What are the key components of a well-child visit for a 24-month-old female, including physical assessment, developmental milestones, immunizations, and anticipatory guidance?

Well-Child Visit for a 24-Month-Old Female

At the 24-month well-child visit, conduct a comprehensive physical assessment including growth parameters, perform developmental screening with a standardized tool, administer any due immunizations, and provide age-specific anticipatory guidance, while identifying at least one abnormal finding related to growth or development that requires intervention.

Physical Assessment

Growth Parameters

• Measure and plot height, weight, and head circumference on WHO or CDC growth curves to assess for growth abnormalities 1, 2
• Calculate and plot body mass index (BMI) to screen for underweight or overweight status 2
• Assess overall body habitus for signs of failure to thrive, obesity, or dysmorphic features 1

Vital Signs

• Obtain complete vital signs including blood pressure, which should be measured at this age 2
• Assess heart rate and respiratory rate 2

Head-to-Toe Physical Examination

• Perform fundoscopic examination or refer for red reflex testing to screen for retinoblastoma and other ocular abnormalities 1
• Examine oral cavity for dental caries, tooth eruption pattern (should have approximately 16 primary teeth), and oral hygiene 1
• Assess skin for lesions, birthmarks, or signs of abuse 1
• Perform cardiovascular and pulmonary examination 1
• Examine abdomen for organomegaly or masses 2
• Inspect genitalia for normal development and any abnormalities 2
• Assess musculoskeletal system including gait, spine alignment, and hip examination 2

Neurological Assessment

• Observe muscle tone, strength, and symmetry of movement 1
• Assess for any focal neurological deficits or asymmetries 1

Developmental Milestones

Standardized Developmental Screening

• Administer a validated developmental screening tool such as Ages and Stages Questionnaire (ASQ) or Parents' Evaluation of Developmental Status (PEDS) at this 24-month visit, as this is not one of the routine screening ages (9,18,30 months) but autism-specific screening is recommended 1, 3
• Perform autism-specific screening using Modified Checklist for Autism in Toddlers (M-CHAT) as recommended at 18 and 24 months 1, 3

Expected Gross Motor Skills at 24 Months

• Child should walk independently and run 1
• Should be able to kick a ball 1
• Should walk up and down stairs (may hold rail) 1
• Should jump with both feet off the ground 1

Expected Fine Motor Skills at 24 Months

• Should grasp and manipulate small objects with precision 1
• Should be able to stack 4-6 blocks 1
• Should use utensils for self-feeding 1
• Should scribble spontaneously 1

Expected Language/Communication Skills

• Should have vocabulary of at least 50 words 1
• Should combine two words together ("more milk," "daddy go") 1
• Should follow two-step commands 1

Expected Social-Emotional Skills

• Should engage in parallel play with other children 1
• Should show interest in other children 1
• Should demonstrate attachment behaviors 1

Red Flags Requiring Immediate Referral

• Loss of previously acquired skills at any age indicates possible progressive neuromuscular disorder and requires urgent evaluation 1
• Persistent asymmetry in movement or tone suggests neuromotor concerns 1, 4
• Absence of walking independently by 18 months (already delayed at 24 months) 1
• Fewer than 50 words or no two-word combinations 1
• Positive autism screening 1, 3

Immunizations

Vaccines Due at 24 Months

Based on the ACIP immunization schedule, review and administer any catch-up vaccines needed 1:

• Hepatitis A vaccine series (if not completed; second dose should be given 6 months after first dose, typically at 18 months) 1
• Hepatitis B series (if not completed; final dose should have been given by 18 months) 1
• DTaP (diphtheria, tetanus, pertussis) - ensure 4 doses completed 1
• Haemophilus influenzae type b (Hib) - ensure series completed 1
• Pneumococcal conjugate vaccine (PCV13) - ensure 4-dose series completed 1
• Inactivated poliovirus vaccine (IPV) - ensure 3 doses completed 1
• MMR (measles, mumps, rubella) - first dose should have been given at 12 months; second dose typically given at 4-6 years but can be given as early as 4 weeks after first dose 1
• Varicella vaccine - first dose should have been given at 12 months 1
• Influenza vaccine - administer annually 1

Documentation

• Use combination vaccines when appropriate and approved by FDA 1
• Report any clinically significant adverse events to VAERS 1
• Update immunization registry 1

Anticipatory Guidance

Safety

• Car seat safety: Child should remain in rear-facing car seat until at least 2 years of age or until height/weight limit for seat is reached 1, 2
• Safe sleep: Continue supine positioning; avoid co-sleeping 1
• Childproofing home: secure furniture, cover electrical outlets, lock cabinets with hazardous materials 1
• Water safety and drowning prevention 2
• Poison control number (1-800-222-1222) 2

Nutrition

• Wean from bottle to cup if not already completed (should be done by 12-15 months to prevent dental caries) 2
• Limit or avoid juice; if given, limit to 4 oz per day of 100% fruit juice 2
• Avoid sugar-sweetened beverages 2
• Encourage family meals and healthy eating patterns 2
• Whole milk (or 2% if overweight) until age 2, then can transition to low-fat milk 2
• Encourage self-feeding with utensils 2

Dental Health

• First dental visit should have occurred by 12 months of age; if not, refer immediately 1
• Brush teeth twice daily with fluoride toothpaste (rice grain-sized amount for children under 3 years) 1
• Discuss fluoride supplementation if water supply is not fluoridated 1
• Avoid prolonged bottle use and nighttime bottles with milk or juice 1

Screen Time and Media Use

• Limit screen time to no more than 1 hour per day of high-quality programming for children 2-5 years of age 1, 2
• Co-view media with child and discuss content 1
• Avoid screen time during meals and before bedtime 1
• Keep screens out of child's bedroom 1

Sleep

• Establish consistent bedtime routine 2
• Expected sleep: 11-14 hours per 24 hours including naps 2
• Address any sleep difficulties 2

Behavior and Discipline

• Discuss positive discipline strategies and setting limits 2
• Address temper tantrums and appropriate responses 2
• Encourage positive reinforcement for desired behaviors 2

Social-Emotional Development

• Encourage play with other children 2
• Read to child daily 2
• Promote language development through conversation 2

Maternal Mental Health

• Screen mother for postpartum depression if infant is under 6 months (not applicable at 24 months, but consider screening for maternal depression if concerns) 2, 3

Environmental and Social Risk Factors

• Assess for social determinants of health including food security, housing stability, and access to care 1
• Screen for domestic violence, substance abuse, and child abuse risk factors 1
• Ensure family has established medical home for ongoing care 1

Example of Abnormal Finding Requiring Intervention

Abnormal Finding: Child is not yet walking independently at 24 months of age (gross motor delay, as independent walking should have been achieved by 18 months) 1. This represents a significant delay requiring referral to early intervention services and possible pediatric neurology or developmental pediatrics evaluation 1.

Alternative Abnormal Finding: Growth parameters plot below the 3rd percentile for weight-for-length (failure to thrive), requiring nutritional assessment, laboratory evaluation, and possible referral to pediatric gastroenterology or nutrition services 2.

Alternative Abnormal Finding: Positive M-CHAT autism screening at 24-month visit, requiring immediate referral for comprehensive autism evaluation and early intervention services 1, 3.