What are the recommended guidelines and orders for a 3-year-old well child visit?

Recommendations for a Three-Year-Old Well Child Visit

At the three-year-old well child visit, providers should conduct comprehensive developmental surveillance, physical examination, growth assessment, blood pressure screening, vision screening, and provide age-appropriate anticipatory guidance and immunizations as recommended by the American Academy of Pediatrics (AAP). 1

Physical Examination Components

Growth Assessment

• Measure and plot height, weight, and BMI on appropriate growth charts
• Compare with previous measurements to assess growth trajectory

Blood Pressure Screening

• Begin annual BP measurement at 3 years of age 1
• Use appropriate cuff size (bladder length 80-100% of arm circumference, width at least 40%)
• Measure in right arm with child seated and arm at heart level
• Compare readings to age, height, and gender-specific norms 1
• If elevated (≥90th percentile), repeat measurement and consider lifestyle interventions 1

Vision Screening

• Conduct visual acuity screening in cooperative 3-year-olds 1
• Consider instrument-based screening as an alternative 1
• Check for strabismus, abnormal light reflexes, and eye movement

Complete Physical Examination

• Head-to-toe examination with special attention to:
  • Cardiac exam (murmurs, rhythm)
  • Pulmonary assessment
  • Abdominal examination
  • Neurological assessment
  • Skin examination
  • Oral health assessment
  • Musculoskeletal system evaluation

Developmental Assessment

Developmental Surveillance

• Assess age-appropriate developmental milestones
• Use standardized developmental screening tools as needed
• Evaluate language development (should use 3-4 word sentences)
• Assess gross motor skills (jumping, climbing stairs)
• Evaluate fine motor skills (copying circles, using utensils)
• Screen for behavioral concerns

Anticipatory Guidance

Nutrition

• Promote healthy eating habits with appropriate portion sizes
• Limit juice to 4 oz per day
• Encourage family meals
• Avoid sugar-sweetened beverages 2

Physical Activity

• Recommend 1 hour of moderate-to-vigorous physical activity daily 1
• Limit total media time to 1-2 hours of quality programming per day 1
• No TV in child's bedroom 1

Safety

• Car seat safety (forward-facing with harness until reaching height/weight limits)
• Home safety (childproofing, poison prevention)
• Water safety (constant supervision around water)
• Sun protection
• Helmet use for tricycles/bicycles

Dental Health

• Brush teeth twice daily with fluoridated toothpaste (pea-sized amount)
• Schedule dental visits every 6 months
• Apply fluoride varnish if not receiving regular dental care 1

Sleep

• Establish consistent bedtime routines
• Expect 10-13 hours of sleep per 24 hours
• Address sleep problems (night waking, resistance)

Toilet Training

• Assess progress if not yet toilet trained
• Provide guidance on readiness signs and techniques
• Normalize occasional accidents

Immunizations

• Review immunization status and administer vaccines according to the CDC/AAP schedule
• Common vaccines at 3 years may include catch-up doses of:
  • Influenza (annual)
  • Any missed vaccines from previous visits

Screening Tests

• Lead screening if not previously done and risk factors present
• Anemia screening if risk factors present
• Tuberculosis risk assessment

Common Pitfalls to Avoid

1. Skipping blood pressure measurement: AAP recommends annual BP screening starting at age 3 1
2. Inadequate developmental surveillance: Clinical judgment alone can miss up to 45% of children eligible for early intervention
3. Overlooking vision screening: Visual acuity screening should begin at age 3 in cooperative children 1
4. Insufficient anticipatory guidance: Tailor guidance to family needs and concerns
5. Neglecting dental health: Fluoride varnish application should continue through 5 years of age 1

Documentation Requirements

• Complete documentation of all components of the visit
• Growth parameters with percentiles
• Developmental assessment findings
• Anticipatory guidance provided
• Immunizations administered
• Plan for follow-up

The next well-child visit should be scheduled at 4 years of age, unless concerns warrant earlier follow-up.