What should be done during a 1-month well-child check?

1-Month Well-Child Check

At the 1-month well-child visit, perform a comprehensive head-to-toe physical examination with growth parameter assessment, hip examination for developmental dysplasia, complete neurological evaluation, and ensure hepatitis B vaccination is on schedule. 1, 2, 3

Growth Assessment and Vital Signs

• Measure and plot weight, length, and head circumference on appropriate growth charts to track growth trajectory and identify any deviations from expected patterns. 2, 3
• For premature infants, correct all growth measurements for gestational age by subtracting the number of weeks born early from chronological age. 4
• Assess overall appearance, activity level, and interaction with caregivers as indicators of general well-being. 4

Physical Examination Components

Head and Neurological Assessment

• Examine fontanelles for size, tension, and shape of head to detect abnormalities such as craniosynostosis or increased intracranial pressure. 4
• Evaluate tone, posture, primitive reflexes (Moro, grasp, rooting, stepping), and spontaneous movements to identify neurological concerns. 4, 2
• Assess for any involuntary movements or coordination impairments. 4

Vision and Eye Examination

• Perform red reflex testing bilaterally to detect abnormalities of the ocular media such as cataracts or retinoblastoma. 4
• Conduct binocular red reflex (Brückner) test to assess symmetry of reflexes. 4
• Perform external inspection of ocular and periocular structures. 4
• Assess pupillary examination and fixation/following behavior. 4

Ear, Nose, and Throat

• Examine tympanic membranes for appearance and mobility. 4
• Assess nares for patency and any discharge. 4
• Examine oral cavity, including palate (to rule out cleft) and tongue (assess for tongue-tie if feeding difficulties present). 4
• Review newborn hearing screening results if not previously done. 4

Cardiovascular and Respiratory

• Auscultate heart for rate, rhythm, and presence of murmurs that may indicate congenital heart disease. 4
• Auscultate lungs for air entry and any abnormal sounds such as wheezing or crackles. 4
• Assess respiratory rate and pattern for signs of respiratory distress. 4

Abdomen and Umbilicus

• Palpate abdomen for organomegaly, masses, or tenderness. 4
• Assess umbilical cord site for complete healing and absence of infection, drainage, or granuloma formation. 4, 2

Genitourinary Examination

• Examine external genitalia for any abnormalities including hypospadias, hydrocele, or ambiguous genitalia. 4
• Assess urinary stream in males and genital appearance in females. 4
• In males, palpate for presence of both testes in the scrotum to detect undescended testes early. 1, 5

Musculoskeletal and Hip Examination

• Perform hip examination using Ortolani and Barlow maneuvers to detect developmental dysplasia of the hip (DDH), as these tests are most sensitive at this age. 1, 4, 6
• Assess for risk factors including female gender, breech positioning, positive family history, or firstborn status. 1
• For high-risk infants (breech presentation, family history, or abnormal physical exam), consider selective ultrasound screening at 4-6 weeks of age. 1, 6

Skin Assessment

• Evaluate skin color, perfusion, and presence of jaundice. 4, 2
• If jaundice is present beyond 2 weeks of age, measure total and direct/conjugated bilirubin to identify cholestasis. 2
• Assess for any rashes, birthmarks, or lesions. 4

Laboratory and Screening Tests

• Review newborn metabolic screening results if not previously reviewed, including thyroid, PKU, and other state-mandated screens. 4, 2
• For infants with prolonged jaundice, check thyroid and galactosemia screening results. 2
• Verify completion of newborn hearing screening or arrange formal assessment if not done. 4

Immunizations

• Verify hepatitis B vaccine administration status. 1, 7
• For infants born to HBsAg-positive mothers, ensure both hepatitis B vaccine and HBIG were given within 12 hours of birth, and plan second dose at 1 month. 1, 7
• For infants born to mothers with unknown HBsAg status at delivery, confirm maternal testing was completed and appropriate follow-up vaccination schedule is being followed. 1

Developmental Assessment

• Assess whether infant lifts head briefly when prone. 4
• Observe for social interaction including eye contact and early social responsiveness. 4
• Ask parents: "Is there anything your child is not doing that you think he or she should be able to do?" and "Is there anything your child is doing that you are concerned about?" 4

Anticipatory Guidance

• Discuss safe sleep practices (supine positioning, firm surface, room-sharing without bed-sharing). 3
• Review feeding patterns (breast or formula), expected frequency, and output. 3
• Address basic infant care including bathing, skin care, and temperature measurement. 4
• Counsel on car seat safety, ensuring rear-facing seat is properly installed. 3
• Discuss normal crying patterns and strategies for soothing. 3

Special Populations

• For premature infants born <32 weeks or <45 weeks postconceptional age, maintain heightened surveillance as they are higher-risk for various complications. 4
• For infants with congenital heart disease, recognize compounded neurodevelopmental risk requiring enhanced monitoring. 4

Common Pitfalls to Avoid

• Do not rely on visual estimation alone for jaundice assessment—always obtain objective measurement with transcutaneous or serum bilirubin, particularly in darkly pigmented infants. 2
• Do not dismiss parental concerns about hip clicks without proper examination, as normal physical exam does not completely exclude DDH development. 6
• Avoid performing hip ultrasound before 2 weeks of age, as this leads to overdiagnosis of physiologic hip immaturity that resolves spontaneously. 6
• Do not assume hearing screening was completed—actively verify results, as missed hearing loss has significant developmental consequences. 4