The well-child examination is a crucial time for health promotion and disease prevention in toddlers and preschool-aged children (ages 1-5 years). Critical components are the physical examination and developmental screening because they provide the opportunity to intervene on developmental delays. Children should be assessed for healthy growth; obesity or growth faltering should be addressed with a stepwise and interdisciplinary approach. Vaccinations are critical for disease prevention and should be administered on time. Screening for anemia, autism spectrum disorder, dental health, hypertension, lead, tuberculosis, and vision should be considered or performed, often dictated by the risk factors of the child. Physicians should provide counseling on behavioral concerns, such as temper tantrums or breath-holding spells, with guidance on planned-ignoring, time-ins or time-outs, and referrals where indicated. Physicians should provide counseling on minimizing screen time and injury prevention. Reassurance and injury prevention strategies should be provided for common sleep disorders, such as night terrors and sleepwalking. Physicians should provide counseling on bathroom training and common issues such as constipation and enuresis. Constipation should be managed via bowel disimpaction and maintenance regimens after excluding red flag features, such as weight loss, hematochezia, bilious vomiting, or inconsolable abdominal pain. First-line therapy for enuresis includes bed alarms and desmopressin.
Case 2. LC is a 3-year-old child brought to your office by her grandmother for a well-child visit. Her growth is normal and she is meeting developmental milestones. Her grandmother asks for your advice about LC’s daily temper tantrums because redirection and time-outs have not been successful.
Well-Child Visit Goals
The well-child examination is the foundation of health for toddlers and preschool-aged children (ages 1-5 years), allowing for health promotion, disease prevention and detection, and anticipatory guidance.1
PHYSICAL EXAMINATION
A complete physical examination should be included in each well-child examination.2 From ages 1 to 5 years, examinations should include measurement of head circumference, length, and weight, which should be plotted on the World Health Organization growth chart. Beginning at age 2 years, body mass index should be calculated and plotted on the Centers for Disease Control and Prevention (CDC) chart. Blood pressure should be measured annually starting at age 3 years, or earlier if risk factors for elevated blood pressure exist. Children with a body mass index ranging from the 5th through 84th percentiles are considered to have a healthy weight.2 Table 1 defines types of weight conditions and provides management approaches for each.2–8
Other specific physical examination maneuvers for this age range include checking for ocular motility and red reflex; signs of caries or gingival inflammation; abdominal masses; descent of the testes or that the labia are open; and cafe au lait spots, nevi, and bruising on skin.2
Table 1 Weight Derangement Definitions and Management for Ages 11 Months to 5 Years
| Condition | Definition | Management |
|---|---|---|
| Overweight | BMI 85th to 94th percentile at age ≥ 2 years | Use motivational interviewing to evoke change, including engaging, focusing, evoking, and planning Decrease screen time, remove added sugars, add nutrient-dense foods, and increase physical activity Consider intensive health behavior and lifestyle treatment in children 2-5 years, although evidence is limited for treatment in this age range When intensive health behavior and lifestyle treatment is not available, collaborate with community resources to support nutrition Social and economic factors should be considered; referrals to programs such as the WIC, CACFP, and SNAP should take place when appropriate |
| Obesity | BMI ≥ 95th percentile at age ≥ 2 years | |
| Growth-faltering | Children who do not meet their expected weight, length, or body mass index secondary to malnutrition Child’s weight, weight to length ratio (in children < 2 years), or BMI (in children ≥ 2 years) is less than the 5th percentile, or there is a persistent drop in any of these metrics by ≥ 2 percentiles over time after establishing a stable weight | For children facing mild to moderate malnutrition with no overt signs of illness, behavioral interventions and caloric deficit correction can be completed in the outpatient setting with close follow-up Consider social factors and provide local resources as indicated Inadequate response to interventions should prompt consideration for further evaluations, including CBC, iron and lead levels, basic metabolic panel, and celiac disease evaluation Hospitalization should be reserved for severe and refractory cases |
BMI = body mass index; CACFP = Child and Adult Care Food Program; CBC = complete blood cell count; SNAP = Supplemental Nutrition Assistance Program; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
Information from references 2-8.
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