What are the primary recommendations for a well-child check in a 5-year-old child?

5-Year-Old Well-Child Check: Primary Recommendations

At the 5-year well-child visit, perform monocular visual acuity testing with HOTV letters or LEA SYMBOLS charts, conduct conventional audiometry screening, apply fluoride varnish, verify immunization completion, and provide anticipatory guidance on physical activity (60 minutes daily) and screen time limits (1 hour daily). 1

Vision Screening

• Perform monocular visual acuity testing using HOTV letters or LEA SYMBOLS charts with proper eye occlusion at the 5-year visit, as treatment efficacy for amblyopia decreases steadily after age 3 and becomes ineffective by age 12 years. 1

• Test each eye separately with the fellow eye covered using an adhesive patch or tape to prevent peeking—this is critical for accurate detection of amblyopia. 1

• Refer immediately for comprehensive ophthalmologic examination after the first screening failure; do not rescreen multiple times, as this delays necessary treatment. 1

• For uncooperative children, instrument-based screening can be offered as an alternative, though it is not superior in cooperative children. 1

Hearing Screening

• Perform age-appropriate audiologic testing with conventional audiometry at the 5-year visit, testing frequencies at 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, with referral for comprehensive audiologic evaluation by an audiologist if the child fails primary care screening. 1

Developmental and Behavioral Assessment

• Screen for speech and language delays, with referral for audiological assessment if speech delay is identified. 1

• Consider autism spectrum disorder screening if there are concerns about social communication or repetitive behaviors. 1

• Do not rely solely on clinical judgment for developmental assessment, as physician impression alone misses 45% of children eligible for early intervention—use validated screening tools like the Parents' Evaluation of Developmental Status (PEDS) or Ages and Stages Questionnaire (ASQ). 2

Note: While formal developmental screening is recommended at 9,18, and 30 months, surveillance should continue at all well-child visits including age 5, with formal screening tools used if any concerns arise. 2

Dental Health

• Apply fluoride varnish at the 5-year visit, continuing the schedule that should have begun at 6 months of age. 1

• Screen for dental caries and recommend twice-yearly dental examinations. 1

Immunizations

• Verify completion of all routine childhood immunizations, including MMR series, varicella series, hepatitis A and B series, and annual influenza vaccine. 1

• This is a critical checkpoint before kindergarten entry to ensure all required immunizations are complete. 1

Physical Examination and Screening

• Measure and plot height, weight, and body mass index (BMI) on appropriate growth charts; screen for obesity (BMI ≥95th percentile for age and sex). 3

• Check blood pressure annually beginning at age 3 years in otherwise healthy children, using age-, height-, and sex-specific percentiles for interpretation. 2, 3

• Perform a comprehensive head-to-toe examination with attention to any parental concerns. 4, 3

Anemia Screening

• Screen for anemia in high-risk populations using hemoglobin concentration or hematocrit. 1

• Use selective screening in non-high-risk populations based on risk factors including low-iron diet, limited food access, consumption of >24 oz daily of cow's milk, and special health-care needs or medications interfering with iron absorption. 1

Anticipatory Guidance

Physical Activity and Screen Time

• Encourage 60 minutes of physical activity daily and limit recreational screen time to one hour per day. 1

Safety Counseling

• Provide guidance on proper use of seat belts and booster seats (children should remain in booster seats until they reach 4 feet 9 inches tall, typically between ages 8-12). 1

• Counsel on helmet use for biking and other sports, water safety and drowning prevention, and firearm safety if applicable. 1

Tobacco Exposure

• Ask about tobacco use in the home or car and provide tobacco use prevention counseling, as messages should start when children are developmentally ready to understand them, typically around age 5. 1

Social and Behavioral Guidance

• Provide guidance on social interactions with peers, bullying prevention, and mental health concerns. 1

• Evaluate family dynamics and provide support for parenting challenges. 1

Common Pitfalls to Avoid

• Do not skip vision screening at age 5—this is a critical window for detecting and treating amblyopia before treatment becomes ineffective. 1

• Do not use informal vision testing methods (like reading letters across the room without proper occlusion)—this misses unilateral vision problems. 1

• Do not delay referral for failed vision or hearing screening—immediate referral maximizes treatment effectiveness. 1

• Do not forget to address screen time limits specifically—many parents are unaware of the 1-hour daily recommendation for this age group. 1