What developmental milestones, immunizations, screenings, growth measurements, and anticipatory guidance should be documented for a 2‑year‑old during a routine well‑child visit?

2-Year-Old Well-Child Visit Documentation

At the 2-year well-child visit, document growth measurements (height, weight, BMI, head circumference plotted on WHO/CDC curves), perform standardized developmental screening with a validated tool, administer age-appropriate immunizations, conduct autism-specific screening, assess vision and hearing, provide anticipatory guidance on safety and nutrition, and screen for social determinants of health. 1, 2, 3, 4

Growth Measurements

• Measure and plot height, weight, body-mass index (BMI), and head circumference on standard growth curves (WHO or CDC). 2, 5, 3
• Document percentiles for all growth parameters to track trends over time. 3

Developmental Screening and Surveillance

Formal Standardized Screening

• Administer a validated, standardized developmental screening tool at the 24-month visit using parent-completed instruments such as the Ages and Stages Questionnaire (ASQ-3) or Parents' Evaluation of Developmental Status (PEDS). 1, 4
• The American Academy of Pediatrics recommends formal developmental screening at 9,18, and 30 months (or 24 months), with the 24-month visit serving as a critical checkpoint. 1, 2
• Parent-completed tools are preferred over directly administered tools because they are more efficient and have comparable accuracy. 1

Expected Developmental Milestones at 24 Months

Gross Motor:

• Rides on a toy without pedals. 2
• Jumps up with both feet leaving the ground. 2
• Walks backward. 2
• Runs. 2

Fine Motor:

• Builds a tower of 3 blocks. 2
• Builds a horizontal train with 3 blocks. 2
• Scribbles spontaneously. 2

Language:

• Uses 2-word phrases. 6
• Points to named pictures or body parts. 6

Social-Emotional:

• Imitates adult activities during play. 6
• Shows interest in other children. 6

Autism-Specific Screening

• Perform autism-specific screening at the 24-month visit using the Modified Checklist for Autism in Toddlers (M-CHAT). 3, 7, 4
• The American Academy of Pediatrics recommends autism screening at both 18 and 24 months. 3, 4

Developmental Surveillance

• Conduct developmental surveillance at every well-child visit by eliciting parental concerns, documenting developmental history, and observing the child's spontaneous motor function, posture, and play. 1, 4
• Parent concern is a valid trigger for formal screening even when clinical observations appear reassuring. 8
• For children born before 36 weeks' gestation, correct for prematurity when assessing milestones for at least the first 24 months. 8, 2, 5

Red Flags Requiring Immediate Evaluation

• Any regression or loss of previously acquired skills (motor, language, or social) warrants urgent evaluation for progressive neuromuscular or neurodevelopmental disorders. 8, 2
• Marked asymmetry in movement or persistent one-sided activities suggests unilateral cerebral palsy. 8
• Absence of independent walking by 15-18 months requires additional assessment. 8
• Failure to use 2-word phrases by 24 months. 6

Immunizations

• Review and update immunizations according to the CDC/AAP immunization schedule. 3
• Typical vaccines at 24 months may include catch-up doses if the child is behind schedule. 3

Vision and Hearing Screening

• Assess vision by observing eye alignment, tracking, and red reflexes; formal vision screening is recommended once between 3 and 5 years of age. 3
• Evaluate hearing through parental report and observation of response to auditory stimuli; perform audiologic testing if there is any suspicion of hearing loss or no record of newborn hearing screening. 2, 3

Physical Examination

• Perform a comprehensive head-to-toe examination including neuromotor assessment (muscle tone, strength, deep tendon reflexes, gait observation). 2, 3
• Observe spontaneous movement quality, symmetry, and coordination during play. 8
• Assess cranial nerves including eye movements, facial symmetry, and oromotor function. 8, 2

Anticipatory Guidance

Safety

• Car seats should remain rear-facing until 2 years of age or until the height or weight limit for the seat is reached. 3
• Discuss home safety including poison prevention, water safety, and fall prevention. 3

Nutrition and Dental Health

• Recommend limiting or avoiding juice and sugar-sweetened beverages; juice should be provided only in limited quantities (no more than 4 oz/day) for children older than 1 year. 3
• Encourage weaning from bottles if not already completed. 3
• Discuss fluoride use and dental care; children should have established dental care by age 1 year. 3
• Provide guidance on balanced nutrition and avoidance of choking hazards. 3

Screen Time

• Limit screen time to no more than 1 hour per day of high-quality programming for children 2 to 5 years of age, with co-viewing encouraged. 3

Sleep

• Document sleep patterns and provide guidance on age-appropriate sleep duration (11-14 hours per 24 hours including naps). 3

Social Determinants of Health

• Screen for social determinants of health including food insecurity, housing stability, parental mental health, and access to resources. 3, 4
• Observe parent-child interaction to assess relational dynamics and parental stress. 2

Referrals and Follow-Up

• If developmental delays are identified or suspected on screening, refer immediately to early intervention services (Part C for children under 3 years) while diagnostic evaluations proceed. 8, 4
• Do not delay referral to early intervention while awaiting subspecialist appointments. 8
• Refer to pediatric subspecialists (neurology, developmental-behavioral pediatrics) as indicated for diagnostic evaluation. 8, 2

Common Pitfalls to Avoid

• Do not rely on informal milestone checklists or clinical judgment alone, as this contributes to underdetection of developmental delays; always use validated screening tools at recommended intervals. 1, 2
• Do not dismiss parental concerns even when clinical observations seem reassuring; parent concern should trigger formal screening. 8, 4
• Do not adopt a "wait-and-see" approach when developmental concerns are identified; early intervention improves outcomes. 4, 6
• Remember to correct for prematurity in children born before 36 weeks' gestation to avoid overestimating delays. 8, 2, 5