What are the key components of an annual preventative exam for children under 18 years of age?

Annual Preventative Exam for Children Under 18

All children under 18 should receive comprehensive annual preventive health visits that include age-specific screening for physical, developmental, behavioral, and psychosocial health issues, with mandatory confidential time alone with the provider starting in early adolescence to address sensitive topics that directly impact morbidity and mortality. 1, 2

Visit Structure and Core Components

History and Assessment

• Medical history review including growth parameters, pubertal development (Tanner staging for adolescents), current health status, acute illnesses since last visit, chronic condition management, medications, and immunization status 2, 3, 4
• Developmental surveillance at every visit for children 0-3 years, with standardized screening at 9,18, and 24-30 months using validated tools like Ages and Stages Questionnaire 5, 3
• School performance assessment serves as developmental surveillance for school-aged children and adolescents 3, 4
• Lifestyle assessment including dietary habits, physical activity level, daily screen time, sleep patterns (8-10 hours for school-age, variable by age), and dental care 2, 3, 4

Physical Examination

• Blood pressure measurement annually starting at age 3 years using proper technique with age-appropriate cuff size; if elevated (≥90th percentile), recommend lifestyle interventions and recheck in 6 months 1, 2, 6
• Complete physical examination including vital signs, skin examination, assessment for signs of physical abuse or neglect 2, 3, 6
• Genitourinary examination for adolescents as clinically indicated 2, 6
• Vision screening with visual acuity testing at ages 3-5 years (if cooperative) and routinely at 4-5 years; instrument-based screening can be offered at 12 and 24 months and at well visits from 3-5 years 1
• Hearing screening annually or every two years in school-aged children 4

Age-Specific Laboratory Screening

Infancy and Early Childhood

• Hematocrit/hemoglobin universal screening at 12 months for iron deficiency anemia; risk-based screening at 15 and 30 months 1
• Fluoride varnish application every 6 months starting at 6 months through 5 years of age to prevent dental caries 1
• Critical congenital heart disease screening with pulse oximetry before newborn hospital discharge 1

School-Age Children (5-10 years)

• Lipid screening at ages 9-11 years due to growing obesity epidemic 1, 6
• Obesity screening at every visit; defined as BMI ≥95th percentile for age and sex; provide resources for comprehensive intensive behavioral interventions when identified 4

Adolescents (11-18 years)

• Lipid panel screening at ages 9-11 years if not previously done, or if family history of hyperlipidemia or cardiovascular disease 1, 6
• HIV screening for adolescents ages 16-18 years, as one in four new HIV infections occurs in persons 13-24 years old 1
• STI screening for sexually active adolescents 6
• Hemoglobin/hematocrit as clinically indicated 6

Behavioral and Mental Health Screening

All Adolescents (11-21 years)

• Depression screening annually starting at age 11 through 21 years, as suicide is a leading cause of death in this age group 1, 2, 6
• Substance use screening using the CRAFFT questionnaire (car, relax, alone, forget, friends, trouble) to assess for alcohol, tobacco, marijuana, and other drug use 1, 2, 6
• Sexual health screening including sexual activity, number of partners, contraception use, STI history, with discussion of consent, healthy relationships, and STI/pregnancy prevention 2, 6
• Trauma exposure screening by asking "Has anything scary or concerning happened to you or your child since the last visit?" 3
• Assessment for violence, bullying, and abuse including involvement or victimization 6
• Eating disorder screening and body image concerns 6

Younger Children

• Psychosocial screening using validated tools like Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire to identify developmental or behavioral concerns 3
• Assessment of mood patterns, social interactions, anxiety, attention abilities, peer relationships, and family stressors 3

Immunizations

Age-Appropriate Vaccines

• Review immunization status at every visit and administer vaccines due per current CDC schedule 2, 3, 6
• HPV vaccine series starting at ages 11-12 years; give strong recommendation emphasizing cancer prevention and normalize by coadministering with other vaccines 6
• Tdap booster at age 11-12 years 6
• Meningococcal conjugate vaccine per schedule 6
• Annual influenza vaccine 6
• Catch up any missed childhood vaccinations 6

Anticipatory Guidance

Safety Counseling

• Injury prevention including seatbelt use, car seat/booster seat use (age-appropriate), bicycle helmet use, water safety, and firearm safety, as unintentional injuries are the leading cause of adolescent death 2, 3, 6
• Distracted and drunk driving avoidance for adolescents 2, 6

Health Promotion

• Physical activity recommendation of at least 60 minutes of moderate to vigorous activity daily, including resistance and flexibility training 2, 6
• Nutrition guidance emphasizing healthy eating patterns, limiting sugar-sweetened beverages, and appropriate portion sizes 2, 3, 6
• Sleep hygiene education appropriate for age 3
• Bullying prevention, social media use, and online safety 3
• Preconception counseling starting at puberty for all individuals of childbearing potential 6

Substance Use Prevention

• Discourage tobacco/nicotine use, electronic cigarettes, vaping, and recreational cannabis use 6
• Discuss risks of alcohol use and harm reduction strategies 6

Confidentiality Requirements

Mandatory private time alone with adolescents starting in early adolescence is essential, as almost 1 in 4 adolescent boys report being too embarrassed to discuss important health issues when parents are present 6. This confidential time allows screening for risky behaviors that cause significant morbidity and mortality 2, 6.

The visit should begin with parent/guardian present for initial assessment, then transition to private discussion with the adolescent to address sensitive topics including sexual activity, substance use, mental health, and relationship concerns 2, 6.

Critical Pitfalls to Avoid

• Never conduct brief "sports physicals" instead of comprehensive examinations, as this lacks psychosocial screening and confidentiality, missing opportunities for early diagnosis and treatment of conditions causing significant morbidity and mortality 2, 6
• Failing to provide confidential time alone with adolescents results in missed screening opportunities for risky behaviors 2, 6
• Skipping depression screening in adolescents 11-21 years—this must be performed annually 6
• Deferring HPV vaccination—give a strong recommendation and normalize it by coadministering with other vaccines 6
• Focusing only on physical health while neglecting behavioral and developmental aspects 3
• Relying solely on parental report without engaging the child directly 3
• Missing opportunities for anticipatory guidance on emerging issues 3

Special Populations

Children with special health care needs require additional assessment of condition management, care coordination, and family support needs 3. Children exposed to trauma may require additional screening and support services 3.