Providing comprehensive medical care for children is an integral and enjoyable part of family medicine that defines a critical distinction between the family physician and other medical specialists. The provision of well child care through a series of periodic examinations forms the foundation for the family physician to build lasting relationships with entire family and their community and to establish the patient’s medical home.

Better nutrition, safety methods, and immunizations have significantly improved the health of US children, but serious childhood health problems persist. Inadequate or delayed prenatal care, childhood obesity, failure to optimize intellectual potential, and poor management of developmental delay are examples of remaining critical issues. Barriers to health care such as insufficient health literacy and lack of insurance coverage compound these issues. One of the key reference guides for pediatric health promotion is the third edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, which was funded by the US Department of Health and Human Services. Bright Futures outlines a system of care that addresses basic concerns of child rearing such as nutrition, parenting, safety, and infectious disease prevention with focused attention on evidenced-based health components and interventions.

The components of routine well child care include the following:

• History taking
  
• Monitoring physical parameters of growth
  
• Developmental/behavioral assessment
  
• Physical examination
  
• Screening tests and procedures
  
• Anticipatory guidance
  
• Administration of immunizations

The underlying purpose is to identify concerns about a child’s development and to intervene with early prevention or treatment to optimize eventual capabilities. Family physicians need to comfortably identify common normal variants as well as abnormal findings that may require referral.

One widely accepted schedule for the periodicity of routine well child visits (Table 1-1) provides ample opportunities to observe the child and family at critical junctures during a child’s growth and development. The periodicity table can be downloaded for direct clinical use from http:// brightfutures.aap.org/clinical_practice.html. It provides a structured framework for anticipatory guidance and developmental screening recommendations at appropriate intervals.

Any encounter, even for an acute illness, is an opportunity to update health screening, provide anticipatory guidance, and administer immunizations. Recognized problems such as growth delay can necessitate additional checkups for more intense follow-up. Supplemental visits may also be required if the child is adopted or living with surrogate parents; is at high risk for medical disorders as suggested by the pregnancy, delivery, or neonatal history; exhibits psychological disorders as suggested by speech delay, persistent temper tantrums, or poor school performance; or if the family is socially or economically disadvantaged; or if the parents request/require additional education or guidance. Table 1-2 lists some developmental “red flags” that necessitate additional visits.

A general principle for well child examinations (ages, newborn to 4 years old) is to perform maneuvers from least to most invasive. Clinicians should first make observations about the child-parent(s) interaction, obtain an interval history, and then perform a direct examination of the child, reserving the use of any specialized instruments until the end. Some parts of the examination are best accomplished when the infant is quiet so they may be done “out of order.” Although most of the communications and decisions about the child’s health are between the physician and the parents, clinicians should attempt to communicate directly with the patient to gauge whether he or she is developmentally appropriate and to develop familiarity directly with the patient. Patient-physician communication is particularly important during adolescence to gain the patient’s trust and to assess comprehension and compliance. A child’s medical record must be kept meticulously. A checklist-based system is an efficient way to ensure completeness in physical and developmental examinations. A table or flow sheet, as found in an electronic medical record, is helpful for tracking immunizations and screening tests. Parents should be encouraged to maintain their own records, especially for immunizations and growth, for each child.

Well child care ideally begins in the preconception period. Family physicians have a unique opportunity to provide such counseling since women routinely present for gynecological examinations before and after pregnancy. Prospective parents should be counseled about appropriate nutrition, including 0.4 mg of folic acid supplementation daily for all women of childbearing age. Prior to conception, referral for genetic screening and counseling should be offered on the basis of age, ethnic background, or family history. Prescription drug and supplement use should be reviewed. Potential exposures to cigarette smoke, alcohol, illicit drugs, or chemicals such as pesticides should be discouraged strongly. Immunizations against hepatitis B, pertussis, tetanus, rubella, and varicella should be completed, and clinicians should discuss prevention of infection with toxoplasmosis, cytomegalovirus, and parvovirus B19.

Prior medical problems such as diabetes, epilepsy, depression, or hypertension warrant special management prior to conception, especially since medications may need to be changed before pregnancy. The “prenatal” visit is an opportunity to discuss occupational and financial issues related to pregnancy, to gather information about preparations for the child’s arrival, to discuss plans for feeding and child care, and to screen for domestic violence. A family’s decision about feeding the infant, often made long before the child is born, is often based on cultural beliefs and value judgments rather than medical knowledge. The prenatal visit is a good opportunity to promote breast-feeding, emphasizing the health benefits for both mother and infant. Having gained familiarity with the family’s background, the physician can dedicate visits with the newborn infant to providing parents with specific guidance about child care.

A brief developmental assessment using the Clinical Neonatal Behavioral Assessment System (CLNBAS), a neurobehavioral assessment, in the presence of the parents can educate them about the capacities of their new child. The CLNBAS consists of 18 behavioral and reflex items designed to examine newborn physiologic and motor states that have an impact on parents’ care given in relation to sleep, feeding, crying, and consolability. Furthermore, parents obtain valuable information regarding their infant’s individuality and temperament, which can enable them to adjust care to better suit the infant’s needs.

Nutrition (See Also Chapter 4)

During the newborn period, all mothers should be strongly encouraged to breast-feed their infants. A widely accepted goal is exclusive breast-feeding for the first 6 months of life. Vitamin D supplement (400 U/d) may be indicated for some breast-fed children. Parents who choose to bottle-feed their newborn have several choices in formulas, but should avoid cow’s milk, because of risks like anemia. Commercial formulas are typically fortified with iron and vitamin D and some contain fatty acids such as docosahexaenoic acid (DHA) and arachidonic acid (ARA) theoretically, but they are not proven to promote nervous system development. Soy or lactose-free formulas can be used, but they do not offer any specific benefit.

An appropriate weight gain is 1 oz/d during the first 6 months of life and 0.5 oz/d during the next 6 months. This weight gain requires a caloric intake of 120 kcal/kg/d during the first 6 months and 100 kcal/kg/d thereafter. Breast milk and most formulas contain 20 cal/oz. Caregivers need to be questioned at every visit about the amount and duration of the child’s feedings. Initially, the child should be fed on demand or in some cases as for twins on a partial schedule.

Solid foods such as cereals or strained, pureed baby foods such as vegetables and fruits are introduced at 4-6 months of age when the infant can support his or her head and the tongue extrusion reflex has extinguished. Delaying introduction of solid foods until this time appears to limit the incidence of food sensitivities. The child can also continue breast- or bottle-feeding, limited to 30 oz/d, because the solids now provide additional calories. Around 1 year of age when the infant can drink from a cup, bottle-feeding should be discontinued to protect teeth from caries. No specified optimum age exists for weaning a child from breast-feeding. After weaning, ingestion of whole or 2% cow’s milk may promote nervous system development.

Older infants can tolerate soft adult foods such as yogurt and mashed potatoes. A well-developed pincer grasp allows children to self-feed finger foods. With the eruption of primary teeth at 8-12 months of age, children may try foods such as soft rice or pastas.

With toddlers, mealtimes can be a source of both pleasure and anxiety as children become “finicky.” The normal child may exhibit specific food preferences or be disinterested in eating. An appropriate growth rate and normal developmental milestones should reassure frustrated parents. Coping strategies include offering small portions of preferred items first and offering limited food choices. Eating as a family gives toddlers a role model for healthy eating and appropriate social behaviors during mealtimes.

Elimination

Regular patterns for voiding and defecation provide reassurance that the child is developing normally. Newborn infants should void within 24 hours of birth. An infant urinates approximately 6-8 times a day. Parents may count diapers in the first few weeks to confirm adequate feeding. The older child usually voids 4-6 times daily. Changes in voiding frequency indicate the child’s hydration status, especially when the child is ill.

Routine circumcision of male infants is not currently recommended so parents who are considering circumcision require additional guidance. Although a circumcised boy has a decreased incidence of urinary tract infections (OR 3-5) and a decreased risk of phimosis and squamous cell carcinoma of the penis, some clinicians raise concerns about bleeding, infection, pain of the procedure, or damage to the genitalia (incidence of 0.2%-0.6%). Therefore, the decision about circumcision is based on the parents’ personal preferences and cultural influences. When done, the procedure is usually performed after the second day of life, on a physiologically stable infant. Contraindications include ambiguous genitalia, hypospadias, HIV, and any overriding medical conditions. The denuded mucosa of the phallus appears raw for the first week post-procedure, exuding a small amount of serosanguineous drainage on the diaper. Infection occurs in less than 1% of cases. Mild soap and water washes are the best method of cleansing the area. By the 2-week checkup, the phallus should be completely healed with a scar below the corona radiata. The parents should note whether the infant’s urinary stream is straight and forceful.

Newborns are expected to pass black, tarry meconium stools within the first 24 hours of life. Failure to pass stool in that period necessitates a workup for Hirschsprung disease (aganglionic colon) or imperforate anus. Later on the consistency of the stool is usually semisolid and soft, with a yellow-green seedy appearance. Breast-fed infants typically defecate after each feeding or at least two times a day. Bottle-fed infants generally have a lower frequency of stooling. Occasionally, some infants may have only one stool every 2 or 3 days without discomfort. If the child seems to be grunting forcefully with defecation or is passing extremely hard stools, treatment with lubricants like glycerin can be advised. Any appearance of blood in the stools is abnormal and warrants investigation. Anal fissure is common.