What are the recommended assessments and interventions for a 2-year-old well-child checkup?

2-Year-Old Well-Child Checkup: Recommended Assessments and Interventions

At the 2-year well-child visit, perform standardized developmental screening using a validated parent-completed tool (Ages and Stages Questionnaire or Parents' Evaluation of Developmental Status), conduct autism-specific screening, assess growth parameters, complete a comprehensive physical examination, update immunizations, and provide anticipatory guidance on nutrition, safety, and screen time. 1

Developmental Screening (Critical Priority)

Use a validated, standardized developmental screening tool at this visit—not clinical surveillance alone. 1

• Administer a parent-completed developmental screening tool such as the Ages and Stages Questionnaire (ASQ) or Parents' Evaluation of Developmental Status (PEDS), as these are more practical than directly administered tools and have been extensively validated 1
• Perform autism-specific screening at 24 months using tools like the M-CHAT (Modified Checklist for Autism in Toddlers), as the American Academy of Pediatrics recommends autism screening at both 18 and 24 months 1
• Clinical surveillance alone misses approximately 45% of children eligible for early intervention—formal screening tools are essential 1

Key developmental milestones to assess at 2 years:

• Motor skills: ability to walk, run, kick a ball, climb stairs 2
• Language: two-word phrases, following simple commands 2
• Social: parallel play, imitation of adults 2

Growth Assessment

• Plot weight, length/height, and head circumference on appropriate growth charts (WHO charts for children under 24 months, CDC charts for 2 years and older) 3, 2
• For premature infants, use corrected age for developmental assessments through at least 24 months and for growth parameters through 36 months if born before 32 weeks gestation 3
• Calculate and plot BMI starting at age 2 years 2

Comprehensive Physical Examination

Head and Neurological:

• Assess fontanelle closure (anterior fontanelle typically closes by 18-24 months) 3
• Evaluate tone, posture, gait, and coordination 3, 4
• Observe for any involuntary movements 3

Vision and Eye Examination:

• Perform red reflex testing bilaterally to detect ocular media abnormalities 1, 3
• Conduct corneal light reflex assessment to screen for strabismus (eye misalignment) 1
• Assess fixation and ability to follow objects 1, 3
• External inspection of eyes and periocular structures 1, 3

Hearing:

• Review newborn hearing screening results if not previously documented 3
• Assess response to sounds and parental concerns about hearing 2

Cardiovascular and Respiratory:

• Auscultate heart for murmurs, rate, and rhythm 3
• Auscultate lungs and assess respiratory pattern 3

Dental:

• Examine teeth and oral cavity 2
• Discuss dental home establishment and fluoride use 2

Musculoskeletal:

• Screen for developmental dysplasia of the hip (though less critical at this age than infancy) 3
• Observe gait and motor coordination 4

Genitourinary:

• Examine external genitalia 3
• Assess Tanner staging (typically prepubertal at age 2) 4

Immunizations

• Review and administer age-appropriate vaccines according to CDC schedule 3, 2
• At 2 years, catch-up vaccines may be needed if behind schedule 2

Screening for Psychosocial Issues

• Screen for maternal postpartum depression if the child is under 6 months (not applicable at 2 years, but important context) 2
• Assess family social history, including living situation, stressors, and access to resources 1, 2
• Ask about parental concerns regarding behavior, mood, or development 1, 3

Anticipatory Guidance

Safety:

• Car seat should remain rear-facing until at least age 2 years or until height/weight limit for the seat is reached 2
• Discuss home safety: outlet covers, stair gates, poison control, water safety 2

Nutrition:

• Avoid juice and sugar-sweetened beverages before age 1; limit to 4 oz daily after age 1 2
• Wean from bottle to cup by 12-15 months to prevent dental caries 2
• Encourage varied diet with fruits, vegetables, whole grains, and adequate protein 2
• Discuss limiting processed foods 5

Dental Health:

• Recommend fluoride supplementation if water supply is not fluoridated 2
• Encourage tooth brushing twice daily with fluoride toothpaste (rice-grain size for children under 3) 2
• Establish dental home by age 1 year if not already done 2

Screen Time:

• Limit screen time to maximum 1 hour per day of high-quality programming for children ages 2-5 years 2
• Discourage screen time during meals and before bedtime 2

Physical Activity:

• Encourage active play and limit sedentary time 5
• Discuss age-appropriate physical activities 5

Sleep:

• Discuss sleep routines and expected sleep duration (11-14 hours per 24 hours including naps) 2

Referrals and Follow-Up

• Refer immediately for early intervention services if developmental screening indicates delays 1
• Refer for comprehensive autism evaluation if autism screening is positive 1
• Refer to ophthalmology if vision screening abnormalities detected 1
• Refer to audiology if hearing concerns identified 3
• Schedule next well-child visit at 30 months (or 2.5 years) with developmental screening 1

Common Pitfalls to Avoid

• Do not rely on clinical judgment alone for developmental assessment—this approach misses nearly half of children with delays 1
• Do not skip autism-specific screening at 24 months even if general developmental screening is normal, as autism may present differently 1
• Do not use chronological age for premature infants without correcting for gestational age through at least 24 months 3
• Do not assume normal vision without formal screening—amblyopia is best treated when detected early 1, 2