What are the necessary assessment items and labs for pediatric well-child visits in patients from newborn to 18 years old, considering their age and developmental stage?

Pediatric Well-Child Visit Assessment Items and Laboratory Tests: Newborn to 18 Years

Developmental Screening Schedule

Perform formal standardized developmental screening using validated tools at 9,18, and 30 months of age, as clinical observation alone misses approximately 45% of children eligible for early intervention. 1, 2

Validated Screening Tools by Age

Infancy and Early Childhood (9-30 months):

• Ages and Stages Questionnaire (ASQ) or Parents' Evaluation of Developmental Status (PEDS) at 9,18, and 30 months 1, 2, 3
• Use parent-completed questionnaires rather than clinical judgment alone 1, 2
• For premature infants, correct for gestational age by subtracting weeks born early from chronological age through at least 24 months 1, 3

Behavioral and Social-Emotional Screening:

• Ages and Stages Questionnaire-Social Emotional (ASQ-SE) at 9,18,24, or 30 months 4
• Brief Infant-Toddler Social and Emotional Assessment at 18 and 30 months 4
• Behavioral screening at 30 and 48 months is especially important for early identification of learning disabilities and ADHD 4

Preschool Through Adolescence (48 months-18 years):

• Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire from 48 months through adolescence 4
• Vanderbilt ADHD Rating Scales from 6 years and older to screen for ADHD, oppositional defiant disorder, conduct disorder, anxiety, and depression 4

Autism Spectrum Disorder Screening

Autism-Specific Screening:

• Modified Checklist for Autism in Toddlers (M-CHAT) at 18 and 24 months 1, 3
• The M-CHAT has lower positive predictive value (0.28) at 16-23 months compared to 24-30 months (0.61), but high positive predictive value (0.98) for any developmental disorder 1, 3
• Refer immediately for comprehensive evaluation if autism concerns are identified 3

Vision and Hearing Assessment

Vision Screening:

• Red reflex testing at every well-child visit in infancy to detect abnormalities of ocular media 3
• Corneal light reflex to assess ocular alignment, with any asymmetry requiring referral 3
• Instrument-based screening at 18 months to assess risk 1
• One-time vision screening between 3-5 years of age to detect amblyopia 5
• For premature infants with risk factors: ophthalmologic examination at 31-33 weeks postmenstrual age or 4 weeks chronological age, whichever is later, for retinopathy of prematurity screening 4

Hearing Assessment:

• Formal audiological assessment by 24-30 months for infants with risk indicators including NICU stay >48 hours, ECMO, or CMV infection 3
• Monitor auditory skills and developmental milestones at each visit 3

Laboratory Screening

Anemia Screening:

• Universal hemoglobin or hematocrit screening at 12 months 1
• Risk assessment at 18 months to determine if additional screening is needed 1

Newborn Metabolic Screening:

• State-mandated newborn screening panel (varies by state but typically includes phenylketonuria, hypothyroidism, galactosemia, sickle cell disease, and other metabolic disorders)

Lead Screening:

• Risk assessment at 6,9,12,18, and 24 months
• Blood lead level testing based on risk factors or universal screening per local guidelines

Lipid Screening:

• Universal screening once between 9-11 years and again between 17-21 years
• Earlier screening for children with risk factors (family history, obesity, diabetes, hypertension)

Tuberculosis Screening:

• Risk assessment annually
• Tuberculin skin test or interferon-gamma release assay if risk factors present

Physical Examination Components

Growth Parameters at Every Visit:

• Weight, length/height, and head circumference (head circumference through 36 months) plotted on appropriate growth charts 3
• For extremely preterm and very preterm infants, use corrected age for growth measures through 36 months 3
• Body mass index calculation and plotting starting at 2 years of age

Cardiovascular Assessment:

• Blood pressure measurement annually beginning at 3 years of age 3
• Earlier blood pressure measurement if child has obesity, renal disease, diabetes, history of aortic arch obstruction/coarctation, or takes medications that increase blood pressure 3

Musculoskeletal Assessment:

• Developmental dysplasia of the hips screening in infancy 3
• Scoliosis screening in early adolescence

Neurologic Assessment:

• Motor milestone assessment at each visit: at 18 months, expect sitting, standing, walking independently, and grasping/manipulating small objects 1, 2
• Muscle tone assessment: increased tone warrants brain MRI; decreased tone warrants serum creatine kinase measurement 1, 2
• Assess for motor symmetry, with asymmetry warranting neurologic evaluation 2

Oral Health:

• Fluoride varnish application from 6 months through 5 years of age 1
• Dental referral by 12 months of age

Maternal Mental Health Screening

Postpartum Depression Screening:

• Screen mothers of infants up to 6 months of age for postpartum depression 5
• PHQ-9 is an appropriate screening tool 6

Immunization Review

At Every Visit:

• Review and update immunizations according to CDC schedule 1, 3
• Fourth dose of DTaP between 15-18 months with minimum 6-month interval from third dose 1, 3
• Hepatitis B series completion by 15 months if not already done 3
• For infants born to HBsAg-positive mothers, postvaccination serologic testing (anti-HBs and HBsAg) at 9-12 months 3

Nutritional Assessment

Feeding History:

• Breastfeeding status and duration (cessation before 6 months associated with childhood obesity) 5
• Transition to solid foods (before 6 months associated with childhood obesity) 5
• Transition from bottle to cup by 12 months 1, 3
• Juice and sugar-sweetened beverage consumption (should be avoided before 1 year and limited thereafter) 5

For High-Risk Infants (e.g., chronic lung disease):

• Urinalysis, electrolytes, blood urea nitrogen, creatinine, calcium, and phosphorus monitoring 4
• Video swallow studies if swallowing dysfunction suspected 4
• Gastroesophageal reflux evaluation (barium swallow, gastric scintiscan, 24-hour esophageal pH monitoring, endoscopy) for symptomatic infants or unexplained failure to thrive 4

Anticipatory Guidance Topics by Visit

Every Visit Should Address:

• Safety (car seat positioning: rear-facing until 2 years or until height/weight limit reached) 5
• Nutrition appropriate for age 3
• Sleep patterns 1, 3
• Dental health 1, 3
• Screen time (avoid except video chatting before 18 months; limit to 1 hour daily for ages 2-5 years) 5

Referral Criteria

Immediate Referral Required:

• Any child failing standardized developmental screening requires referral to early intervention programs 1, 2
• Do not delay referral while pursuing diagnostic workup—these should occur concurrently 1
• Absent expected motor milestones (e.g., not walking independently or grasping small objects at 18 months) 1, 2
• Loss of previously acquired skills mandates urgent neurologic evaluation 2
• Abnormal muscle tone findings 1, 2
• Positive autism screening 3

Common Pitfalls to Avoid

• Do not rely on clinical judgment alone for developmental screening, as this approach misses up to half of children with developmental delays 1, 2, 3
• Do not forget to correct for prematurity when assessing development in infants born before 37 weeks gestation through at least 24 months 1, 3
• Do not use milestone checklists as a substitute for formal standardized developmental screening tools 2
• Do not administer DTaP-IPV/Hib (Pentacel) as the 4-6 year booster, as it is not indicated and a fifth IPV dose will be needed 3