What are the recommended assessments and interventions for a 5-year well-child checkup?

5-Year Well-Child Checkup: Recommended Assessments and Interventions

At the 5-year well-child visit, perform monocular visual acuity testing using HOTV letters or LEA SYMBOLS charts with proper eye occlusion, screen for anemia in high-risk populations, apply fluoride varnish, verify immunization completion, and provide anticipatory guidance on nutrition, physical activity, screen time, and safety. 1

Vision Screening

Visual acuity testing is the single most critical screening at this visit, as treatment efficacy for amblyopia decreases steadily after age 3 and becomes ineffective by age 12 years. 1

• Test each eye separately (monocularly) using HOTV letters or LEA SYMBOLS charts as the preferred optotypes. 2, 1
• Cover the fellow eye with an adhesive patch or tape to prevent peeking, which can produce false-negative results. 2, 1
• Do not use Snellen letters, Allen figures, Lighthouse chart, or Kindergarten (Sailboat) Eye Chart, as these have not been validated or do not meet WHO standards. 2, 1
• Refer immediately for comprehensive ophthalmologic examination after the first screening failure—do not rescreen multiple times. 2, 1
• For uncooperative children, instrument-based screening (photoscreening or autorefraction) can be offered as an alternative, though it is not superior to visual acuity testing in cooperative children. 2, 1
• Perform additional assessments including red reflex examination, external inspection of eyes and lids, ocular motility assessment, and pupil examination. 2, 1

Hearing Screening

• Perform age-appropriate audiologic testing with conventional audiometry. 3
• Use a fail criterion of >20 dB HL at one or more frequencies (500,1000,2000,4000 Hz) in either ear. 3
• Refer for comprehensive audiologic evaluation by an audiologist if the child fails primary care screening. 3

Anemia Screening

In high-risk populations (low-income families, WIC-eligible, migrant children, recently arrived refugees), screen annually from ages 2 to 5 years using hemoglobin concentration or hematocrit. 2

For selective screening in non-high-risk populations, assess for risk factors including:

• Low-iron diet or limited food access due to poverty. 2
• Consumption of >24 oz daily of cow's milk. 2
• Special health-care needs or medications interfering with iron absorption. 2
• Screen only if risk factors are present. 2

If anemia is detected, treat with 3 mg/kg per day of iron drops administered between meals, and recheck in 4 weeks. 2

Developmental and Behavioral Assessment

• Screen for speech and language delays, and refer immediately for audiological assessment if speech delay is identified. 3
• Consider autism spectrum disorder screening if there are concerns about social communication or repetitive behaviors. 3
• Assess school readiness, attention, learning concerns, and emotional well-being. 4
• Do not rely solely on clinical judgment for developmental assessment, as physician impression alone misses 45% of children eligible for early intervention. 2, 3

Dental Health

• Apply fluoride varnish at this visit, continuing the schedule that should have begun at 6 months of age. 1
• Screen for dental caries, which is the most common chronic disease in young children. 1
• Recommend twice-yearly dental examinations. 2
• For children living in areas with inadequate water fluoride (<0.6 ppm), prescribe daily fluoride supplementation. 4

Immunizations

• Verify completion of all routine childhood immunizations including MMR series, varicella series, hepatitis A and B series, and annual influenza vaccine. 1, 4
• Administer any missed immunizations according to catch-up schedules. 4

Growth and Nutrition Assessment

• Measure height, weight, and calculate body mass index (BMI). 4
• Screen for obesity (BMI ≥95th percentile for age and sex) and provide resources for comprehensive behavioral interventions if present. 4
• Counsel on healthy eating habits, appropriate portion sizes, and limiting juice and sugar-sweetened beverages. 1, 5
• Recommend at least 400 IU of vitamin D daily. 4

Physical Activity and Screen Time

• Encourage 60 minutes of physical activity daily. 1
• Limit recreational screen time to one hour per day for children this age. 1, 5

Safety Counseling

Provide guidance on:

• Proper use of seat belts and booster seats (car seats should remain rear-facing until age 2 or until height/weight limit is reached). 1, 5
• Helmet use for biking and other sports. 1
• Water safety and drowning prevention. 1
• Firearm safety if applicable. 1

Tobacco Exposure Screening

• Ask if the child lives with anyone who uses tobacco, if anyone smokes in the home or car, and if caregivers use tobacco products. 1
• Provide tobacco use prevention counseling, as messages should start when children are developmentally ready to understand them, typically around age 5. 1

Blood Pressure

• Check blood pressure annually beginning at age 3, though evidence for screening before age 18 is mixed. 4

Social and Behavioral Guidance

• Provide guidance on social interactions with peers, bullying prevention, and mental health concerns. 1
• Evaluate family dynamics and provide support for parenting challenges. 1
• Begin establishing independent health communication with confidential time with the child. 1