What are the key components of primary care management for a pediatric well visit?

Primary Care Management for Pediatric Well Visits

Primary care pediatricians should serve as the child's medical home and deliver comprehensive preventive, acute, and chronic care services through structured well-child visits that include developmental surveillance at every visit, formal developmental screening at 9,18, and 30 months, autism-specific screening at 18 and 24 months, immunization updates, age-appropriate anticipatory guidance, and universal screening for maternal postpartum depression in infants up to 6 months. 1, 2

Core Components of Well-Child Visits

History and Assessment

• Birth history, prior screenings, diet, sleep patterns, dental care, and comprehensive medical, surgical, family, and social histories should be obtained at each visit 2
• Developmental surveillance must occur at every well-child visit, with formal standardized developmental screening performed at 9,18, and 30 months of age 1, 2
• Autism-specific screening should be conducted at 18 and 24 months using validated tools 2
• Universal screening for postpartum depression in mothers of infants up to 6 months of age is recommended to identify families needing additional support 2

Physical Examination

• Complete head-to-toe examination with growth parameter review (height, weight, head circumference plotted on growth charts) should be performed at each visit 2
• One-time vision screening between 3 and 5 years of age to detect amblyopia 2

Immunizations

• Review and update immunizations according to current schedules at each appropriate visit 2
• Preventive services including immunizations should not be subject to deductibles or copayments 1

Age-Specific Anticipatory Guidance

Safety

• Car seats must remain rear-facing until 2 years of age or until the height/weight limit for the seat is reached 2

Nutrition and Feeding

• Breastfeeding should continue for at least 6 months, as cessation before 6 months is associated with childhood obesity 2
• Transition to solid foods should not occur before 6 months of age 2
• Juice and sugar-sweetened beverages should be avoided before 1 year of age and provided only in limited quantities after age 1 year 2
• Weaning to a cup by 12 months of age may improve dental health 2

Dental Health

• Fluoride use and limiting/avoiding juice should be discussed to promote optimal dental health 2

Screen Time

• Screen time should be avoided in children younger than 18 months (with the exception of video chatting) 2
• For children 2 to 5 years of age, screen time should be limited to 1 hour per day 2

Medical Home Principles

Care Coordination

• The primary care pediatrician serves as care coordinator, ensuring all referrals are medically necessary and maintaining 24/7 accessibility or appropriate coverage arrangements 1
• For children with special health care needs (those with or at increased risk for chronic physical, developmental, behavioral, or emotional conditions requiring services beyond those needed by children generally), the primary care medical home provides a triad of services: preventive care, acute illness management, and chronic-condition management 1

Quality Assurance

• Consistent implementation of AAP periodicity schedules and confidentiality protections for adolescents 1
• Early identification of health problems should be incentivized through appropriate screening and surveillance 1

Special Populations

Adolescents

• Developmentally appropriate care with attention to confidentiality as teenagers develop autonomy and adult identity 1
• Multiple sources of care may be needed to ensure comprehensive services 1

Children with Special Health Care Needs

• When developmental disorders or motor delays are identified, initiate chronic condition management with written care plans, explicit co-management with specialists, and appropriate patient education 1
• Create and maintain a registry for children with special health care needs in the practice 1
• The locus of management may shift between primary care and specialty care depending on acuity and complexity, but the medical home remains in primary care 1

Common Pitfalls to Avoid

• Do not delay developmental screening until concerns are obvious—universal screening at specified intervals identifies problems earlier across all populations 1
• Do not assume low sensitivity in clinical judgment alone—formal screening tools improve detection rates 1
• Do not neglect maternal mental health screening—postpartum depression affects child outcomes and should be addressed in the infant's medical home 2
• Avoid fragmented care—the medical home model requires comprehensive coordination, not just episodic acute care 1