What are the recommended assessments and interventions for an 8-month-old child during a well-child exam?

8-Month Well-Child Examination

Developmental Assessment

At 8 months, infants must demonstrate rolling to both sides, sitting well without support, and motor symmetry—absence of these skills requires immediate referral to early intervention services and pediatric physical therapy. 1

Motor Milestones to Assess

• Gross motor skills: Rolling supine to prone, sitting without support, pulling to stand, coming to sit from lying, crawling, and demonstrating motor symmetry 1
• Fine motor skills: Reaching for cubes, transferring objects between hands, raking small objects with 4 fingers, and picking up small objects with 3 fingers 1

Critical Red Flags Requiring Immediate Referral

• Regression of any previously acquired motor skills suggests progressive neuromuscular disorder 1
• Asymmetry in movement or hand use suggests unilateral cerebral palsy 1
• Failure to sit without support at this age 1
• Absence of rolling to both sides 1

Developmental Screening

While formal standardized developmental screening is recommended at 9 months, developmental surveillance should occur at every visit with specific questions to parents about concerns regarding development, regression of skills, or difficulty with age-appropriate tasks 1, 2

Physical Examination

Growth Parameters

• Measure and plot head circumference, weight, and length on CDC or WHO growth curves 1
• Microcephaly or macrocephaly warrant further evaluation 1
• Poor weight gain may suggest oral motor weakness 1

Vision Screening

Primary care providers should perform comprehensive vision screening including red reflex testing, external inspection of ocular and periocular structures, pupillary examination, and assessment of fixation and following behavior. 3, 4

• Red reflex testing (Brückner test) to detect abnormalities of the ocular media and assess symmetry 3, 4
• Poor eye contact after 8 weeks of age warrants further assessment 3
• By 6 months of age, children should have normal binocular alignment 3

Hip Examination

All infants should be evaluated for developmental dysplasia of the hip (DDH) through physical examination at well-baby visits during the first year of life. 3

• Despite normal physical examination findings, imaging (radiography or ultrasound) should be performed in all infants at risk 3
• Risk factors include breech presentation and positive family history 3
• Female infants born in breech position require hip imaging; optional for male infants born breech or females with positive family history 3

Neuromotor Examination

• Assess cranial nerves: Eye movements, visual confrontation, pupillary reactivity 1
• Evaluate tone and strength: Postural tone, extremity tone, muscle bulk 1
• Assess reflexes: Primitive reflexes (should be diminishing), protective reflexes (should be emerging), deep tendon reflexes 1

Complete Head-to-Toe Examination

• Skin: Color, perfusion, rashes or lesions 4
• Head: Fontanelles, shape, abnormalities 4
• Eyes: As detailed above in vision screening 4
• Ears: Tympanic membranes 4
• Nose: Patency, discharge 4
• Mouth: Oral cavity, palate, tongue 4
• Cardiovascular: Heart rate, rhythm, murmurs 4
• Respiratory: Lung sounds, respiratory rate and pattern 4
• Abdomen: Organomegaly, masses, tenderness 4
• Genitalia: External examination for abnormalities 4
• Musculoskeletal: Hip examination as above, overall symmetry 4

Hearing Assessment

Review results of newborn hearing screening if not previously done, and perform formal audiogram with tympanometry if not completed or if concerns exist. 4, 1

Immunizations

Administer age-appropriate immunizations according to CDC recommended schedule. 4

• For infants born to HBsAg-positive mothers, ensure proper hepatitis B vaccine and hepatitis B immune globulin administration 4

Nutritional Assessment and Guidance

• Evaluate feeding, swallowing, and growth 1
• Screen for gastroesophageal reflux and constipation 1
• Discuss transition to solid foods and continued breastfeeding or formula feeding 2
• All children should receive at least 400 IU of vitamin D daily 5
• Children in areas with inadequate water fluoride (<0.6 ppm) should receive daily fluoride supplement 5

Anticipatory Guidance

Safety

• Car seat safety: Ensure rear-facing car seat use until 2 years of age or until height/weight limit reached 2
• Discuss water safety, fall prevention, and poison prevention 2

Dental Health

• Discuss fluoride use and limiting or avoiding juice 2
• Encourage weaning to cup by 12 months 2

Sleep and Development

• Discuss age-appropriate sleep patterns and safe sleep practices 2
• Provide guidance on encouraging motor development through supervised floor time 1

Special Considerations for Premature Infants

For infants born before 36 weeks gestation, correct for prematurity when assessing developmental milestones for at least the first 24 months of life. 4, 1

• Calculate corrected age by subtracting weeks born early from chronological age 4
• Apply correction to all developmental domains: motor, social, language, and cognitive 4

Follow-Up

Schedule 9-month well-child visit for formal developmental screening with standardized tool 1, 2

Instruct parents to return immediately if child loses any motor skills or develops new concerns 1