Well-baby examination

Definition

Well-baby examinations are scheduled regularly during the first two years of life due to the rapid growth and change that occurs during infancy. During each visit the pediatrician monitors, advises, and answers questions on a baby's growth and development.

Purpose

The American Academy of Pediatrics recommends the newborn infant see a physician for a check-up at birth, two weeks, two months, four months, six months, nine months, 12 months, 15 months, 18 months, and 24 months, and annually thereafter. Most pediatricians follow this schedule, or some variation of it, in prescribing a check-up regimen for their patients. A well-baby exam consists of questions the parents will be asked about the baby's general health and development, followed by a physical exam. The exam includes measurements of length and height, weight and head circumference (the distance around the head), vital signs, and a general physical examination. Special attention is paid to whether the baby has met normal developmental milestones. The physician will question parents or guardians about the activities of the baby to help assess developmental issues that are not observable by an office visit.

Description

A pediatrician performs a thorough physical exam at birth to determine the physical status of the newborn. This exam includes assessing size, weight, head circumference, chest circumference, genitalia, physical mobility, eyes, ears, nose, mouth, lungs, heart, elimination, presence of neonatal reflexes , and much more. If the hospital pediatrician is not the same as the one used for follow-up exams, it is important to obtain the birth records to bring to the first office visit. Because the majority of states have laws governing newborn testing, most hospitals do a hearing screen, metabolic screen to assess thyroid activity, and screen for phenylketonuria (PKU), a genetic disorder than can be easily corrected by diet.

The first well-baby visit occurs at two weeks, and a family medical history is usually taken at this time. The baby's height, weight, and head circumference will be measured. (Head circumference is an indirect measure of brain growth.) Abnormally slow or fast growth may indicate a problem that needs investigation. The health-care provider can show parents a graph that indicates where the baby's measurements are on a standard growth curve. The trend in growth over time is more important than what a baby's weight and height are at any particular visit. A complete head-to-toe exam will be performed, during which the parent may want to ask questions related to birth marks or anything that is perceived as unusual.

In addition to the physical exam, the physician will ask questions related to what the baby can do physically, i.e., lift the head briefly, respond to loud sounds, etc. These are developmental milestones that represent a normal progression of physical and mental maturity. Although each baby develops differently, these milestones indicate a child's progress over time. The physician may want to observe development if possible. The physician may provide guidance related to possible dangers in the home, such as the importance of installing and maintaining smoke detectors, keeping a baby away from plastic bags, and never leaving the baby unattended while on a changing table. During this visit, the parent will be asked about the stress of having a new baby and the situation at home. It is a provider's responsibility to evaluate every child for abuse, and this questioning should not be taken personally. Finally, if the hepatitis B vaccine was not given in the hospital, the first shot may be given at this visit. All other vaccines begin at the two-month visit.

The two-month visit will be a repeat of the two week visit with a physical exam, developmental and behavioral assessment , guidance for upcoming developmental changes, and immunizations. During the visit, a parent should never hesitate to ask any question that will assure them the baby is healthy and progressing normally. It is a good idea to make a list of questions before the office visit, because many parents inevitably forget what they wanted to ask. Many parents inquire about what could be given to the baby if there is a reaction to the injections. The immunizations received at this time include:

• DTP vaccine (or DtaP, diphtheria , tetanus , pertussis)—DTP (or DtaP) injections are given as a series of five injections and usually at ages two months, four months, six months, 15–18 months, and four to six years of age. At age 11 or 12, Td vaccine (tetanus and diphtheria) should be given if at least five years have elapsed since the last dose of DTaP. Td boosters are recommended every 10 years.
• Hib vaccine (Haemophilus influenzae type B)—Hib is given as a series of four injections at ages two months, four months, and six months, with a booster dose at 12–15 months.
• Polio vaccine (IPV, or inactivated poliovirus vaccine)—This is usually given in a series of five vaccines, at ages two months, four months, six to 18 months, and four to six years.
• Hep B (hepatitis B vaccine)—Hep B is given as a series of three injections. The first is given soon after birth and sometimes before hospital discharge. It the mother of a newborn carries the hepatitis B virus (HBV) in her blood, the baby needs to receive the first shot within 12 hours of birth. If the mother shows no evidence of HBV in her blood, the first dose may be deferred to the two-month exam. If the first shot was given in the hospital, the second shot is given at two months and the third at six months. If the first shot was given at two months, the second is given at three to four months, and the third at six to 18 months.
• PCV (Pneumococcal vaccine)—The newest addition to the immunization schedule, these vaccinations are often given as a series of four injections at two months, four months, six months, and 12–15 months of age.

The four-month exam proceeds in the same manner as the previous two—a physical exam, developmental and behavioral assessment with questions about what has been observed at home, and more immunizations. At this period, the baby should be babbling and making noises, turning over, and trying to put everything in the mouth. Parents and the physician may discuss adding solid foods to the baby's diet, usually in the form of cereal. The immunizations given will depend on how and when the series was started.

The six-month exam is again similar. Generally the baby may be able to sit alone by this stage and may be ready to add pureed food to the diet. Once more the required immunizations will depend on the baby's history and previous injections. In October 2003, the Advisory Committee on Immunization Practices (ACIP) recommended universal influenza immunization of all children six through 23 months of age. They also recommend influenza immunization of household members and out-of-home caregivers of children younger than 24 months. Children under eight years of age who are receiving the flu vaccine for the first time should receive two doses separated by at least six weeks. Children under five years of age should not be vaccinated with the nasal-spray flu vaccine (LAIV).

The nine-month exam represents quite a change in baby from birth. The parent usually has many questions by this time regarding the baby's sleep habits, feeding patterns, teething, standing up, and so on. Again, a list is helpful to remind the parent of their own questions. The physical exam is performed, plotted on the standard growth curve, and any deviations are noted. Developmental assessment is commonly done by questioning. Does he/she pay attention to small objects and try to pick them up using his/her index finger and thumb? Can he/she locate sounds? Does he/she sit by himself/herself? Does she/he transfer objects from one hand to another? Does she/he show stranger anxiety ? Guidance of what to expect over the next three months will again be provided. For example, the baby may begin to walk alone, make sounds, say the beginnings of words, or play peek-a-boo. The physician may discuss ways to keep a baby safe, including placing gates at the top and bottom of stairs; never leaving the baby alone in the bathtub; keeping the baby rear-facing in the car seat until 20 lbs (9 kg) and one year of age; and monitoring the temperature of the hot water heater to prevent burns . If the hepatitis B injection was not completed at the six month visit, it will be given at this exam.

Reaching the one-year exam is a big event in itself. The baby may be walking (assisted or unassisted) and talking a bit at this stage. The pediatrician will continue in the same manner as before—doing a physical exam and noting changes, asking questions about development, and inquiring about feeding and sleeping habits. A blood test for anemia may be performed at this visit if it was not done at the nine-month exam. Formula-fed babies are more at risk for iron deficiency than breast-fed babies. If there is a risk of lead paint exposure, a test for this may be done as well. The parent may have more questions relating to physical changes or developmental changes, because the baby is now on the verge of toddlerhood. Immunizations due at this time include:

• Measles, mumps , and rubella (MMR vaccine)—These are given by injection in two doses. The first is given at 12–15 months and the second is usually given before four to six years of age.
• Varicella (chickenpox vaccine)—Given by injection between the ages of 12–18 months or later for children who have not had chickenpox. Susceptible teens over 13 years of age should receive two doses given at least four weeks apart.
• Flu vaccine—For influenza, if needed.

Parents who may have to move during this first year or in any subsequent years should have the child's immunization and health record with them for a new provider to review.

The 15-month visit is very comparable to the previous visits but it does mark a few milestones in the child's health. It is a time when the little boy or girl that was in the baby you have known for the last 15 months can be seen. It is usually the last time immunizations are given before the pre-kindergarten shots. The typical physical exam and developmental evaluation will be performed and guidance on future development will be given. It is important to now be certain that doors and cabinets have locks, electrical sockets are covered, and objects on which the child can choke are removed from reach. The immunizations given at this visit will depend on those given at the prior visit.

The next exam will be at 18 months and will the same as the 15-month exam. If any immunizations were missed, they can be caught-up at this time. The same is true for the two-year check-up. Many pediatricians order various tests during the first two years depending on the family's history and the child's symptoms, i.e., urinalysis, tuberculin test, and blood tests. The American Academy of Pediatrics recommends cholesterol screening of children over age two whose parents have a history of cardiovascular disease before age 55, or have blood cholesterol levels above 240mg/dl.

Precautions

There are essentially no precautions to take for a visit. However, parents who may have a history of auto-immune disorders in their family should be aware that a preservative, thimersal, which contains mercury and is used in vaccines, has a possible link to autism and auto-immune disorders. Many pharmaceutical companies now use a safer preservative called 2-phenoxy ethanol.

Preparation

The primary preparation for a well-baby exam involves the parent or guardian making a list of questions for the pediatrician.

Aftercare

The only aftercare necessary is when an infant has a slight reaction to the immunizations. The provider needs to inform the parent what to expect and what can be done to alleviate symptoms. Pain at the immunization size and a slight fever are often easily treated with acetaminophen .

Risks

There are few risks associated with well-baby visits. The risks with the preservative, thimersal, which is used in vaccines are mentioned above. Serious reactions to vaccines are extremely rare. More common problems associated with doctor visits are dealing with fears babies have of strangers touching them, and managing the child's pain from vaccinations.

Parental concerns

Concerns of many parents revolve around developmental delays and what could be done to assist advancement through these milestones. The parent needs to remember that all babies and children advance at their own pace and should never be compared to other children but only to the progress made individually. Of course, some children do have conditions that preclude normal development, and any significant lag should be monitored and investigated by the physician.

Developmental milestones that usually occur within the first year period are:

KEY TERMS

Diphtheria —A serious, frequently fatal, bacterial infection that affects the respiratory tract. Vaccinations given in childhood have made diphtheria very rare in the United States.

Haemophilus influenzae —An anaerobic bacteria associated with human respiratory infections, conjunctivitis, and meningitis.

Hepatitis B —An infection of the liver that is caused by a DNA virus, is transmitted by contaminated blood or blood derivatives in transfusions, by sexual contact with an infected person, or by the use of contaminated needles and instruments.

Pertussis —Whooping cough, a highly contagious disease of the respiratory system, usually affecting children, that is caused by the bacterium Bordetella pertussis and is characterized in its advanced stage by spasms of coughing interspersed with deep, noisy inspirations.

Polio —Poliomyelitis, an acute viral disease marked by inflammation of nerve cells of the brain stem and spinal cord and can cause paralysis.

Tetanus —A potentially fatal infection caused by a toxin produced by the bacterium Clostridium tetani. The bacteria usually enter the body through a wound and the toxin they produce affects the central nervous system causing painful and often violent muscular contractions. Commonly called lockjaw.

• Month one: lift head; move head from side to side; prefers the human face over shapes; turns toward familiar sounds; blinks at bright lights; focuses on items 8–12 inches (20–30 cm) away; has strong reflexes.
• Month two: smiles; tracks objects with eyes; makes noises other than crying; may make sounds that resemble vowels, as "ah" or "ooh."
• Months three and four: tracks moving objects; grasps items with hands and reaches for dangling objects; controls head; may begin trying to sit alone; recognizes people or familiar objects; develops a social smile; babbles and amuses self; responds to colors and shades; explores objects with mouth; recognizes breast or bottle; communicates pain, loneliness, or discomfort through crying; responds to rattle or bell.
• Months five and six: begins teething process; uses hands in a raking fashion to get toys closer; experiments with cause and effect; sits by self with minimal support; opens mouth for spoon; rolls over and back; copies facial expressions; makes two-syllable sounds.
• Months seven and eight: can self-feed some finger foods; turns in direction of voice; plays peek-a-boo; imitates many sounds; distinguishes emotions by tone of voice; responds to name; experiments with gravity by dropping things; has different reactions for different family members; gets into crawling position; shows some anxiety when removed from parent.
• Months nine and 10: picks up tiny objects; begins to identify self in mirror; drops objects and looks for them; starts to understand object permanence; goes from tummy to sitting by self; pulls to standing; transfers object from hand to hand; gets upset if toy removed.
• Months 11 and 12: says "ma-ma" and "da-da" discrimately; understands "no" claps hands; waves byebye; triples birth weight and is 29–32 inches (75–81 cm) long; puts objects into containers and pulls them out; crawls well; shakes head no; afraid of strangers; interested in books; identifies self in mirror; shares toys but wants them back.

See also Cognitive development; Fine motor skills; Gross motor skills.

Resources

BOOKS

Murkhoff, H., S. Hathaway, and A. Eisenberg. What to Expect the First Year, 2nd ed. New York: Workman Publishing Co., 2003.

James, Walene. Immunization: The Reality Behind the Myth. Westport, CT: Bergin & Garvey, 1995.

PERIODICALS

Osterrieth, Paul. "Oral polio vaccine: fact vs. fiction." Vaccine 22 (2004): 1831–5. Available online at: <www.elsevier.com/locate/vaccine>.

ORGANIZATIONS

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL, 60007. (847) 434-4000. Web site: <www.aap.org>.

WEB SITES

Center of Disease Control and Prevention. 1600 Clifton Rd., Atlanta, GA 30333. 2004 Childhood and Adolescent Immunization Schedule. Available online at: <www.cdc.gov/nip/recs/child-schedule.htm#Printable>.

Linda K. Bennington, MSN, CNS