What are the American Academy of Pediatrics (AAP) guidelines for preventive care and well‑child visits in children from birth through 21 years of age?

AAP Guidelines for Preventive Care and Well-Child Visits (Birth Through 21 Years)

The American Academy of Pediatrics recommends a structured schedule of well-child visits with specific developmental screenings, immunizations, and anticipatory guidance at defined intervals from birth through adolescence, following the Bright Futures Periodicity Schedule. 1, 2

Visit Schedule and Core Components

Infancy and Early Childhood (Birth to 3 Years)

Well-child visits should occur at: newborn (before hospital discharge), 3-5 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, and 30 months 3, 2

At each visit, perform:

• Growth monitoring: Plot weight, length/height, and head circumference on appropriate growth charts; correct for prematurity in preterm infants through 36 months 3, 2
• Physical examination: Comprehensive head-to-toe assessment including red reflex testing, ocular alignment assessment, and developmental dysplasia of the hip screening 3, 4
• Vision screening: Red reflex examination at every visit; introduce instrument-based screening (photoscreening/autorefraction) between 12-36 months to detect amblyopia risk factors 4

Middle Childhood (3 to 10 Years)

Well-child visits should occur annually 2

Key screening additions:

• Visual acuity testing: Begin at age 4 years (cooperative 3-year-olds may be tested) using LEA SYMBOLS or HOTV optotypes; test each eye monocularly with fellow eye patched 4
• Blood pressure measurement: Begin annual screening at age 3 years for otherwise healthy children 3
• Dyslipidemia screening: Screen children 9-11 years of age due to the obesity epidemic 1

Adolescence (11 to 21 Years)

Annual well-child visits are recommended 1, 2

Critical adolescent-specific components:

• Confidential time alone: Provide private discussion time, as nearly 1 in 4 adolescent boys report being too embarrassed to discuss important health issues when parents are present 2
• HEADSS assessment: Structure interviews around home, education/employment, activities, drugs, sexuality, and suicide/depression 1
• Depression screening: Screen annually starting at age 11, as suicide is a leading cause of adolescent death 2
• HIV screening: Screen adolescents 16-18 years of age, as one in four new HIV infections occurs in persons 13-24 years of age 1

Developmental Screening Requirements

Formal standardized developmental screening using validated tools must occur at 9,18, and 30 months 3, 2

• Use parent-completed validated tools such as Parents' Evaluation of Developmental Status (PEDS) or Ages and Stages Questionnaire (ASQ) at the 15-month visit 3
• Clinical observation alone misses approximately 45% of children eligible for early intervention 2
• Autism-specific screening: Perform at 18 and 24 months; remain vigilant for early signs at 15 months 3
• Prematurity correction: Subtract weeks born early from chronological age through at least 24 months when assessing development in infants born before 37 weeks gestation 3, 2

Immunization Schedule

Infancy (Birth to 12 Months)

• Hepatitis B: First dose before hospital discharge; if mother is HBsAg-positive, administer HepB and 0.5 mL HBIG within 12 hours of birth 2
• DTaP, Hib, IPV, PCV, Rotavirus: Begin at 2 months with subsequent doses at 4 and 6 months 2
• Influenza: Begin annual vaccination at 6 months 2

Early Childhood (12 Months to 6 Years)

• MMR and Varicella: First dose at 12 months, second dose at 4-6 years 2
• Hepatitis A: First dose at 12 months, second dose 6-18 months later 2
• DTaP fourth dose: Administer between 15-18 months with minimum 6-month interval from third dose 3, 2
• DTaP fifth dose: Administer at 4-6 years 2

Adolescence (11 to 21 Years)

• Tdap: Single dose at 11 years; booster at 16 years if ≥4 years since previous dose 2
• HPV: Begin series at 11 years with doses at 0,1-2, and 6 months 2
• Meningococcal conjugate: First dose at 11 years; booster at 16 years if ≥4 years since previous dose 2

Laboratory Screening

• Hematocrit/hemoglobin: Universal screening at 12 months; risk-based screening at 15 and 30 months 1
• Lead screening: Follow state-specific requirements and risk assessment 1
• Hearing surveillance: Monitor auditory skills at each visit; ensure audiological assessment by 24-30 months for infants with risk indicators (NICU stay >48 hours, ECMO, CMV infection) 3

Anticipatory Guidance Priorities

Safety

• Car seat safety: All infants/toddlers ride rear-facing until reaching highest weight/height allowed by manufacturer; all children <13 years restrained in rear seats 1
• Injury prevention: Address age-appropriate safety concerns at each visit 3

Nutrition and Oral Health

• Discuss transition from bottle to cup, introduction of whole milk at 12 months, and dental health 3

Sexual Health (Adolescents)

• Discuss abstinence as most effective prevention; provide comprehensive barrier method counseling for sexually active adolescents 1
• Address contraception, STI prevention, and healthy relationships 1

Common Pitfalls to Avoid

• Do not rely on clinical judgment alone for developmental screening—formal tools are essential as clinical observation misses up to half of children with delays 3, 2
• Do not forget prematurity correction—failure to adjust for gestational age leads to over-diagnosis of developmental delays 3, 2
• Do not skip confidential time with adolescents—this is when critical health issues are most likely to be disclosed 2
• Do not repeat failed vision screening—immediate referral is indicated, as repeat screening only delays necessary treatment 4
• Do not administer DTaP-IPV/Hib (Pentacel) as the 4-6 year booster—it is not indicated for that age and will necessitate a fifth IPV dose 3