What is the plan of care for a 15-month-old child's check-up?

15-Month Well-Child Visit Plan of Care

At the 15-month well-child visit, perform a comprehensive physical examination with growth assessment, administer the fourth DTaP vaccine (if due), conduct developmental surveillance using a validated screening tool, and provide anticipatory guidance on nutrition, safety, and developmental expectations. 1

Immunizations

• Administer the fourth dose of DTaP vaccine between 15-18 months of age, with a minimum interval of 6 months from the third dose 1
• Ensure completion of other age-appropriate immunizations including MMR, varicella, hepatitis A, and Hib vaccines 1
• Complete the hepatitis B series if not already done 1
• For infants born to HBsAg-positive mothers, perform postvaccination serologic testing (anti-HBs and HBsAg) at 9-12 months if not previously completed 1

Growth Assessment

• Plot weight, length, and head circumference on appropriate growth charts 1, 2
• For premature infants, use corrected age for growth measures through 36 months for extremely preterm (<28 weeks) and very preterm (28 to <32 weeks) infants 1, 3
• Calculate corrected age by subtracting the number of weeks born early from chronological age 1, 3

Physical Examination

Perform a comprehensive head-to-toe examination with particular attention to: 1

• Growth parameters: weight, length, head circumference plotted on growth charts 1, 2
• Developmental dysplasia of the hips: assess hip stability and range of motion 1
• Vision assessment: perform red reflex testing to detect abnormalities of the ocular media 4, 1
• Eye examination: assess ocular alignment, external inspection of eyes and lids, pupil examination 4
• Cardiovascular: auscultate heart for rate, rhythm, and murmurs 2
• Respiratory: assess respiratory rate, pattern, and lung sounds 2
• Abdominal: palpate for organomegaly or masses 2
• Genitourinary: examine external genitalia 2
• Neurological: evaluate tone, posture, and spontaneous movements 2

Developmental Screening

• Use a validated, parent-completed developmental screening tool such as the Parents' Evaluation of Developmental Status (PEDS) or Ages and Stages Questionnaire (ASQ) 1
• For premature infants, correct for gestational age by subtracting weeks born early from chronological age through at least 24 months 1, 3
• Do not rely on clinical judgment alone, as up to half of children with developmental delays may be missed without formal screening tools 1
• Formal developmental screening is recommended at 9,18, and 30 months, with surveillance at all other visits 1, 2

Autism Screening Considerations

• While formal autism-specific screening is recommended at 18 and 24 months, remain vigilant for early signs at 15 months 4, 2
• The M-CHAT has lower positive predictive value (0.28) in toddlers aged 16-23 months compared to those 24-30 months (0.61), but high PPV (0.98) for any developmental disorder 4
• Refer immediately for comprehensive evaluation if autism concerns are identified 4

Hearing and Vision Surveillance

• Monitor auditory skills and developmental milestones consistent with the AAP periodicity schedule 4
• For infants with risk indicators for hearing loss (including NICU stay >48 hours, ECMO, CMV infection), ensure audiological assessment is planned by 24-30 months 4
• Perform red reflex examination in a darkened room using direct ophthalmoscope; any asymmetry in color, brightness, or size warrants referral 4
• Assess ocular alignment using corneal light reflex; any eye movement or asymmetry requires referral 4

Blood Pressure Measurement

• Blood pressure measurement is not routinely required at 15 months unless the child has obesity, renal disease, diabetes, history of aortic arch obstruction/coarctation, or is taking medications known to increase BP 4
• Annual BP measurement begins at 3 years of age for otherwise healthy children 4

Anticipatory Guidance

Provide counseling on the following topics: 1, 2

Nutrition

• Transition from bottle to cup should be completed or nearly complete 1
• Offer whole milk (not low-fat) until 2 years of age 2
• Limit milk intake to avoid iron deficiency; excessive cow's milk (>24 oz daily) is a risk factor for anemia 5
• Avoid juice before 12 months; if given after 12 months, limit to 4 oz daily 2
• Encourage self-feeding and family meals 2

Safety

• Car seat safety: ensure rear-facing car seat use continues until at least 2 years of age or until height/weight limit is reached 2
• Discuss fall prevention, water safety, and poison prevention 1, 2
• Address firearm safety if applicable 5

Dental Health

• Apply fluoride varnish at this visit 5
• Encourage twice-daily tooth brushing with fluoride toothpaste (rice grain-sized amount) 2
• Recommend establishing a dental home by 12 months if not already done 5

Sleep

• Discuss age-appropriate sleep patterns (typically 11-14 hours total including naps) 1
• Address any sleep concerns or difficulties 2

Development and Behavior

• Discuss expected developmental milestones for the coming months 1
• Encourage reading, talking, and interactive play 2
• Limit screen time: avoid screen time except video chatting for children under 18 months 5, 2

Common Pitfalls to Avoid

• Do not forget to correct for prematurity when assessing development in infants born before 37 weeks gestation 1, 3
• Do not administer DTaP-IPV/Hib (Pentacel) as the 4-6 year booster, as it is not indicated for that age 1
• Do not rely solely on clinical impression for developmental assessment; always use validated screening tools 1, 5
• Do not overlook vision screening; perform red reflex testing at every well-child visit 4, 1

Follow-Up and Referrals

• Schedule next well-child visit at 18 months 2
• Refer for comprehensive developmental evaluation if screening indicates delays 1
• Refer to ophthalmology for any abnormal red reflex or ocular alignment concerns 4
• Refer to audiology if hearing concerns identified or risk factors present 4
• Ensure caregivers understand when to seek urgent care versus routine follow-up 1