What are the recommended assessments and interventions for a 6-year-old female during a well-child check?

6-Year-Old Female Well-Child Check

At the 6-year well-child visit, perform monocular visual acuity testing with HOTV or LEA SYMBOLS charts, conventional audiometry screening, apply fluoride varnish, verify immunization completion, and provide anticipatory guidance on physical activity (60 minutes daily), screen time limits (1 hour daily), safety, and social development. 1

Vision Screening

Visual acuity testing is the priority screening at this age and must be performed monocularly with proper occlusion. 1

• Use HOTV letters or LEA SYMBOLS charts—these are validated optotypes specifically designed for young children 2, 1
• Test each eye separately with the fellow eye covered using an adhesive patch or tape to prevent peeking 2, 1
• Refer immediately to ophthalmology after the first screening failure—do not rescreen multiple times in the primary care setting 1
• For uncooperative children, instrument-based screening can be offered as an alternative, though it offers no advantage in cooperative children 1

Critical timing consideration: Treatment efficacy for amblyopia decreases steadily after age 3 and becomes ineffective by age 12 years, making detection at age 6 still valuable but time-sensitive 1

Hearing Screening

• Perform conventional audiometry testing at frequencies of 500,1000,2000, and 4000 Hz in both ears 1
• Use a fail criterion of >20 dB HL at one or more frequencies in either ear 1
• Refer to an audiologist for comprehensive evaluation if the child fails primary care screening 1

Physical Examination

• Conduct a complete head-to-toe examination with careful attention to growth parameters (weight, height, BMI) plotted on appropriate growth charts 3, 4
• Screen for obesity, defined as BMI at or above the 95th percentile for age and sex 4
• Measure blood pressure annually beginning at age 3—this should already be established practice by age 6 4
• Perform external inspection of eyes, red reflex testing, and assessment of ocular alignment 2

Common pitfall: Do not perform routine scoliosis screening or testicular examination, as the U.S. Preventive Services Task Force recommends against these 4

Developmental and Behavioral Assessment

• Screen for speech and language delays; if identified, refer for audiological assessment 1
• Consider autism spectrum disorder screening if there are concerns about social communication or repetitive behaviors 1
• Assess school performance as a form of developmental surveillance 4
• Screen for behavioral concerns, bullying, and mental health issues 1

Critical warning: Do not rely solely on clinical judgment for developmental assessment—physician impression alone misses 45% of children eligible for early intervention 1

Dental Health

• Apply fluoride varnish at this visit 1
• Screen for dental caries and recommend twice-yearly dental examinations 1
• For children living in areas with inadequate water fluoridation (<0.6 ppm), prescribe daily fluoride supplements 4

Immunizations

• Verify completion of all routine childhood immunizations including MMR series, varicella series, hepatitis A and B series 1
• Administer annual influenza vaccine 1
• Address any missed immunizations from earlier visits 4

Anticipatory Guidance

Safety Counseling

• Discuss proper use of seat belts and booster seats—children should remain in booster seats until they reach the height/weight limit 1, 3
• Provide guidance on helmet use for biking and other sports 1
• Address water safety and drowning prevention 1
• If applicable, counsel on firearm safety 1

Lifestyle and Health Promotion

• Encourage 60 minutes of physical activity daily 1
• Limit recreational screen time to 1 hour per day 1
• Discuss healthy dietary habits, limiting juice and sugar-sweetened beverages 3
• Address adequate sleep for age 4

Tobacco and Substance Exposure

• Ask about tobacco use in the home or car 1
• Provide tobacco use prevention counseling—age 5-6 is when children are developmentally ready to understand these messages 1

Social and Emotional Development

• Provide guidance on social interactions with peers and bullying prevention 1
• Evaluate family dynamics and provide support for parenting challenges 1

Selective Screening Considerations

Anemia Screening

• Screen annually in high-risk populations using hemoglobin or hematocrit 1
• Consider selective screening based on risk factors: low-iron diet, limited food access, consumption of >24 oz daily of cow's milk, special health-care needs, or medications interfering with iron absorption 1

Common pitfall: There is insufficient evidence to recommend universal dyslipidemia screening or depression screening before age 12 in otherwise healthy children 4