Even before teeth begin pushing their way through your baby’s gums, your child’s doctor will be examining your infant’s mouth at well-child checkups looking for signs of infection (such as thrush) or other oral health problems. He or she will give you advice about teething and tooth care and may refer you to a pediatric dentist for a checkup or treatment if a problem is suspected. When it comes to routine visits to the dentist, the AAP recommends starting them around three years of age (if problems aren’t picked up before then), but various dental societies recommend starting by 12 months.

Other Screenings

The doctor may screen your child for tuberculosis, lead poisoning, high blood cholesterol level, or anemia if he or she thinks your child may be at risk for these problems.

Counseling and Guidance

One of the major reasons for well-child visits is so you can receive advice and information to help you raise a healthy, happy child. You should expect your child’s doctor, nurses, and other staff to devote a sizable portion of the well-child visit to providing you with this information. They should thoroughly and clearly answer any specific questions you have about your child’s health. Although this is mainly accomplished through face-to-face conversations, most practices and clinics will also have printed information sheets, pamphlets, booklets, and the like. These can give you more detail, offer suggestions about how to find additional information (such as books, reputable Web sites, and support groups), or help you remember what was said after you leave the office. Some practices and clinics offer group sessions at which parents of similar-aged children can discuss health, developmental, or behavioral topics with health care personnel.

The topics covered at your child’s visits should include what pediatricians call “anticipatory guidance.” This means telling you about physical and emotional changes you are likely to see in your child before they happen. You’ll talk about things like how to prevent accidents, what foods are best for your child, and how to encourage your child’s natural curiosity. Such guidance can help you know what to expect and give you more confidence as a parent. It can also help you keep your child safe from injury as he becomes more mobile. It can prepare you to deal with difficult but normal developments such as the appearance of separation anxiety. It may prevent some health or behavioral problems from occurring in the first place. And it can help you encourage, nurture, and fully enjoy your child’s growing abilities.

In practice, some doctors may rush past the advising and counseling aspects of a visit. Sadly, in these days of managed care, doctors may be under pressure to spend as little time as possible on each visit. If your child is healthy, the doctor may be particularly eager to move on to the next patient. If that’s the case with your child’s doctor, it may help if you prepare for a visit, as explained later in this chapter. And you can let the doctor know in a polite way if you don’t feel comfortable with the amount of time allotted or with your ability to get your questions answered. If things don’t improve, you may want to look for a doctor who is less pressed or more communicative. On the other hand, if you trust the doctor’s medical judgment and don’t feel the need for more counseling, you may want to stick with the doctor you have.

Immunizations

The schedule of health visits for infants and young children is built in part around the timing of immunizations. The development of highly safe, effective vaccines to prevent a range of potentially fatal and crippling diseases has been a towering human triumph. Making sure your child gets these immunizations is one of the most important things you can do to ensure your child’s health. Work with your child’s doctor to make sure that your child not only gets all recommended vaccines but also gets them on schedule. Delays in immunization can leave your child unnecessarily vulnerable to illness.

Larger group practices and hospital-based clinics may offer other services at routine checkups:

• A social worker may help families with financial or insurance problems, help coordinate care with other providers or agencies, assist in obtaining special supplies or equipment, or address issues related to family problems or child abuse or neglect.

• A psychologist, counselor, or other mental health professional may help with emotional, behavioral, or learning problems.

• A dietitian or nutritionist may be available for counseling children with special dietary needs.

Your child’s primary care physician should play the role of “quarterback” in coordinating referrals and care delivered to your child by other specialists. This is particularly important if your child has complex medical problems or special needs. If your child is enrolled in a managed health care plan, you should work closely with the doctor’s office staff and the health plan to complete the procedures and paperwork that may be required to authorize lab tests, X-rays, or specialist referral for your child.