What assessments and evaluations should be performed at a 6-month well appointment for a healthy child?

6-Month Well-Child Visit Assessment

At the 6-month well-child visit, you should perform a comprehensive physical examination with growth assessment, developmental screening, vision and hearing evaluation, and administer scheduled immunizations.

Growth Parameters

• Measure and plot weight, length, and head circumference on appropriate growth charts to assess growth trajectory and identify any deviations from expected patterns 1.
• Compare current measurements to previous visits to ensure adequate growth velocity 1.

Physical Examination

Head and Eyes

• Perform red reflex testing to detect abnormalities of the ocular media, cataracts, or retinoblastoma 2, 1.
• Conduct binocular red reflex (Brückner) test to assess symmetry of red reflexes 1.
• External inspection of ocular and periocular structures, including pupillary examination 2, 1.
• Assess fixation and following behavior - by 6 months, children should have normal binocular alignment 2.
• Examine fontanelles and head shape for any abnormalities 1.

Cardiovascular and Respiratory

• Auscultate heart for rate, rhythm, and presence of murmurs 1.
• Auscultate lungs for air entry and abnormal sounds 1.
• Assess respiratory rate and pattern 1.

Abdomen and Genitourinary

• Palpate abdomen for organomegaly, masses, or tenderness 1.
• Examine external genitalia for any abnormalities 1.

Musculoskeletal and Neurological

• Examine hips for signs of developmental dysplasia 1.
• Evaluate muscle tone, posture, and spontaneous movements - this is critical as motor delays may first become apparent around this age 2, 1.
• Assess for motor symmetry 2.

Skin

• Assess skin color, perfusion, and presence of any rashes or lesions 1.

Developmental Assessment

Motor Milestones

• By 6 months, infants should roll to both sides and sit well without support - absence of these skills at 9 months (the next screening visit) signifies delay 2.
• Observe for motor symmetry in all movements 2.
• Assess ability to grasp and manipulate objects 2.

Social and Communication

• Evaluate social interaction, including eye contact and social responsiveness 1.
• Ask parents specific developmental questions: "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 used to be able to do that he or she can no longer do?" 1.

Important caveat: While formal standardized developmental screening is recommended at 9,18, and 30 months per AAP guidelines 2, continuous developmental surveillance should occur at every visit 2. If parents express concerns or you observe delays, do not wait until the 9-month visit to act.

Hearing Assessment

• Review newborn hearing screening results if not previously documented 1.
• If newborn screening was not completed or if there are parental concerns about hearing, refer for formal audiological assessment 1.

Immunizations

• Administer the third dose of the following vaccines (completing the primary series for most): DTaP, IPV, Hib, PCV13, and hepatitis B 3.
• Administer the third dose of rotavirus vaccine (depending on brand - some complete at 6 months, others at 4 months) 3.
• If during influenza season (typically October-March), begin the 2-dose influenza vaccine series separated by 28 days for infants receiving influenza vaccine for the first time 3.

Critical pitfall: Missing the 6-month immunization visit significantly delays completion of the primary vaccine series. Most undervaccinated children need only one additional visit to complete their series 4.

Anticipatory Guidance

Safety

• Reinforce safe sleep practices: back to sleep on firm surface, no co-sleeping 5.
• Verify proper car seat use: rear-facing car seat appropriately installed 5.
• Discuss injury prevention as infant becomes more mobile.

Nutrition

• Discuss introduction of solid foods if not already started.
• Continue breastfeeding or formula feeding as primary nutrition source.
• Avoid excessive vitamin D supplementation - while adequate vitamin D is important, excessive supplementation should be used with caution, particularly in certain populations 2.

Parental Well-being

• Screen for maternal postpartum depression using a validated tool if not done at previous visits 5.

Special Populations

• For premature infants, use corrected age when assessing developmental milestones through at least 24 months of life 1.
• For infants with risk factors (prematurity, Down syndrome, cerebral palsy, family history of vision problems), maintain heightened surveillance for developmental concerns 2, 1.

Follow-up

• Schedule the 9-month well-child visit, which includes formal standardized developmental screening 2.
• Ensure parents understand developmental expectations for the next period 1.