Bright Futures

BRIGHT FUTURES

Guidelines for Health Supervision of

Infants, Children, and Adolescents

THIRD EDITION

POCKET GUIDE

Editors

Joseph F. Hagan, Jr, MD, FAAP

Judith S. Shaw, RN, MPH, EdD

Paula M. Duncan, MD, FAAP

FUNDED BY

US Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau

PUBLISHED BY

The American Academy of Pediatrics

CITE AS

Hagan JF, Shaw JS, Duncan P, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and

Adolescents, Third Edition. Pocket Guide. Elk Grove Village, IL: American Academy of Pediatrics.

reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photo-

copying, recording, or otherwise, without prior written permission from the publisher.

Library of Congress Catalog Card Number: 2007929964

ISBN-13: 978-1-58110-224-6

ISBN-10: 1-58110-224-0

BF0027

PUBLISHED BY

American Academy of Pediatrics

141 Northwest Point Blvd

Elk Grove Village, IL 60007-1098

USA

847-434-4000

AAP Web site: www.aap.org

Bright Futures Web site: http://brightfutures.aap.org

Additional copies of this publication are available from the American Academy of Pediatrics Online Bookstore at

www.aap.org/bookstore.

This publication has been produced by the American Academy of Pediatrics under its cooperative agreement

(U06MC00002) with the US Department of Health and Human Services, Health Resources and Services Administration

(HRSA), Maternal and Child Health Bureau (MCHB).

iii

TABLE OF CONTENTS

Bright Futures at the American Academy of Pediatrics. . . . . . . . . v

How to Use This Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Core Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Building Effective Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

Fostering Family-Centered Communication . . . . . . . . . . . . . . . . . . . xi

Promoting Health and Preventing Illness. . . . . . . . . . . . . . . . . . . . . . xii

Managing Time for Health Promotion . . . . . . . . . . . . . . . . . . . . . . . xiii

Educating Families Through Teachable Moments . . . . . . . . . . . . . . xiv

Advocating for Children, Families, and Communities . . . . . . . . . . . xv

Supporting Families Successfully . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Children and Youth With Special Health Care Needs . . . . . . . . . . . xvii

Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Complementary and Alternative Care . . . . . . . . . . . . . . . . . . . . . . xviii

Bright Futures Themes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Bright Futures Health Supervision Visits . . . . . . . . . . . . . . . . . . . . 1

Acronyms Used in the Bright Futures Health Supervision Visits. . . . . 1

Prenatal Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Newborn Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

First Week Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

4 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

6 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

9 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

12 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

15 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

18 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

2 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

3 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

4 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

5 and 6 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

7 and 8 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

9 and 10 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Early Adolescence (11 to 14 Year Visits) . . . . . . . . . . . . . . . . . . . . . 42

Middle Adolescence (15 to 17 Year Visits). . . . . . . . . . . . . . . . . . . . 46

Late Adolescence (18 to 21 Year Visits) . . . . . . . . . . . . . . . . . . . . . . 50

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Developmental Milestones at a Glance — Infancy . . . . . . . . . . . . . 54

Developmental Milestones at a Glance — Early Childhood . . . . . . 55

Social and Emotional Development in Middle Childhood . . . . . . . . 56

Domains of Adolescent Development . . . . . . . . . . . . . . . . . . . . . . . 57

Recommended Medical Screening — Infancy. . . . . . . . . . . . . . . . . 58

Recommended Medical Screening — Early Childhood . . . . . . . . . . 59

Recommended Medical Screening — Middle Childhood . . . . . . . . 60

Recommended Medical Screening — Adolescence . . . . . . . . . . . . 61

Tooth Eruption Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Sexual Maturity Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Useful Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Bright Futures at the American

Academy of Pediatrics

ounded in 1930, the American Academy of

Pediatrics (AAP) is an organization of 60,000 pedia-

tricians who are committed to the attainment of

optimal physical, mental, and social health and well-

being for all infants, children, adolescents, and young

adults.

The Bright Futures initiative was launched in 1990

under the leadership of the Federal Maternal and Child

Health Bureau (MCHB) of the Health Resources and

Services Administration (HRSA) to improve the quality of

health services for children through health promotion and

disease prevention. In 2002, the MCHB selected the AAP

to lead the Bright Futures initiative. With the encourage-

ment and strong support of the MCHB, the AAP and its

many collaborating partners set out to update the

Bright

Futures Guidelines

as a uniform set of recommendations

for health care professionals. The

Bright Futures

Guidelines

are the cornerstone of the Bright Futures initia-

tive and the foundation for the development of all Bright

Futures materials.

What Is Bright Futures?

Bright Futures is a set of principles, strategies, and tools

that are theory based, evidence driven, and systems

oriented that can be used to improve the health and

well-being of all children through culturally appropriate

interventions that address their current and emerging

health promotion needs at the family, clinical practice,

community, health system, and policy levels.

Goals of Bright Futures

! Enhance health care professionals’ knowledge, skills,

and practice of developmentally appropriate health care

in the context of family and community.

! Promote desired social, developmental, and health

outcomes of infants, children, and adolescents.

! Foster partnerships between families, health care pro-

fessionals, and communities.

! Increase family knowledge, skills, and participation in

health-promoting and prevention activities.

! Address the needs of children and youth with special

health care needs through enhanced identification and

services.

For more information about Bright Futures and

available materials and resources, visit http://

brightfutures.aap.org.

vii

How to Use This Guide

he Pocket Guide is based on Bright Futures:

Guidelines for Health Supervision of Infants,

Children, and Adolescents, Third Edition. Presenting

key information from the Guidelines, the Pocket Guide

serves as a quick reference tool and training resource for

health care professionals.

Sections of the Pocket Guide

Themes: Highlights 10 cross-cutting child health topics

that are discussed in depth in the Guidelines. These

themes are important to families and health care profes-

sionals in their mission to promote the health and well-

being of all children. The

Pocket Guide lists these themes;

see the Guidelines for the full text.

The Health Visit: Focuses on specific age-appropriate

health and developmental issues.

Visit Priorities: The Bright Futures Expert Panels

acknowledge that the most important priority is to

attend to the concerns of the parent or youth. In addi-

tion, they have developed 5 priority health supervision

topics for each visit.

Developmental Observation: Includes observation of

parent-child interaction, developmental surveillance, and

school performance questions.

Physical Exam: Recommends a complete physical exam,

including specific issues for each visit.

Screening: Includes universal and selective screening

procedures and risk assessment.

Immunizations: Provides Centers for Disease Control

and Prevention/National Immunization Program and

American Academy of Pediatrics Red Book Web sites for

current schedules.

Anticipatory Guidance: Presents guidance for

families, organized by the 5 priorities of each visit.

Sample questions also are provided for selected topics.

Guidance and questions in

black type are intended for

the parent; guidance and questions in

green type are

intended for the child/adolescent/young adult. These can

be modified to match the health care professional’s

communication style.

viii

Appendices: Includes developmental milestones at-a-

glance charts for infancy and early childhood, a chart on

social and emotional development in middle childhood,

a chart on domains of adolescent development,

recommended medical screening tables, a tooth eruption

chart, a sexual maturity ratings chart, and a list of useful

Web sites.

Core Concepts

n today’s complex and changing health care system,

health care professionals can improve the way they

carry out each visit by using an innovative health

promotion curriculum developed specifically to help

professionals integrate Bright Futures principles into

clinical practice.

This unique curriculum, developed by a health promo-

tion work group supported by the Maternal and Child

Health Bureau, includes 6 core concepts:

! Partnership

! Communication

! Health promotion/illness prevention

! Time management

! Education

! Advocacy

A summary of each of these core concepts is present-

ed on the following pages to help all professionals, both

those in training and experienced practitioners, bring

Bright Futures alive and make it happen for children and

families. For more information about this unique health

promotion curriculum, visit www.pediatricsinpractice.org.

All 6 core concepts rely on the health care profession-

als’ skills in using open-ended questions to communicate

effectively, partner with and educate children and their

families, and serve as their advocates to promote health

and prevent illness in a time-efficient manner.

Open-ended questions

! Help to start a conversation

! Ask: “Why?” “How?” “What?”

! Are interpretive

! Have a wide range of possible answers

! Stimulate thinking

! Promote problem solving

EXAMPLES:

• How do you and your partner manage the baby’s behavior?

What do you do when you disagree?

•

(To a child) Tell me about your favorite activities at school.

Techniques

! Begin with affirming questions.

EXAMPLE:

•“What are some games you’re really good at?”

! Wait at least 3 seconds to allow the family to respond

to the question.

! Ask questions in a supportive way to encourage

communication.

Building Effective Partnerships

A clinical partnership is a relationship in which participants

join together to ensure health care delivery in a way that

recognizes the critical roles and contributions of each part-

ner (child, family, health care professional, and communi-

ty) in promoting health and preventing illness. Following

are 6 steps for building effective health partnerships:

1. Model and encourage open, supporting commu-

nication with child and family.

! Integrate family-centered communication strategies.

! Use communication skills to build trust, respect, and

empathy.

2. Identify health issues through active listening and

“fact finding.”

! Selectively choose Bright Futures Anticipatory Guidance

questions.

! Ask open-ended questions to encourage more com-

plete sharing of information.

! Communicate understanding of the issues and provide

feedback.

3. Affirm strengths of child and family.

! Recognize what each person brings to the partnership.

! Acknowledge and respect each person’s contributions.

! Commend family for specific health and developmental

achievements.

4. Identify shared goals.

! Promote view of health supervision as partnership

between child, family, health care professional, and

community.

! Summarize mutual goals.

! Provide links between stated goals, health issues, and

available resources in community.

5. Develop joint plan of action based on stated

goals.

! Be sure that each partner has a role in developing the

plan.

! Keep plan simple and achievable.

! Set measurable goals and specific timeline.

! Use family-friendly negotiation skills to ensure

agreement.

! Build in mechanism and time for follow-up.

6. Follow up to sustain the partnership.

! Share progress, successes, and challenges.

! Evaluate and adjust plan.

! Provide ongoing support and resources.

Fostering Family-Centered Communication

Effective Behaviors

! Greet each family member and introduce self.

! Use names of family members.

! Incorporate social talk in the beginning of the interview.

! Show interest and attention.

! Demonstrate empathy.

! Appear patient and unhurried.

! Acknowledge concerns, fears, and feelings of child and

family.

! Use ordinary language, not medical jargon.

! Use Bright Futures Anticipatory Guidance questions.

! Give information clearly.

! Query level of understanding and allow sufficient time

for response.

! Encourage additional questions.

! Discuss family life, community, and school.

Active Listening Skills: Verbal Behaviors

! Allow child and parents to state concerns without

interruption.

! Encourage questions and answer them completely.

! Clarify statements with follow-up questions.

! Ask about feelings.

! Acknowledge stress or difficulties.

! Allow sufficient time for a response (wait time

>3 seconds).

! Offer supportive comments.

! Restate in the parent’s or child’s words.

! Offer information or explanations.

Active Listening Skills: Nonverbal Behaviors

! Nod in agreement.

! Sit down at the level of the child and make eye contact.

! Interact with or play with the child.

! Show expression, attention, concern, or interest.

! Convey understanding and empathy.

! Touch child or parent (if appropriate).

! Draw pictures to clarify.

! Demonstrate techniques.

xii

Promoting Health and Preventing Illness

Because families often hesitate to begin discussion, it is

essential that health care professionals identify and focus

on the individual needs of the child and family.

1. Identify relevant health promotion topics.

! Ask open-ended, nonjudgmental questions to obtain

information and identify appropriate guidance.

! Ask specific follow-up questions to communicate

understanding and focus the discussion.

EXAMPLE:

• “How often and for how long do you breastfeed the baby? How

do you know when he wants to be fed?”

! Listen for verbal, and observe nonverbal, cues to

discover underlying or unidentified concerns.

EXAMPLE:

• “How do you balance your roles of partner and parent? When

do you make time for yourself?”

Note:

! If parent hesitates with an answer, try to determine the

reason.

! If parent brings in child multiple times for minor

problems, explore the possibility of another unresolved

concern.

2. Give personalized guidance.

! Introduce new information and reinforce healthy

practices.

EXAMPLES:

• Take time for self and partner for leisure and exercise.

• Encourage partner to help care for child.

• Accept support from friends, family.

3. Incorporate family and community resources.

! Approach child within context of family and

community.

! Identify each family member’s role.

EXAMPLES:

• “Tell me about your child’s bedtime routine.”

• “Who’s responsible for household chores?”

! Identify community resources, such as a lactation

consultant or local recreation centers.

! Develop working relationships with community profes-

sionals and establish lines of referral.

! Create a list of local resources with contact information.

4. Come to closure.

! Be sure that the health message is understood.

EXAMPLES:

• “Have I addressed your question?”

• “Do you have any other concerns about your teen’s health?”

! Identify possible barriers.

EXAMPLE:

• “What problems do you think you might have in following

through with what we discussed today?”

xiii

Managing Time for Health Promotion

1. Maximize time for health promotion.

! Use accurate methods that minimize documentation

time.

! Ask family to complete forms in waiting area.

! Organize chart in consistent manner.

! Scan chart before meeting with child and family.

! Train staff to elicit information and provide follow-up

with family.

2. Clarify health care professional’s goals for visit.

! Review screening forms and other basic health data.

! Observe parent-child interaction.

! Identify needs, then rank them in order of importance.

! Clarify visit priorities.

Note:

The Pocket Guide organizes each visit’s Anticipatory

Guidance by designated priorities.

3. Identify family’s needs and concerns for visit.

! Selectively use Bright Futures Anticipatory Guidance

sample questions.

! Include open-ended questions to draw family into visit.

EXAMPLE:

• “Tell me about the baby’s sleeping habits. What position does she

sleep in?

(Elicits more than yes/no answer and presents “teach-

able moment” on “back to sleep” and sudden infant death syn-

drome.)

4. Work with the family to prioritize goals for the

visit.

! Explain purpose of visit (identify and address specific

concerns and overall health and development).

! Identify family’s and health care professional’s shared

goals.

! Prioritize needs through family-friendly negotiation.

EXAMPLE:

• “I appreciate your concerns about _____. While you are here, I

would also like to talk about ____.”

5. Suggest other options for addressing unmet

goals.

! Acknowledge importance of issues that could not be

fully addressed during the visit.

! Offer additional resources (handouts, CDs, videotapes/

DVDs, Web-based materials).

! Suggest a follow-up visit or phone call.

! Provide referral to professional or community resource.

TEACHING STRATEGIES ADVANTAGES

•Telling (explain, provide information, give direction) Works well when giving initial explanations or clarifying concepts

•Showing (demonstrate, model, draw) Illustrates concepts for visual learners

•Providing resources (handouts, videos/DVDs, Web sites) Serves as a reference after family leaves the office/clinic

•Questioning (ask open-ended questions, allow time for response) Promotes problem solving, critical thinking; elicits better information; stimulates recall

•Practicing (apply new information) Reinforces new concepts

•Giving constructive feedback (seek family’s perspective, restate, clarify) Affirms family’s knowledge; corrects misunderstandings

xiv

Educating Families Through Teachable Moments

Teachable moments occur multiple times each day, but

often go unrecognized. Health supervision visits present

opportunities for the health care professional to teach

the child and family.

1. Recognize teachable moments in health visit.

2. Clarify learning needs of child and family.

3. Set a limited agenda and prioritize needs together.

4. Select teaching strategy.

5. Seek and provide feedback.

6. Evaluate effectiveness of teaching.

Four characteristics of the teachable moment

! Provides “information bites” (small amounts of informa-

tion)

! Is directed to the child’s or family’s specific needs

! Is brief (eg, a few seconds)

! Requires no preparation time

Advocating for Children, Families, and Communities

Health care professionals can be involved in advocacy

either at an individual level (eg, obtaining services for a

child or family) or at a local or national level (eg, speaking

with the media, community groups, or legislators).

1. Identify family needs or concerns.

! Use open-ended questions to identify specific needs or

concerns of the family.

EXAMPLE:

• “What are some of the main concerns in your life right now?”

! Choose a specific area of focus.

EXAMPLE:

• Obtaining special education services for a child.

! Clarify family’s beliefs and expectations about the issue.

! Determine what has been done to date, and what has

(or hasn’t) worked.

EXAMPLE:

• Parents may have tried unsuccessfully to obtain services for their

child.

! Obtain data through some initial “fact finding.”

EXAMPLE:

• Contact board of education or local public health department.

! Talk with others; determine progress.

EXAMPLE:

• Do any local school coalitions address this issue?

2. Assess the situation.

! Determine existing community resources.

! Learn about existing laws that address the issue.

! Review the data and resources to be sure they support

the issue.

! Assess political climate to determine support or

opposition.

EXAMPLE:

• Is this issue of interest to anyone else (eg, school/early interven-

tion teacher, local policy makers)? Who (or what) might oppose

the advocacy efforts? Why?

3. Develop a strategy.

! Limit efforts to a specific issue.

EXAMPLE:

• Obtaining special education services for one child rather than

changing the laws for all.

! Use existing resources.

! Start with small steps, then build upon successes.

4. Follow through.

! Be passionate about the issue, but willing to negotiate.

! Review the outcome.

! Evaluate your efforts.

! Determine next steps with family.

! Recognize that health care professionals and families

can learn from one another about effective advocacy.

xvii

Supporting Families Successfully

nderstanding and building on the strengths of

families requires health care professionals to com-

bine well-honed clinical interview skills with a will-

ingness to learn from families. Families demonstrate a

wide range of beliefs and priorities in how they structure

daily routines and rituals for their children and how they

use health care resources. This edition of the

Bright

Futures Guidelines places special emphasis on 3 areas of

vital importance to caring for children and families.

Children and Youth With Special Health Care Needs

As of 2000, more than 9 million children in the United

States have special health care needs. This means that 1

of every 5 households includes a child with a develop-

mental delay, chronic health condition, or some form of

disability. Family-centered care that promotes strong

partnerships and honest communication is especially im-

portant when caring for children and youth with special

health care needs. These children and youth now live

normal life spans and tend to require visits with health

care professionals more frequently than other children.

At the same time, the impact of

specialness or exten-

sive health care needs should not overshadow the

child.

The child or youth with special health care needs shares

most health supervision requirements with her peers.

Bright Futures uses screening, ongoing assessment,

health supervision, and anticipatory guidance as essential

interventions to promote wellness and identify differ-

ences in development, physical health, and mental health

for all children.

Cultural Competence

Cultures form around language, gender, disability, sexual

orientation, religion, or socioeconomic status. Even peo-

ple who have been fully acculturated within mainstream

society can maintain values, traditions, communication

patterns, and child-rearing practices of their original cul-

ture. Immigrant families, in particular, face many cultural

stressors.

It is important for health care professionals who serve

children and families from backgrounds other than their

own to listen and observe carefully, learn from the family,

and work to build trust and respect. If possible, the pres-

ence of a staff member who is familiar with a family’s

community and fluent in the family’s language is helpful

during discussions with families.

xviii

Complementary and Alternative Care

Families must be empowered as care participants. Their

unique ability to choose what is best for their children

must be recognized. The health care professional must

be aware of the disciplines or philosophies that are cho-

sen by the child’s family, especially if the family chooses a

therapy that is unfamiliar or outside the scope of stan-

dard care. Such therapies are not necessarily harmful or

without potential benefit. Providers of standard care need

not be threatened by such choices. Therapies can be safe

and effective, safe and ineffective, or unsafe.

The use of complementary and alternative care is par-

ticularly common when a child has a chronic illness or

condition. Parents are often reluctant to tell their health

care professional about such treatments, fearing disap-

proval. Health care professionals should ask parents

directly, in a nonjudgmental manner, about the use of

complementary and alternative care.

Consultation with colleagues who are knowledgeable

about complementary and alternative care might be nec-

essary. Discussion with a complementary and alternative

care therapist also may be useful.

xix

Bright Futures Themes

number of themes are of key importance to fam-

ilies and health care professionals in their com-

mon mission to promote the health and

well-being of children from birth through adolescence.

These themes are:

! Promoting Family Support

! Promoting Child Development

! Promoting Mental Health

! Promoting Healthy Weight

! Promoting Healthy Nutrition

! Promoting Physical Activity

! Promoting Oral Health

! Promoting Healthy Sexual Development and Sexuality

! Promoting Safety and Injury Prevention

! Promoting Community Relationships and Resources

The

Bright Futures Guidelines provide an in-depth,

state-of-the-art discussion of these themes, with evidence

regarding effectiveness of health promotion interventions

at specific developmental stages from birth to early adult-

hood. Health care professionals can use these compre-

hensive discussions to help families understand the

context of their child’s health and support their child’s

and family’s development.

Because of the overwhelming importance to overall

health and well-being of mental health and healthy

weight, and the prevalence of problems in these areas,

the Bright Futures authors have designated Promoting

Mental Health and Promoting Healthy Weight as

Significant Challenges to Child and Adolescent

Health for this edition.

Bright Futures Health Supervision Visits

his section presents all the Bright Futures Visits from

the Prenatal Visit to the 21 Year Visit. The Table

below lists the acronyms used in this section.

ACRONYMS USED IN THE BRIGHT FUTURES HEALTH SUPERVISION VISITS

AAP American Academy of Pediatrics

ATV All-terrain vehicle

BMI Body mass index

CBE Clinical breast examination

CDC Centers for Disease Control and Prevention

CPR Cardiopulmonary resuscitation

DVD Digital Versatile Disc

HIV Human immunodeficiency virus

IEP Individualized Education Program

OTC Over-the-counter

SMR Sexual maturity rating

STI Sexually transmitted infection

TV Television

WIC The Special Supplemental Nutrition Program for Women, Infants, and Children

INFANCY | PRENATAL VISIT

Observation of Parent-Child Interaction: Who asks

questions and who provides responses to questions?

(Observe parent with partner, other children, other family

members.) Do the verbal and nonverbal behaviors/

communication among family members indicate support

and understanding, or differences of opinion and conflicts?

Screening

Discuss the purpose and importance of the newborn

screening tests (metabolic, hearing) that will be done in

the hospital before the baby is discharged.

Immunizations

Discuss routine initiation of immunizations.

Anticipatory Guidance

FAMILY RESOURCES

Family support systems, transition home (assistance after

discharge), family resources, use of community resources

• Your family’s health values/beliefs/practices are impor-

tant to the health of your baby.

What health practices do you follow to keep your family healthy?

• Anticipate challenges of caring for new baby.

• Ensure support systems at home (friends, relatives).

• Contact community resources for help, if needed.

Tell me about your living situation. How are your resources for

caring for the baby?

PARENTAL (MATERNAL) WELL-BEING

Physical/mental/oral health; nutritional status; medication

use; pregnancy risks

• Maintain your health (medical appointments, vitamins,

diet, sleep, exercise, personal safety).

What have you been doing to keep yourself and your baby

healthy? Do you always feel safe with your partner? Would you like

information on where to go or who to contact if you ever need

help?

• Know your HIV status.

• Consider your feelings about the pregnancy.

How do you, your family, the father feel about your pregnancy?

What works for communicating with each other/making decisions?

Key= Guidance for parents, questions

INFANCY | PRENATAL VISIT

BREASTFEEDING DECISION

Breastfeeding plans, breastfeeding concerns (past experi-

ences, prescription or nonprescription medications/drugs,

family support of breastfeeding), breastfeeding support

systems, financial resources for infant feeding

• Choose breastfeeding if possible; use iron-fortified

formula if formula feeding.

What are your plans for feeding your baby?

• Tell me about supplement/OTC use.

• Contact WIC/community resources if needed.

Are you concerned about having enough money to buy food or

infant formula? Would you be interested in resources that would

help you afford to care for you and your baby?

SAFETY

Car safety seats, pets, alcohol/substance use (fetal effects,

driving), environmental health risks (smoking, lead, mold),

guns, fire/burns (water heater setting, smoke detectors),

carbon monoxide detectors/alarms

• Use safety belt.

• Install rear-facing car safety seat in back seat.

• Learn about pet risks.

Do you have pets at home? If you have cats, have you been tested

for toxoplasmosis antibodies?

• Don’t use alcohol/drugs.

• Keep home/vehicle smoke-free; check home for lead,

mold.

• Remove guns from home; if gun necessary, store

unloaded and locked with ammunition separate.

Do you keep guns at home? Are there guns in homes you visit

(grandparents, relatives, friends)?

• Set home water temperature <120°F; install smoke

detectors, carbon monoxide detector/alarm.

NEWBORN CARE

Introduction to the practice, illness prevention, sleep (back to

sleep, crib safety, sleep location), newborn health risks (hand

washing, outings)

• Ask for information about practice.

• Put baby to sleep on back; choose crib with slats <

apart; have baby sleep in your room, in own crib.

• Wash hands frequently (diaper changes, feeding).

• Limit baby’s exposure to others.

INFANCY | NEWBORN VISIT

Observation of Parent-Child Interaction: Do parents

recognize and respond to the baby’s needs? Are they

comfortable when feeding, holding, or caring for the

baby? Do they have visitors or other signs of a support

network?

Surveillance of Development: Has periods of wakeful-

ness, is responsive to parental voice and touch, is able to

be calmed when picked up, looks at parents when

awake, moves in response to visual or auditory stimuli.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference; plot weight-for-

length. Assess/Observe alertness, distress, congenital

anomalies; skin lesions or jaundice; head shape/size,

fontanelles, signs of birth trauma; eyes/eyelids, ocular

mobility. Examine pupils for opacification, red reflexes.

Assess/Observe pinnae, patency of auditory canals, pits or

tags; nasal patency, septal deviation; cleft lip or palate,

natal teeth, frenulum; heart rate/rhythm/sounds, heart

murmurs. Palpate femoral pulses. Examine/Determine

umbilical cord/cord vessels; descended testes, penile

anomalies, anal patency. Note back/spine/foot deformi-

ties. Perform Ortolani and Barlow maneuvers. Detect

primitive reflexes.

Screening (See p 58.)

Universal: Metabolic and Hemoglobinopathy; Hearing

Selective: Blood Pressure; Vision

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY READINESS

Family support, maternal wellness, transition, sibling

relationships, family resources

• Accept help from family, friends.

• Never hit or shake baby.

What makes you get upset with the baby? What do you do when

you get upset?

• Take care of yourself; make time for yourself, partner.

• Feeling tired, blue, or overwhelmed in first weeks is

normal. If it continues, resources are available for help.

• Community agencies can help.

Tell me about your living situation. What are your resources for

caring for the baby?

INFANT BEHAVIORS

Infant capabilities, parent-child relationship, sleep (location,

position, crib safety), sleep/wake states (calming)

Key= Guidance for parents, questions

INFANCY | NEWBORN VISIT

• Learn baby’s temperament, reactions.

• Create nurturing routines; physical contact (holding,

carrying, rocking) helps baby feel secure.

• Put baby to sleep on back; don’t use loose, soft

bedding; have baby sleep in your room, in own crib.

FEEDING

Feeding initiation, hunger/satiation cues, hydration/jaundice,

feeding strategies (holding, burping), feeding guidance

(breastfeeding, formula)

• Exclusive breastfeeding during the first 4-6 months pro-

vides ideal nutrition, supports best growth and develop-

ment; iron-fortified formula is recommended substitute;

recognize signs of hunger, fullness; develop feeding

routine; adequate weight gain = 6-8 wet diapers a day,

no extra fluids; cultural/family beliefs.

•

If breastfeeding: 8-12 feedings in 24 hours; continue

prenatal vitamin; avoid alcohol.

•

If formula feeding: Prepare/store formula safely; feed

every 2-3 hours; hold baby semi-upright; don’t prop

bottle.

• Contact WIC/community resources if needed.

Are you concerned about having enough money to buy food for

yourself or infant formula?

SAFETY

Car safety seats, tobacco smoke, falls, home safety (review of

priority items if no prenatal visit was conducted)

• Rear-facing car safety seat in back seat; never put baby

in front seat of vehicle with passenger air bag. Baby

must remain in car safety seat at all times during travel.

• Always use safety belt; do not drive under the influence

of alcohol or drugs.

• Keep home/vehicle smoke-free.

• Keep hand on baby when changing diaper/clothes.

• Keep home safe for baby.

What changes have you made in your home to ensure your baby's

safety?

ROUTINE BABY CARE

Infant supplies, skin care, illness prevention, introduction to

practice/early intervention referrals

• Use fragrance-free soap/lotion, avoid powders; avoid

direct sunlight.

• Change diaper frequently to prevent diaper rash.

• Cord care: “air drying” by keeping diaper below; call if

bad smell, redness, fluid from the area.

• Wash your hands often.

What suggestions have you heard about things you can do to keep

your baby healthy?

• Avoid others with colds/flu.

INFANCY | FIRST WEEK VISIT

Observation of Parent-Child Interaction: Do parents

and newborn respond to each other? Do parents appear

content, depressed, angry, fatigued, overwhelmed? Are

parents responsive to newborn’s distress? Do the parents

appear confident in caring for newborn? What are the

parents’ and newborn’s interactions around comforting,

dressing/changing diapers, and feeding? Do parents sup-

port each other?

Surveillance of Development: Is able to sustain peri-

ods of wakefulness for feeding, will gradually become

able to establish longer stretch of sleep (4-5 hours at

night); turns and calms to parent’s voice, communicates

needs through behaviors, has undifferentiated cry; is able

to fix briefly on faces or objects, follows face to midline;

is able to suck/swallow/breathe, shows strong primitive

reflexes, lifts head briefly in the prone position.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Assess/Observe rashes, jaundice, dysmorphic fea-

tures; eyes/eyelids, ocular mobility. Examine pupils for

opacification, red reflexes. Assess dacryocystitis. Ascult for

heart murmurs. Palpate femoral pulses. Inspect umbilical

cord/cord vessels. Perform Ortolani/Barlow maneuvers.

Assess/Observe posture, neurologic tone, activity level,

symmetry of movement, state regulation.

Screening (See p 58.)

Universal: Metabolic and Hemoglobinopathy; Hearing

Selective: Blood Pressure; Vision

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

PARENTAL (MATERNAL) WELL-BEING

Health and depression, family stress, uninvited advice, parent

roles

• Recognize fatigue, “baby blues.” Rest and sleep when

baby sleeps.

How is the adjustment to the new baby going? Are there times

when you feel sad, hopeless, or overwhelmed?

• Accept help from partner, family, friends.

• Maintain family routines; spend time with your other

children.

• Handle unwanted advice by acknowledging, then

changing subject.

Key= Guidance for parents, questions

INFANCY | FIRST WEEK VISIT

NEWBORN TRANSITION

Daily routines, sleep (location, position, crib safety), state

modulation (calming), parent-child relationship, early

developmental referrals

• Help baby to develop sleep and feeding routines. Put

baby to sleep on back; choose crib with slats <2

apart, keep sides up; don’t use loose, soft bedding;

have baby sleep in your room, in own crib.

• Help baby wake for feeding by patting/diaper

change/undressing.

• Calm baby with stroking head or gentle rocking.

NUTRITIONAL ADEQUACY

Feeding success (weight gain), feeding strategies (holding,

burping), hydration/jaundice, hunger/satiation cues, feeding

guidance (breastfeeding, formula)

• Exclusive breastfeeding during the first 4-6 months pro-

vides ideal nutrition, supports best growth and develop-

ment; iron-fortified formula is recommended substitute;

recognize signs of hunger, fullness; develop feeding

routine; adequate weight gain = 6-8 wet diapers a day,

no extra fluids; cultural/family beliefs.

How do you know if your baby is hungry? Had enough to eat?

• If breastfeeding: Avoid own allergens; wait 1 month

before offering pacifier.

How is breastfeeding going? What concerns do you have?

• If formula feeding: Prepare/store formula safely; feed 2

oz every 2-3 hours and more if still seems hungry; hold

baby semi-upright; don’t prop bottle.

• Contact WIC/lactation consultant if needed.

SAFETY

Car safety seats, tobacco smoke, hot liquids (water

temperature)

• Use rear-facing car safety seat in back seat; never put

baby in front seat of vehicle with passenger air bag.

• Always use safety belt; do not drive under the influence

of alcohol or drugs.

• Don’t smoke; keep home/vehicle smoke-free.

• Avoid drinking hot liquids while holding baby; set

home water temperature <120ºF.

NEWBORN CARE

When to call (temperature taking), emergency readiness

(CPR), illness prevention (hand washing, outings), skin care

(sun exposure)

• Take temperature rectally, not by ear.

What thermometer do you use? Do you know how to use it?

• Create emergency preparedness plan (first-aid kit, list of

telephone numbers).

• Wash hands often; avoid crowds.

• Avoid sun, use children’s sunscreen; ask if rash is a concern.

INFANCY | 1 MONTH VISIT

Observation of Parent-Child Interaction: Do

parents appear content, depressed, angry, fatigued,

overwhelmed? Do parents appear uncertain or nervous?

How do the parent and infant interact? How do parents

respond to the infant’s cues? Do they appear to be com-

fortable with each other and with the baby?

Surveillance of Development: Responsive to calming

actions when upset; able to follow parents with eyes,

recognizes the parents’ voices; has started to smile; is

able to lift his head when on tummy.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Assess/Observe positional skull deformities; red

reflexes, eye color/intensity/clarity, opacities, clouding of

cornea. Ascult for heart murmurs. Palpate femoral pulses.

Search for abdominal masses. Note umbilicus healing.

Perform Ortolani/Barlow maneuvers. Assess neurologic

tone, attentiveness to visual and auditory stimuli.

Screening (See p 58.)

Universal: Metabolic and Hemoglobinopathy; Hearing

Selective: Blood Pressure; Vision; Tuberculosis

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

PARENTAL (MATERNAL) WELL-BEING

Health (maternal postpartum checkup, depression, substance

abuse), return to work/school (breastfeeding plans, child care)

• Have postpartum checkup; recognize “baby blues.”

How are your spirits? What are your best and most difficult times

of day with the baby? Do you find you’re drinking, using herbs, or

taking drugs to help you feel better?

• Make back-to-work/school plans; plan for breastfeed-

ing, child care.

FAMILY ADJUSTMENT

Family resources, family support, parent roles, domestic

violence, community resources

• Contact community resources if needed.

Tell me about your living situation. How are your resources for

caring for your baby (heat, appliances, housing, knowledge, insur-

ance, money)? Who helps you with the baby?

• Take time for self, partner.

Key= Guidance for parents, questions

INFANCY | 1 MONTH VISIT

• Ask for help with domestic violence.

Do you always feel safe in your home? Has your partner or ex-

partner ever hit you? Are you scared that you or other caretakers

may hurt the baby? Would you like information on where to go

and who to contact for help?

• Learn infant first-aid/CPR/temperature taking; know

emergency telephone numbers; wash hands often.

INFANT ADJUSTMENT

Sleep/wake schedule, sleep position (back to sleep, location,

crib safety), state modulation (crying, consoling, shaken

baby), developmental changes (bored baby, tummy time),

early developmental referrals

• Develop consistent sleep/feeding routines.

• Put baby to sleep on back; choose crib with slats <

apart; don’t use loose, soft bedding; have baby sleep in

your room, in own crib; choose mesh playpen with

weave <

"; never leave baby in with drop side down.

• Hold, cuddle, talk to baby often; calm baby by talking,

patting, stroking, rocking; never shake baby.

• Start “tummy time” when awake.

FEEDING ROUTINES

Feeding frequency (growth spurts), feeding choices (types of

foods/fluids), hunger cues, feeding strategies (holding,

burping), pacifier use (cleanliness), feeding guidance

(breastfeeding, formula)

• Exclusive breastfeeding during the first 4-6 months is

ideal; iron-fortified formula is recommended substitute;

recognize signs of hunger, fullness; develop feeding

routine; adequate weight gain = 5-8 wet diapers a day,

3-4 stools a day; burp at natural breaks; no extra fluids,

food; recognize growth spurts.

How do you know if your baby is hungry?

• If breastfeeding: Continue prenatal vitamin; wait until

4-6 weeks before offering pacifier/bottle.

• If formula feeding: Prepare/store formula safely; feed 2

oz every 2-3 hours and more if still seems hungry; hold

baby semi-upright; don’t prop bottle.

SAFETY

Car safety seats, toys with loops and strings, falls, tobacco

smoke

• Use rear-facing car safety seat in back seat; never put

baby in front seat of vehicle with passenger air bag.

• Always use safety belt; do not drive under the influence

of alcohol or drugs.

• Keep hand on baby when changing diaper/clothes;

keep bracelets, toys with loops, strings/cords away

from baby.

• Don’t smoke; keep home/vehicle smoke-free.

INFANCY | 2 MONTH VISIT

Observation of Parent-Child Interaction: How

responsive are parents and infant to each other? Do

parents appear content, depressed, angry, fatigued, over-

whelmed? Are parents comfortable and confident with

the infant? What are the parent-infant interactions

around feeding/eating, comforting, and responding to in-

fant cues? Do parent and partner support each other?

Surveillance of Development: Attempts to look at

parent, smiles, is able to console and comfort self; begins

to demonstrate differentiated types of crying, coos, has

clearer behaviors to indicate needs. Indicates boredom; is

able to hold up head and begins to push up in prone

position, has consistent head control in supported sitting

position, shows symmetrical movements of head, arms,

and legs, shows diminishing newborn reflexes.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Assess/Observe rashes or bruising, fontanelles;

eyes/eyelids, ocular mobility, pupil opacification, red

reflexes; heart murmurs, femoral pulses. Perform

Ortolani/Barlow maneuvers. Assess torticollis, neurologic

tone, strength and symmetry of movements.

Screening (See p 58.)

Universal: Metabolic and Hemoglobinopathy; Hearing

Selective: Blood Pressure; Vision

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

PARENTAL (MATERNAL) WELL-BEING

Health (maternal postpartum checkup and resumption of

activities, depression), parent roles and responsibilities, family

support, sibling relationships

• Have postpartum checkup; talk with partner about

family planning.

• Take time for self, partner; maintain social contacts.

• Engage other children in care of baby, as appropriate.

INFANT BEHAVIOR

Parent-child relationship, daily routines, sleep (location,

position, crib safety), developmental changes, physical

activity (tummy time, rolling over, diminishing newborn

reflexes), communication and calming

Key= Guidance for parents, questions

INFANCY | 2 MONTH VISIT

• Hold, cuddle, talk/sing to baby.

What do you and your partner enjoy most about your baby? What

is challenging?

• Maintain regular sleep/feeding routines.

• Put baby to sleep on back; choose crib with slats <2

apart, keep sides up; don’t use loose, soft bedding;

have baby sleep in your room, in own crib.

• Use “tummy time” when awake.

• Learn baby’s responses, temperament, likes/dislikes.

• Develop strategies for fussy times.

How much is your baby crying? What are some ways you have

found to calm your baby? What do you do if that doesn’t work?

IN FA NT-FA M ILY S YN CHR ONY

Parent-infant separation (return to work/school), child care

• Plan for return to school/work.

• Choose quality child care; recognize that separation is

hard.

How do you feel about leaving your baby with someone else?

NUTRITIONAL ADEQUACY

Feeding routine, feeding choices (delaying complementary

foods, herbs/vitamins/supplements), hunger/satiation cues,

feeding strategies (holding, burping), feeding guidance

(breastfeeding, formula)

• Exclusive breastfeeding during the first 4-6 months is

ideal; iron-fortified formula is recommended substitute;

recognize signs of hunger, fullness; burp at natural

breaks; no extra fluids or food.

•

If breastfeeding: Continue with 8-12 feedings in 24

hours; plan for pumping/storing breast milk if returning

to work/school.

•

If formula feeding: Prepare/store formula safely; feed

every 3-4 hours; hold baby semi-upright; don’t prop

bottle; no bottle in bed.

SAFETY

Car safety seats, water temperature (hot liquids), choking,

tobacco smoke, drowning, falls (rolling over)

• Use rear-facing car safety seat in back seat; never put

baby in front seat of vehicle with passenger air bag.

• Always use safety belt; do not drive under the influence

of alcohol or drugs.

• Don’t drink hot liquids while holding baby; set home

water temperature <120°F.

• Don’t smoke; keep home/vehicle smoke-free.

• Don’t leave baby alone in tub or high places (changing

tables, beds, sofas); keep hand on baby.

• Keep small objects, plastic bags away from baby.

INFANCY | 4 MONTH VISIT

Observation of Parent-Child Interaction: Are parents

and infant responsive to each other? Do parents comfort

when infant cries? Are parents attentive to infant? Do

parents and infant demonstrate reciprocal engagement

around feeding/eating? Do parents respond to infant’s

cues and how does the infant respond?

Surveillance of Development: Smiles spontaneously,

elicits social interactions, shows solidified self-consolation

skills; cries in differentiated manner, babbles expressively

and spontaneously; responds to affection/changes in en-

vironment, indicates pleasure/displeasure; pushes chest to

elbows, has good head control, demonstrates symmetri-

cal movements of arms/legs, begins to roll and reach for

objects.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Assess/Observe rashes, bruising; positional skull

deformities; ocular mobility for lateral gaze, pupil opacifi-

cation, red reflexes. Ascult for heart murmurs. Palpate

femoral pulses. Assess/Observe developmental hip dyspla-

sia; neurologic tone, strength, and movement symmetry.

Screening (See p 58.)

Universal: None

Selective: Blood Pressure; Vision; Hearing; Anemia

Immunizations

DC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY FUNCTIONING

Parent roles/responsibilities, parental responses to infant,

child care providers (number, quality)

• Take time for self, partner; maintain social contacts;

spend time with your other children.

• Hold, cuddle, talk/sing to baby.

• Learn baby’s responses, temperament, likes/dislikes.

What do you think your baby is trying to tell you when she cries,

looks at you, turns away, smiles?

• Make quality child care arrangements.

INFANT DEVELOPMENT

Consistent daily routines, sleep (crib safety, sleep location),

parent-child relationship (play, tummy time), infant self-

regulation (social development, infant self-calming)

• Continue regular feeding/sleeping routines; put baby to

bed awake but drowsy.

Key= Guidance for parents, questions

INFANCY | 4 MONTH VISIT

• Put baby to sleep on back; don’t use loose, soft bed-

ding; lower crib mattress before baby can sit up;

choose mesh playpen with weave <

"; never leave

baby in with drop side down.

• Use quiet (reading, singing) and active (“tummy time”)

playtime; provide safe opportunities to explore.

• Continue calming strategies when fussy.

What do you do to calm your baby? Do you ever feel that you or

other caretakers may hurt the baby? How do you handle that feel-

ing?

NUTRITION ADEQUACY AND GROWTH

Feeding success, weight gain, feeding choices (complementary

foods, food allergies), feeding guidance (breastfeeding,

formula)

• Exclusive breastfeeding during the first 4-6 months is

ideal; iron-fortified formula is recommended substitute.

• Cereal can be introduced between 4-6 months, when

child is developmentally ready.

•

If breastfeeding: Recognize growth spurts; plan for safe

pumping/storing of breast milk.

•

If formula feeding: Prepare/store formula safely; 8 to 12

times in 24 hours; hold baby semi-upright; don’t prop

bottle; no bottle in bed; consider contacting WIC.

ORAL HEALTH

Maternal oral health care, use of clean pacifier, teething/

drooling, avoidance of bottle in bed

• Don’t share spoon or clean pacifier in your mouth;

maintain good dental hygiene.

• Avoid bottle in bed, propping, “grazing.”

SAFETY

Car safety seats, falls, walkers, lead poisoning, drowning,

water temperature (hot liquids), burns, choking

• Use rear-facing car safety seat in back seat; never put

baby in front seat of vehicle with passenger air bag.

• Always use safety belt; do not drive under the influence

of alcohol or drugs.

• Don’t leave baby alone in tub, high places (changing

tables, beds, sofas); keep hand on baby; don’t use

infant walker.

• Set home water temperature <120°F.

• Avoid burn risk to baby (hot liquids, cooking, ironing,

smoking).

• Keep small objects, plastic bags away from baby.

• Check for sources of lead in home.

INFANCY | 6 MONTH VISIT

Observation of Parent-Child Interaction: Are the

parents and infant responsive to one another? Do the

parents show confidence with infant? Does the parent-

infant relationship demonstrate comfort, adequate

feeding/eating, and response to the infant’s cues?

Do parents/partners support each other?

Surveillance of Development: Is socially interactive

with parent, recognizes familiar faces, babbles, enjoys

vocal turn taking, starts to know own name; uses visual

and oral exploration to learn about environment; rolls

over and sits, stands and bounces; moves to crawling

from prone; rocks back and forth; is learning to rotate in

sitting; will move from sitting to crawling.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Assess/Observe rashes, bruising; ocular mobility,

eye alignment, pupil opacification, red reflexes. Ascult for

heart murmurs. Palpate femoral pulses. Assess/Observe

developmental hip dysplasia, neurologic tone, movement

strength and symmetry.

Screening (See p 58.)

Universal: Oral Health

Selective: Blood Pressure; Vision; Hearing; Lead;

Tuberculosis

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY FUNCTIONING

Balancing parent roles (health care decision making, parent

support systems), child care

• Use support networks.

How are you balancing your roles of partner and parent? Who are

you able to go to when you need help with your family?

• Choose responsible, trusted child care providers;

consider playgroups.

INFANT DEVELOPMENT

Parent expectations (parents as teachers), infant develop-

mental changes (cognitive development/learning, playtime),

communication (babbling, reciprocal activities, early

intervention), emerging infant independence (infant self-

regulation/behavior management), sleep routine (self-

calming/putting self to sleep, crib safety)

• Use high chair/upright seat so baby can see you.

Key= Guidance for parents, questions

INFANCY | 6 MONTH VISIT

• Engage in interactive, reciprocal play. Talk/sing to,

read/play games with baby.

How does your baby communicate or tell you what he wants and

needs?

• Continue regular daily routines; put baby to bed awake

but drowsy.

• Put baby to sleep on back; choose crib with slats <2

apart; don’t use loose, soft bedding; lower crib mat-

tress; choose mesh playpen with weave <

"; never

leave baby in with drop side down.

NUTRITION AND FEEDING: ADEQUACY/GROWTH

Feeding strategies (quantity, limits, location, responsibilities),

feeding choices (complementary foods, choices of fluids/juice),

feeding guidance (breastfeeding, formula)

• Exclusive breastfeeding during the first 4-6 months is

ideal; iron-fortified formula is recommended substitute;

recognize slowing rate of growth.

• Determine whether baby is ready for solids; introduce

single-ingredient foods one at a time; provide iron-rich

foods; respond to baby’s cues.

• Begin cup; limit juice (2-4 oz a day).

•

If breastfeeding: Continue as long as mutually desired.

•

If formula feeding: Don’t switch to milk; contact

WIC/community resources for help.

ORAL HEALTH

Fluoride, oral hygiene/soft toothbrush, avoidance of bottle in

bed

• Assess fluoride source.

• Brush with soft toothbrush/cloth and water.

• Avoid bottle in bed, propping, “grazing.”

SAFETY

Car safety seats, burns (hot water/hot surfaces), falls (gates at

stairs and no walkers), choking, poisoning, drowning

• Use rear-facing car safety seat in back seat until 1 year

AND 20 pounds; never put in front seat of vehicle with

passenger air bag.

• Do home safety check (stair gates, barriers around

space heaters, cleaning products).

• Don’t leave baby alone in tub, high places (changing

tables, beds, sofas); don’t use infant walker.

• Keep baby in high chair/playpen when in kitchen.

• Set home water temperature <120°F.

• Avoid burn risk to baby (stoves, heaters).

• Keep small objects, plastic bags, away from baby.

• To prevent choking, limit “finger foods” to soft bits.

INFANCY | 9 MONTH VISIT

Observation of Parent-Child Interaction: Do parents

stimulate the infant with language, play? Do parents and

infant demonstrate reciprocal engagement around

feeding/eating? Can infant move away from parent to

explore and check back with parent visually and

physically? Are parents’ developmental expectations

appropriate? How do parents respond to infant’s

independent behavior within a safe environment?

Surveillance of Development: Has developed

apprehension with strangers, seeks out parent; uses

repetitive consonants and vowel sounds, points out

objects; develops object permanence, learns interactive

games, explores environment; expands motor skills.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Assess/Observe positional skull deformities; ocular

mobility, eye alignment, pupil opacification, red reflexes.

Ascult for heart murmurs. Palpate femoral pulses.

Assess/Observe developmental hip dysplasia; neurologic

tone, movement strength and symmetry. Elicit parachute

reflex.

Screening (See p 58.)

Universal: Development; Oral Health

Selective: Blood Pressure; Vision; Hearing; Lead

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY ADAPTATIONS

Discipline (parenting expectations, consistency, behavior

management), cultural beliefs about child-rearing, family

functioning, domestic violence

• Use consistent, positive discipline (limit use of the word

“No,” use distraction, be a role model).

• Make time for self, partner, friends.

• Ask for help with domestic violence.

Do you always feel safe in your home? Has your partner or ex-

partner ever hit you? Are you scared that you or other caretakers

may hurt the baby? Would you like information on where to go

and who to contact for help?

Key= Guidance for parents, questions

INFANCY | 9 MONTH VISIT

INFANT INDEPENDENCE

Changing sleep pattern (sleep schedule), developmental

mobility (safe exploration, play), cognitive development

(object permanence, separation anxiety, behavior and

learning, temperament versus self-regulation, visual

exploration, cause and effect), communication

• Keep consistent daily routines.

• Provide opportunities for safe exploration, be realistic

about abilities.

How does your baby adapt to new situations, people, and places?

• Recognize new social skills, separation anxiety; be sensi-

tive to temperament.

• Play with cause-and-effect toys; talk/sing/read together;

respond to baby’s cues.

How do you think the baby is learning? How is he communicating

with you?

• Avoid TV, videos, computers.

FEEDING ROUTINE

Self-feeding, mealtime routines, transition to solids (table-

food introduction), cup drinking (plans for weaning)

• Gradually increase table foods; ensure variety of foods,

textures.

• Provide 3 meals, 2-3 snacks a day.

• Encourage use of cup; discuss plans for weaning.

• Continue breastfeeding if mutually desired.

SAFETY

Car safety seats, burns (hot stoves, heaters), window guards,

drowning, poisoning (safety locks), guns

• Use rear-facing car safety seat in back seat until 1 year

AND 20 pounds; never put baby in front seat of vehicle

with passenger air bag.

• Always use safety belt; do not drive under the influence

of alcohol or drugs.

• Don’t leave heavy objects, hot liquids on tablecloths.

• Do home safety check (stair gates, barriers around

space heaters, cleaning products, electrical cords).

• Keep baby in high chair/playpen when in kitchen.

• Install operable window guards on second- and higher-

story windows.

• Be within arm’s reach (“touch supervision”) near water,

pools, bathtubs.

• Put Poison Control Center number at each telephone.

EARLY CHILDHOOD | 12 MONTH VISIT

Observation of Parent-Child Interaction: How does

parent interact with toddler? Does child check back with

parent visually? Does toddler bring an object to show

parent? How does parent react to praise of self or child

by health care professional? How do siblings interact with

toddler? Does parent seem positive about child?

Surveillance of Development: Plays interactive games,

imitates activities, hands parent a book when wants a

story, waves “bye-bye,” has strong attachment with

parent and shows distress on separation; demonstrates

protodeclarative pointing; imitates vocalizations/sounds;

speaks 1-2 words; jabbers with normal inflections; fol-

lows simple directions, identifies people upon request;

bangs 2 cubes held in hands, stands alone.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Examine for red reflexes. Perform cover/uncover

test. Observe for caries, plaque, demineralization, stain-

ing. Observe gait. Determine whether testes fully de-

scended.

Screening (See p 59.)

Universal: Anemia; Lead (high prevalence/Medicaid)

Selective: Oral Health; Blood Pressure; Vision; Hearing;

Lead (low prevalence/no Medicaid); Tuberculosis

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY SUPPORT

Adjustment to the child’s developmental changes and

behavior, family-work balance, parental agreement/

disagreement about child issues

• Discipline with time-outs and positive distractions;

praise for good behaviors.

When your child is troublesome, what do you do?

• Make time for self and partner; time with family; keep

ties with friends.

• Maintain or expand ties to your community; consider

parent-toddler playgroups, parent education, or sup-

port group.

Who do you talk to about parenting issues?

Key= Guidance for parent, questions

EARLY CHILDHOOD | 12 MONTH VISIT

ESTABLISHING ROUTINES

Family time, bedtime, teeth brushing, nap times

• Establish family traditions.

What do you all do together? Tell me about your family’s

traditions.

• Continue 1 nap a day; nightly bedtime routine with

quiet time, reading, singing, a favorite toy.

• Establish teeth brushing routine.

FEEDING AND APPETITE CHANGES

Self-feeding, nutritious foods, choices, “grazing”

• Encourage self-feeding; avoid small, hard foods.

• Feed 3 meals and 2-3 nutritious snacks a day; be sure

caregivers do the same.

• Provide nutritious food and healthy snacks.

• Trust child to decide how much to eat (toddlers tend to

“graze”).

ESTABLISHING A DENTAL HOME

First dental checkup, dental hygiene

• Visit the dentist by 12 months or after first tooth.

• Brush teeth twice a day with plain water, soft

toothbrush.

• If still using bottle, offer only water.

SAFETY

Home safety, car safety seats, drowning, guns

• “Childproof” home (medications, cleaning supplies,

heaters, dangling cords, stairs, small or sharp objects).

• Use a rear-facing car safety seat until at least 1 year old

AND at least 20 pounds.

• It is best to use a rear-facing car safety seat until high-

est weight or height allowed by manufacturer; make

necessary changes when switching to forward facing;

never place rear-facing car safety seat in front seat of

vehicle with passenger air bag; back seat is safest.

• Stay within an arm’s reach (“touch supervision”) when

near water; empty buckets, pools, bathtubs immediate-

ly after use.

• Remove guns from home; if gun necessary, store un-

loaded and locked, with ammunition locked separately.

EARLY CHILDHOOD | 15 MONTH VISIT

Observation of Parent-Child Interaction: What is the

emotional tone between parent and child? How does

parent support toddler’s need for safety and reassurance

in exam? Does toddler check back with parent visually?

How does parent react to praise from health care profes-

sional? How do siblings react to toddler?

Surveillance of Development: Listens to a story, imi-

tates activities, may help in house; indicates wants by

pulling/pointing/grunting, brings objects to show, hands

a book when wants a story; says 2-3 words with mean-

ing; understands/follows simple commands, scribbles;

walks well, stoops, recovers, can step backwards; puts

block in cup, drinks from cup.

Physical Exam. Complete, including: Measure and

plot length, weight, head circumference. Plot weight-for-

length. Examine red reflexes. Perform cover/uncover test.

Observe for caries, plaque, demineralization, staining.

Observe for stranger avoidance.

Screening (See p 59.)

Universal: None

Selective: Blood Pressure; Vision; Hearing

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

COMMUNICATION AND SOCIAL DEVELOPMENT

Individuation, separation, attention to how child

communicates wants and interests, signs of shared attention

• When possible, allow child to choose between 2

options acceptable to you.

• “Stranger anxiety” and separation anxiety reflect new

cognitive gains; speak reassuringly.

• Use simple, clear words and phrases to promote lan-

guage development and improve communication.

How does your child communicate what she wants? Does she

point to something she wants and then watch to see if you see

what she’s doing?

SLEEP ROUTINES AND ISSUES

Regular bedtime routine, night waking, no bottle in bed

• Maintain consistent bedtime and nighttime routine;

tuck in when drowsy, but still awake.

• If night waking occurs, reassure briefly, give stuffed

animal or blanket for self-consolation.

• Do not give bottle in bed.

Key= Guidance for parent, questions

EARLY CHILDHOOD | 15 MONTH VISIT

TEMPER TANTRUMS AND DISCIPLINE

Conflict predictors, distraction, praise for accomplishments,

consistency

• Some conflict/tantrums can be avoided by “toddler-

proofing” home, using distractions, accepting messi-

ness, allowing child to choose (when appropriate).

What kinds of things do you find yourself saying “No” about?

• Praise good behavior and accomplishments.

• Use discipline for teaching/protecting, not punishing.

How are you and your partner managing your child’s behavior?

What do you do when you disagree?

HEALTHY TEETH

Brushing teeth, bottle usage

• Schedule first dental visit if hasn’t seen dentist yet.

• Brush teeth twice a day with soft brush and plain

water.

• Prevent tooth decay by good family oral health habits

(brushing, flossing), not sharing utensils or cup.

• If nighttime bottle, use water only.

SAFETY

Car safety seats, parental use of safety belts, poison,

fire safety

• It is best to use rear-facing car safety seat until highest

weight or height allowed by manufacturer; make nec-

essary changes when switching a convertible seat to

forward facing; never place rear-facing car safety seat in

front seat of vehicle with passenger air bag; back seat

is safest.

• Make sure everyone uses a safety belt.

• Review home safety (remove or lock up poisons,

cleaning supplies; use stair gates; install operable win-

dow guards on second- and higher-story windows).

When did you last examine your home to make sure it is safe?

What emergency numbers do you have posted near your phones?

• Install smoke detector on every level, test monthly/

change batteries annually; make fire escape plan; set

hot water <120°F.

• Keep hot liquids, lighters, matches out of reach.

EARLY CHILDHOOD | 18 MONTH VISIT

Observation of Parent-Child Interaction: How do the

parent and child communicate? Does child show parent

book? Does parent ask child many questions or give

many directions? What is the tone of parent-child inter-

actions? How does parent guide child to safe limits?

Surveillance of Development: Is interactive/withdrawn,

friendly/aggressive; laughs in response to others, explores

alone but with parent nearby; vocalizes and gestures,

speaks 6 words, points to indicate wants; points to 1

body part, follows simple instructions, knows names of

favorite books; walks up steps/runs; stacks 2 or 3 blocks,

scribbles, uses spoon/cup without spilling.

Physical Exam. Complete, including: Measure and

plot recumbent length, weight, head circumference. Plot

weight-for-length. Observe gait, hand control, arm/spine

movement. Examine for red reflexes. Perform cover/

uncover test. Observe for nevi, café au lait spots, birth-

marks, bruising; caries, plaque, demineralization, staining,

injury.

Screening (See p 59.)

Universal: Development, Autism

Selective: Oral Health, Blood Pressure, Vision, Hearing,

Anemia, Lead, Tuberculosis

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY SUPPORT

Parental well-being, adjustment to toddler’s growing

independence and occasional negativity, queries about a

new sibling planned or on the way

• Create family times; spend time with each child; take

actions to ensure own health.

What activities do you do as a family? Tell me if you have ever

been in a relationship where you have been hurt, threatened, or

treated badly? What did you do?

• Support emerging independence but reinforce limits

and appropriate behavior.

• Prepare toddler for new sibling by reading books

together about a new baby.

Key= Guidance for parent, questions

EARLY CHILDHOOD | 18 MONTH VISIT

CHILD DEVELOPMENT AND BEHAVIOR

Adaptation to nonparental care and anticipation of return to

clinging, other changes connected with new cognitive gains

• Anticipate anxiety/clinging in new situations.

• Praise good behavior/accomplishments.

• Be consistent with discipline/enforcing limits, share with

other caregivers.

• Enjoy daily playtime.

LANGUAGE PROMOTION/HEARING

Encouragement of language, use of simple words/phrases,

engagement in reading/singing/talking

• Encourage language development by reading and

singing; talk about what you see.

• Use simple words to describe pictures in book.

• Use words that describe feelings and emotions to help

child learn about feelings.

How does your child communicate what she wants?

TOILET TRAINING READINESS

Recognizing signs of readiness, parental expectations

• Wait until child is ready (dry for periods of about 2

hours, knows wet and dry, can pull pants up/down,

can indicate bowel movement).

• Read books about using the potty, praise attempts to

sit on the potty.

SAFETY

Car safety seats; parental use of safety belts; falls, fires, and

burns; poisoning; guns

• It is best to use a rear-facing car safety seat until

highest weight or height allowed by manufacturer;

make necessary changes when switching a convertible

seat to forward facing; never place rear-facing car

safety seat in front seat of vehicle with passenger air

bag; back seat is safest.

• Make sure everyone uses a safety belt.

• Use stair gates, install operable window guards on

second- and higher-story windows.

• Prevent burns (hot liquids/stove/matches/lighters).

Install smoke detectors.

• Remove guns from home; if gun necessary, store un-

loaded and locked, with ammunition locked separately.

Note: Bright Futures recommends anticipatory

guidance on reading aloud at every visit from 6

months to 5 years and encourages giving a book

at these visits. For more information, visit

www.reachoutandread.org.

EARLY CHILDHOOD | 2 YEAR VISIT

Observation of Parent-Child Interaction: How do par-

ent and child communicate? What is tone of the interac-

tion and the feelings conveyed? Does child feel free to

explore the room? How does the parent set limits?

Surveillance of Development: Imitates adults, plays

alongside other children, refers to self as “I” or “me,”

has at least 50 words, uses 2-word phrases, asks parent

to read a book; follows 2-step commands, completes

sentences and rhymes in familiar books; stacks 5 or 6

blocks, makes or imitates horizontal and circular strokes

with crayon, turns pages one at a time, imitates food

preparation, throws ball overhand; goes up and down

stairs one step at a time, jumps up.

Physical Exam. Complete, including: Measure stand-

ing height (preferred) or recumbent length, weight, head

circumference. Calculate and plot BMI, or plot weight-

for-length. Examine for red reflexes. Perform cover/

uncover test. Observe for caries, plaque, demineraliza-

tion, staining, injury, gingivitis. Observe running,

scribbling, socialization, ability to follow commands.

Assess language acquisition/clarity.

Screening (See p 59.)

Universal: Autism; Lead (high prevalence/Medicaid)

Selective: Oral Health; Blood Pressure; Vision; Hearing;

Anemia; Lead (low prevalence/no Medicaid); Tuberculosis;

Dyslipidemia

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

ASSESSMENT OF LANGUAGE DEVELOPMENT

How child communicates, expectations for language

• Model appropriate language.

• Read together every day; child may love same story

over and over.

• Recognize that child may struggle to respond quickly;

talk and question slowly.

• Should be able to follow simple 1 or 2 step commands.

What do you think your child understands?

Key= Guidance for parent, questions

EARLY CHILDHOOD | 2 YEAR VISIT

TEMPERAMENT AND BEHAVIOR

Sensitivity, approachability, adaptability, intensity

• Praise good behavior/accomplishments; listen to and

respect your child.

• Help child express such feelings as joy, anger, sadness,

frustration.

• Encourage self-expression.

Tell me about your child’s typical play.

• Learn child’s way of reacting to people/situations.

• Encourage child to play with other children.

How does your child act around other children?

TOILET TRAINING

What have parents tried, techniques, personal hygiene

• Begin when child is ready (dry for periods of 2 hours,

knows wet and dry, can pull pants up/down, can indi-

cate bowel movement).

• Plan for frequent toilet breaks (up to 10 times a day).

• Teach personal hygiene (wash hands, sneeze/cough

into shoulder).

TELEVISION VIEWING

Limits on viewing, promotion of reading, promotion of

physical activity and safe play

• Limit TV and video to no more than 1-2 hours of

quality programming per day.

• If you allow TV, watch together and discuss.

• Choose TV alternatives (reading, games, singing).

• Encourage physical activity; be active as a family.

SAFETY

Car safety seats, parental use of safety belts, bike helmets,

outdoor safety, guns

• Install car safety seat in back seat.

• Make sure everyone else uses a safety belt.

• Use bike helmet.

• Supervise child outside, especially around cars,

machinery, in streets.

• Remove guns from home; if gun necessary, store un-

loaded and locked, with ammunition locked separately.

EARLY CHILDHOOD | 2

YEAR VISIT

Observation of Parent-Child Interaction: How actively

do parent and child communicate? Does the child use

questions and phrases at appropriate age level? Do par-

ent and child look at book, discuss, and interact? How

well does parent calm child?

Surveillance of Development: Play includes other chil-

dren; has fears about unexplained changes in environ-

ment/unexpected events; uses phrases of 3-4 words, is

understandable to others 50% of the time; knows the

correct action for animal or person (eg, bird flies, man

talks), points to 6 body parts; jumps up and down in

place, throws ball overhand, brushes teeth with help,

puts on clothes with help, copies vertical line.

Physical Exam. Complete, including: Measure and

plot standing height (preferred) or recumbent length,

weight, head circumference. Calculate and plot BMI, or

plot weight-for-length. Examine red reflexes. Perform

cover/uncover test. Observe coordination, language

acquisition/clarity, socialization. Assess vocalizations.

Screening (See p 59.)

Universal: Development

Selective: Oral Health; Blood Pressure; Vision; Hearing

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY ROUTINES

Parental consistency, day and evening routines, enjoyable

family activities

• Reach agreement with all family members on how best

to support child’s emerging independence while main-

taining consistent limits.

How well do you and your family agree on limits and discipline for

your child?

• Encourage family exercise (walking, swimming, biking).

Tell me how you have fun with your family.

• Maintain regular family routines (meals, daily reading).

LANGUAGE PROMOTION AND COMMUNICATION

Interactive communication through song, play, and reading

• Read together every day; go to the library.

Does he enjoy having stories read to him? Does he enjoy songs,

rhymes, and games with you?

• Limit TV and video to no more than 1-2 hours a day;

monitor what child watches.

Key= Guidance for parent, questions

EARLY CHILDHOOD | 2

YEAR VISIT

• Listen when child speaks; repeat, using correct

grammar.

Is your child speaking in sentences?

PROMOTING SOCIAL DEVELOPMENT

Play with other children, limited reciprocal play, imitation of

others, choices

• Encourage play with other children, but supervise

because child not ready yet to share/play cooperatively.

• Build independence by offering choices between 2

acceptable alternatives.

Does your child enjoy making independent decisions? What are

some of the new things your child is doing?

PRESCHOOL CONSIDERATIONS

Readiness for early childhood programs, playgroups, or

playdates

• Consider group child care, preschool program, organ-

ized playdates or playgroups.

What are your plans for child care or preschool in the year ahead?

• Encourage toilet-training success by dressing child in

easy-to-remove clothes, establish daily routine, place on

potty every 1-2 hours, praise, maintain relaxed environ-

ment by reading/singing.

SAFETY

Water safety, car safety seats, outdoor health and safety

(pools, play areas, sun exposure), pets, fires and burns

• Stay within an arm’s reach (“touch supervision”) near

water, bathtubs, pools, toilet.

• Properly install car safety seat in back seat.

• Supervise child outside, especially around cars, machin-

ery; use bike helmet; limit sun, use sunscreen.

• Install smoke detectors on every level, test monthly and

change batteries annually; make fire escape plan; keep

matches out of sight.

EARLY CHILDHOOD | 3 YEAR VISIT

Observation of Parent-Child Interaction: How do

parent and child communicate? Does parent give child

choices? Does parent encourage the child’s cooperation?

Does unacceptable behavior elicit appropriate responses?

Surveillance of Development: Has self-care skills (eg,

feeding, dressing); imaginative play becomes more

elaborate, enjoys interactive play; converses in 2-3

sentences, understandable to others 75% of the time,

names a friend; knows name, identifies self as girl/boy;

builds tower of 6-8 cubes, throws ball overhand, walks

up stairs alternating feet; copies a circle, draws person

with 2 body parts; day toilet trained for bowel and

bladder.

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Attempt ophthalmoscopic exam of optic nerve

and retinal vessels. Observe for caries, plaque, demineral-

ization, staining, injury, gingivitis; language acquisition,

speech clarity; adult-child interaction.

Screening (See p 59.)

Universal: Visual Acuity

Selective: Oral Health; Hearing; Anemia; Lead;

Tuberculosis

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

FAMILY SUPPORT

Family decisions, sibling rivalry, work balance

• Be aware of differences/similarities in your parenting

style and that of your parents.

• Show affection; handle anger constructively; reinforce

limits/appropriate behavior.

Tell me how family members show affection, anger? Describe what

your family does together.

• Help children develop good relations with each other;

spend time with each child.

How do your children get along together?

What do you like to do best with your brothers and sisters?

• Take time for yourself; spend time alone with your

partner.

Key= Guidance for parent, questions; Guidance for child, questions

EARLY CHILDHOOD | 3 YEAR VISIT

ENCOURAGING LITERACY ACTIVITIES

Singing, talking, describing, observing, reading

• Read, sing, play rhyme games together.

• Talk about pictures in books (don’t always have to

read); let child “tell” story.

• Encourage child to talk about friends, experiences.

How does your child tell you what he wants? How well does the

family understand his speech?

PLAYING WITH PEERS

Interactive games, play opportunities

• Encourage play with appropriate toys and safe explo-

ration; fantasy play.

Tell me about your child’s typical play.

• Encourage interactive games with peers; taking turns.

PROMOTING PHYSICAL ACTIVITY

Limits on inactivity

• Create opportunities for family to share time and exer-

cise together.

• Promote daily physical activity at home, in child care or

in preschool.

• Limit all screen time to no more than 1-2 hours a day;

no TV/DVD player in bedroom; monitor programs

watched.

SAFETY

Car safety seats, pedestrian safety, falls from windows, guns

• Use forward-facing car safety seat, properly installed in

back seat.

• Switch to belt-positioning booster seat when child

reaches highest weight/height allowed by manufacturer

of forward-facing seat with harness.

• Supervise all play near streets/driveways; do not allow

child to cross street alone.

• Move furniture away from windows; install operable

window guards on second- and higher-story windows.

• Remove guns from home; if gun necessary, store un-

loaded and locked, with ammunition locked separately;

ask if guns in home where child plays.

EARLY CHILDHOOD | 4 YEAR VISIT

Observation of Parent-Child Interaction: How do

parent and child communicate? Does parent allow child

to answer questions? Does child separate from parent

during exam? Does child dress and undress self? How do

parent, child, siblings interact? If offered books, does

parent let child choose?

Surveillance of Development: Describes features of

self; listens to stories, engages in fantasy play; gives

first/last name, knows what to do if cold/tired/hungry,

most speech clearly understandable; names 4 colors,

plays board/card games, draws a person with 3 parts;

hops on one foot, balances on one foot for 2 seconds,

builds tower of 8 blocks, copies a cross; brushes own

teeth, dresses self.

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Observe fine/gross motor skills. Assess language

acquisition, speech fluency/clarity, thought content/

abstraction.

Screening (See p 59.)

Universal: Visual Acuity; Hearing

Selective: Anemia; Lead; Tuberculosis; Dyslipidemia

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

SCHOOL READINESS

Structured learning experiences, opportunities to socialize

with other children, fears, friends, fluency

• Children are very sensitive, easily encouraged or hurt;

model respectful behavior and apologize if wrong;

praise when demonstrates sensitivity to feelings of

others.

• Provide opportunities to play with other children.

How interested is your child in other children? How confident is

she socially and emotionally?

Do you have a favorite friend?

• Consider structured learning (preschool, Head Start, or

community program); visit parks, museums, libraries.

How happy are you with your child care arrangements? Does she

seem happy to go?

• Reading is important to help child like reading and be

ready for school.

Key= Guidance for parent, questions; Guidance for child, questions

EARLY CHILDHOOD | 4 YEAR VISIT

• Give child time to finish sentences; encourage speaking

skills by reading/talking together.

How does your child communicate what she wants and knows?

DEVELOPING HEALTHY PERSONAL HABITS

Daily routines that promote health

• Create calm bedtime ritual, mealtimes without TV,

toothbrushing twice a day with pea-sized toothpaste.

TELEVISION/MEDIA

Limits on viewing, promotion of physical activity and safe

play

• Limit TV and video to 1-2 hours a day; no TV in bed-

room; watch programs together and discuss.

• Make opportunities for daily play; be physically active as

a family.

CHILD AND FAMILY INVOLVEMENT AND SAFETY IN THE COMMUNITY

Activities outside the home, community projects, educational

programs, relating to peers and adults, domestic violence

• Maintain or expand participation in community

activities.

• Expect curiosity about the body; use correct terms,

answer questions.

• Teach your child rules for how to be safe with adults,

using 3 principles: (1) no adult should tell a child to

keep secrets from parents, (2) no adult should express

interest in private parts, (3) no adult should ask a child

for help with his/her private parts.

• Know that help is available if personal safety is a

concern.

Many children I see have parents who have been hurt by someone

else, so I ask about it routinely. Are you scared that your partner or

someone else may try to hurt you or your child?

SAFETY

Belt-positioning booster seats, supervision, outdoor safety,

guns

• Use a forward-facing car safety seat installed in back

seat until child reaches highest weight or height al-

lowed by manufacturer of forward-facing seat with

harness. Then switch to belt-positioning booster seat.

Where do you sit when you ride in the car? Do you have a special

seat?

• Supervise all outdoor play, never leave child alone

outside; do not allow child to cross street alone.

• Remove guns from home; if gun necessary, store un-

loaded and locked, with ammunition locked separately.

Ask if guns are in homes where child plays.

MIDDLE CHILDHOOD | 5 AND 6 YEAR VISITS

Observation of Parent-Child Interaction: How do par-

ent and child interact with health care professional? How

do parent and child interact? Does parent have realistic

expectations about child?

Surveillance of Development: Balances on one foot,

hops, and skips; able to tie a knot. Shows school readi-

ness skills: has mature pencil grasp, can draw a person

with at least 6 body parts, prints some letters and

numbers, is able to copy squares and triangles, has good

articulation/language skills, counts to 10, names 4+

colors, follows simple directions, listens and attends.

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Attempt ophthalmoscopic exam of optic nerve

and retinal vessels. Observe for caries, gingival inflamma-

tion, malocclusion; fine/gross motor skills, gait. Assess

language acquisition, speech fluency/clarity, thought

content, ability to understand abstract thinking.

Screening (See p 60.)

5 Year Visit

Universal: Vision; Hearing

Selective: Anemia; Lead; Tuberculosis

6 Year Visit

Universal: Vision; Hearing

Selective: Oral Health; Anemia; Lead; Tuberculosis;

Dyslipidemia

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Anticipatory Guidance

SCHOOL READINESS

Established routines, after-school care and activities,

parent-teacher communication, friends, bullying, maturity,

management of disappointments, fears

• Prepare child for school; tour school; attend back-to-

school events.

What concerns do you have about your child’s ability to do well in

school?

• Be sure after-school care is safe, positive.

• Talk to child about school experiences.

• Talk to parents about school, worries.

Tell me about your new school. Do kids ever call you mean names

or tease you?

Key= Guidance for parent, questions; Guidance for child, questions

MIDDLE CHILDHOOD | 5 AND 6 YEAR VISITS

MENTAL HEALTH

Family time, routines, temper problems, social interactions

• Continue family routines; assign household chores.

• Show affection/respect; model anger management/self-

discipline.

• Use discipline for teaching, not punishing.

• Solve conflict/anger by talking, going outside and play-

ing, walking away.

What makes you sad, angry? How do you handle it?

NUTRITION AND PHYSICAL ACTIVITY

Healthy weight; appropriate well-balanced diet; increased

fruit, vegetable, whole-grain consumption; adequate calcium

intake; 60 minutes of exercise a day

• Eat breakfast; eat 5+ servings of fruits/vegetables a day.

• Limit candy/soda/high-fat snacks.

• Have at least 2 cups low-fat milk/other dairy a day.

• Be physically active 60 minutes a day.

• Limit TV to 2 hours a day; no TV in bedroom.

ORAL HEALTH

Regular visits with dentist, daily brushing and flossing,

adequate fluoride

• Help child with brushing if needed.

• Visit dentist twice a year.

• Give fluoride supplement if dentist recommends.

• Brush teeth twice a day; floss once.

SAFETY

Pedestrian safety, booster seat, safety helmets, swimming

safety, child sexual abuse prevention, fire escape/drill plan

and smoke detectors, carbon monoxide detectors/alarms,

guns

• Teach safe street habits (crossing/riding school bus).

• Use properly positioned belt-positioning booster seat in

back seat.

• Ensure child uses safety equipment (helmet, pads).

• Teach child to swim; supervise around water; use sun-

screen.

• Teach rules for how to be safe with adults: (1) no adult

should tell a child to keep secrets from parents, (2) no

adult should express interest in private parts, (3) no

adult should ask a child for help with his/her private

parts; explain “privates.”

Have you talked to your child about ways to avoid sexual abuse?

What would you do if a grown-up made you scared? Who could

you tell? Who would help you?

• Install smoke detectors/carbon monoxide detector/

alarms; make fire escape plan.

• Remove guns from home; if gun necessary, store un-

loaded and locked with ammunition locked separately.

MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS

Observation of Parent-Child Interaction: How do par-

ent and child interact? Does parent have realistic expecta-

tions about child? How does child interact with adults

other than parents?

Surveillance of Development:

• Physical, cognitive, emotional, social, moral

competencies

• Caring, supportive relationship with family, other adults,

peers

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Observe hip/knee/ankle function. Observe for

caries, gingival inflammation, and malocclusion. Assess

for SMR.

Screening (See p 60.)

7 Year Visit

Universal: None

Selective: Vision; Hearing; Anemia; Tuberculosis

8 Year Visit

Universal: Vision; Hearing

Selective: Anemia; Tuberculosis; Dyslipidemia

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Key= Guidance for parent, questions; Guidance for child, questions

MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS

Anticipatory Guidance

SCHOOL

Adaptation to school, school problems (behavior or learning

issues), school performance/progress, involvement in school

activities and after-school programs, bullying, parental

involvement, IEP or special education services

• Show interest in school and activities.

How is your child doing in school? How do you help your child

solve conflicts?

How do you like school? Are you picked on by others?

• If concerns, ask teacher about evaluation for special

help/tutoring; help with bullying.

DEVELOPMENT AND MENTAL HEALTH

Independence, self-esteem, establishing rules and

consequences, temper problems, managing and resolving

conflicts, puberty/pubertal development

• Encourage competence/independence.

What new things have you tried recently?

• Show affection, praise child.

• Be positive role model; do not hit or let others hit.

• Discuss rules, consequences.

What types of discipline do you use most often?

• Talk about worries.

Who do you talk to about your worries and things that make you

mad?

• Be aware of pubertal changes; answer questions

simply.

What have you told your child about how to care for his changing

body?

Do you know what puberty is? Has anyone talked with you about

how your body will change during puberty?

NUTRITION AND PHYSICAL ACTIVITY

Healthy weight, appropriate food intake, adequate calcium,

water instead of soda, adequate physical activity in organized

sports/after-school programs/fun activities, limits on screen

time

• Encourage nutritious food choices.

What do you think of your child’s weight and growth over the past

year?

• Eat 5+ servings of fruits/vegetables a day; eat breakfast.

• Limit candy/soda/high-fat snacks.

• Get at least 2 cups low-fat milk/other dairy a day.

• Eat meals as a family.

• Be physically active 60 minutes a day.

How often do you go outside to play?

• Limit screen time to 2 hours a day; no TV/computer in

bedroom.

How much time do you spend each day with TV or computers?

MIDDLE CHILDHOOD | 7 AND 8 YEAR VISITS

ORAL HEALTH

Regular visits with dentist, daily brushing and flossing,

adequate fluoride

• Take child to dentist twice a year.

• Give fluoride supplement if dentist recommends.

• Brush teeth twice a day; floss once.

• Wear mouth guard during sports.

SAFETY

Knowing child’s friends and their families, supervision with

friends, safety belts/booster seats, helmets, playground

safety, sports safety, swimming safety, sunscreen, smoke-free

home/vehicles, guns, careful monitoring of computer use

(games, Internet, e-mail)

• Know child’s friends; teach home safety rules for fire/

emergencies; teach rules for how to be safe with

adults: (1) no adult should tell a child to keep secrets

from parents, (2) no adult should express interest in

private parts, (3) no adult should ask a child for help

with his/her private parts.

Do you know what to do if you get home and Mom or Dad are

not there? What would you do if you felt unsafe at a friend’s

house? Has anyone touched you in a way that made you feel

uncomfortable?

• Use belt-positioning booster seat in back seat until the

lab/shoulder belt fits.

• Ensure child uses safety equipment (helmet, pads).

• Teach child to swim; supervise around water; use

sunscreen.

• Keep home/vehicle smoke-free.

• Remove guns from home; if gun necessary, store un-

loaded and locked with ammunition locked separately.

• Monitor computer use; install safety filter.

How much do you know about your child’s Internet use? Do you

have rules for the Internet?

What would you do if you came to a site that scared you?

Key= Guidance for parent, questions; Guidance for child, questions

MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS

Observation of Parent-Child Interaction: Does parent

allow child to talk with health care professional directly?

Surveillance of Development:

• Physical, cognitive, emotional, social, and moral compe-

tencies

• Behaviors that promote wellness and contribute to a

healthy lifestyle

• Caring, supportive relationship with family, other adults,

and peers

• Sense of self-confidence and hopefulness

• Increasingly responsible and independent decision

making

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Observe tattoos/piercings/signs of abuse,

self-inflicted injuries. Note nevi or birthmarks. Examine

back. Assess SMR.

Screening (See p 60.)

9 Year Visit

Universal: None

Selective: Vision; Hearing; Anemia; Tuberculosis

10 Year Visit

Universal: Vision; Hearing

Selective: Anemia; Tuberculosis; Dyslipidemia

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Key= Guidance for parent, questions; Guidance for child, questions

MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS

Anticipatory Guidance

SCHOOL

School performance, homework, bullying

• Show interest in school performance and activities; if

concerns, ask teacher about extra help.

What are some things you are good at?

• Create quiet space for homework.

• Get help from teacher/trusted adult if bullied.

DEVELOPMENT AND MENTAL HEALTH

Emotional security and self-esteem, family communication

and family time, temper problems and setting reasonable

limits, friends, school performance, readiness for middle

school, sexuality (pubertal onset, personal hygiene, initiation

of growth spurt, menstruation and ejaculation, loss of “baby

fat” and accretion of muscle, sexual safety)

• Promote independence, self-responsibility; assign

chores; provide personal space at home.

• Be a positive role model; discuss respect, anger

management.

• Know child’s friends; supervise activities with peers.

What do you and your friends like to do together? What do you

do when friends pressure you to do things you don’t want to do?

• Anticipate new adolescent behaviors, importance of

peers.

• Answer questions about puberty/sexuality; counsel to

avoid sexual activity; teach rules for how to be safe

with adults: (1) no adult should tell a child to keep se-

crets from parents, (2) no adult should express interest

in private parts, (3) no adult should ask a child for help

with his/her private parts.

How well do you and your partner agree on how to talk with your

child about sexual development and sexuality? How would you

respond if your child asked you about homosexuality?

What questions do you have about the way your body is

developing?

NUTRITION AND PHYSICAL ACTIVITY

Weight concerns, body image, importance of breakfast, limits

on high-fat foods, water rather than soda or juice, eating as a

family, physical activity

• Encourage nutritious food choices.

What do you think of your child’s weight and growth over the past

year?

What did you eat for breakfast today? Are you able to eat 5 or

more fruits and vegetables every day? How do you feel about how

you look? How often have you cut back on how much you eat or

dieted to lose weight?

• Be physically active 60 minutes a day; limit non-

academic screen time to 2 hours a day.

How often do you go outside and play?

MIDDLE CHILDHOOD | 9 AND 10 YEAR VISITS

ORAL HEALTH

Regular visits with dentist, daily brushing and flossing,

adequate fluoride

• Visit dentist twice a year.

• Give fluoride supplement if dentist recommends.

• Brush teeth twice a day; floss once.

• Wear mouth guard during sports.

SAFETY

Safety belts, helmets, bicycle safety, swimming, sunscreen,

tobacco/alcohol/drugs, knowing child’s friends and their

families, supervision of child with friends, guns

• The back seat is the safest place to ride. Switch from

booster seat to safety belt in rear seat, when the safety

belt fits.

• Use safety equipment (helmets, pads).

• Teach child to swim, supervise around water; use

sunscreen.

• Counsel about avoiding tobacco, alcohol, drugs.

Is smoking, alcohol, or drug use a concern in your family? Is your

child exposed to substance abuse?

• Know child’s friends; make plan for personal safety.

What would you do if you felt unsafe at a friend’s house? Has any-

one touched you in a way that made you feel uncomfortable?

• Remove guns from home; if gun necessary, store un-

loaded and locked with ammunition separate.

Homicide and completed suicide are more common in homes with

guns. Have you considered not owning a gun because it poses a

danger to the family?

What have your parents taught you about guns and gun safety?

Key= Guidance for parent, questions; Guidance for child, questions

EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS

Observation of Parent-Youth Interaction: How com-

fortably do youth and parent interact? Who asks and

answers most questions? Does youth express interest in

managing his own health?

Surveillance of Development:

• Physical, cognitive, emotional, social, and moral

competencies

• Behaviors that contribute to a healthy lifestyle

• Caring, supportive relationship with family, other adults,

and peers

• Positive engagement with community

• Self-confidence, hopefulness, well-being, and resiliency

when confronted with life stressors

• Increasingly responsible and independent decision

making

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Inspect for acne, acanthosis nigricans, atypical

nevi, tattoos/piercings, signs of abuse or self-inflicted

injury. Examine back.

Females: Assess SMR; signs of STIs.

Perform pelvic exam if warranted. Males: Observe for

gynecomastia. Assess SMR, signs of STIs. Examine

testicles for hydrocele, hernias, varicocele, masses.

Screening (See p 61.)

Universal: Vision (once in early adolescence)

Selective: Vision (when universal screening not per-

formed); Hearing; Anemia; Tuberculosis; Dyslipidemia;

STIs; Pregnancy; Cervical Dysplasia; Alcohol or Drug Use

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Note: Beginning with the Early Adolescence Visits, many health care professionals conduct the first part of the medical

interview with the parent in the examination room, and then spend time with the adolescent alone. This approach

helps adolescents build a unique relationship with their health care professional, promotes confidence and full

disclosure of health information, and enhances self-management. When explained within the context of healthy

adolescent development, parents usually support this approach.

Key= Guidance for parent, questions; Guidance for youth, questions

EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS

Anticipatory Guidance

PHYSICAL GROWTH AND DEVELOPMENT

Physical and oral health, body image, healthy eating, physical

activity

• Visit dentist twice a year; give fluoride supplement if

dentist recommends.

• Brush teeth twice a day, floss once.

• Support healthy self-image by praising

activities/achievements, not appearance.

• Encourage fruits/vegetables, whole grains, low-fat

dairy; limit candy/chips/soda.

• Have 3+ servings low fat milk/other dairy a day;

eat with your family.

• Be physically active 60 minutes a day; limit non-

academic screen time to 2 hours a day.

SOCIAL AND ACADEMIC COMPETENCE

Connectedness with family, peers, and community;

interpersonal relationships; school performance

• Clearly communicate rules/expectations/family responsi-

bilities; spend time with your youth, get to know

friends.

• Stay connected with family; follow family rules and

curfews.

• Help youth follow their interests to new activities,

increase awareness of community issues/needs.

• Explore interests and new activities, including those that

help others.

• Praise positive efforts in school; help with organization/

priority setting; encourage reading.

• Take responsibility for schoolwork; talk to parent/trusted

adult about problems at school.

EMOTIONAL WELL-BEING

Coping, mood regulation and mental health, sexuality

• Involve youth in family decision making; encourage her

to think through problems.

• Find ways to deal with stress.

• Tell me your concerns about your child’s behavior,

moods, mental health, or substance use.

Do you have concerns about your child’s emotional health?

• Everyone has difficult times and disappointments but

usually they’re temporary. Talk with parents/trusted

adult/me if you are feeling sad, depressed, nervous,

hopeless, or angry, especially if it makes it hard for you

to keep on track with school, family, friends, and a

generally positive attitude toward life.

Have you been feeling bored, sad, or irritable most of the time? Do

you ever feel so upset that you wished you were not alive or that

you wanted to die?

EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS

• Youth go through puberty at different times; talk to

your youth about the physical changes that occur

during puberty, including menstruation for girls.

• Discuss your expectations/values about dating, relation-

ships, and sex.

• Get accurate information about physical development,

sexual feelings, and sexuality; talk to parents/trusted

adult/me.

For females: Have you had your first period? If so, tell me more

(how often, how heavy?) For females and males: Have you talked

with your parents about dating and sex?

RISK REDUCTION

Tobacco, alcohol, or other drugs; pregnancy; STIs

• Know youth’s friends and activities; clearly discuss rules,

expectations.

• Talk with youth about tobacco/alcohol/drugs; praise

him for not using; be a role model.

• Consider locking liquor cabinet, putting prescription

medicines in a place where youth cannot get them.

Do you regularly supervise your child’s social and recreational

activities? What have you and your child discussed about the risk

of using alcohol/tobacco/drugs?

• Don’t smoke, drink, use drugs; avoid situations with

drugs/alcohol; support friends who don’t use; talk

with me if concerned about your own, or a family

member’s, use.

Have you ever experimented with smoking/tobacco/alcohol/

drugs/steroids? Do you ever sniff, “huff,” or breathe anything to

get high?

• Talk about relationships, sex, values; encourage sexual

abstinence; provide opportunities for safe activities.

How do you plan to help your child deal with pressures to have

sex?

• The safest way to prevent pregnancy and STIs is to not

have sex, including oral sex.

• Plan how to avoid risky situations; if sexually active,

protect against STIs/pregnancy.

Have you had sex? Was it wanted or unwanted? Have you ever

been forced or pressured to do something sexual that you haven’t

wanted to do? Were your partners male or female, or have you

had both male and female partners? Were your partners younger,

older, or your age? Did you use a condom or other contraceptive?

VIOLENCE AND INJURY PREVENTION

Safety belt and helmet use, substance abuse and riding in a

vehicle, guns, interpersonal violence (fights), bullying

• Wear safety belt; don’t allow ATV riding.

• Wear safety belt, helmet, protective gear, life jacket.

• Help youth make plan for handling situation in which

she feels unsafe riding in a car.

• Don’t ride in car with driver who has used

alcohol/drugs; call parents/trusted adult for help.

Do you have someone you can call for a ride if you feel unsafe

riding with someone?

Key= Guidance for parent, questions; Guidance for youth, questions

• Remove guns from home; if gun necessary, store un-

loaded and locked with ammunition locked separately.

Homicide and completed suicide are more common in homes with

guns. Have you considered not owning a gun because it poses a

danger to the family?

Do you ever carry a gun or knife?

• Healthy dating relationships are built on respect and

concern; saying NO is okay.

Have you ever been touched in a way that made you feel uncom-

fortable or was unwelcome? Have you ever been touched on your

private parts against your wishes? Has anyone ever forced you to

have sex?

• Teach nonviolent conflict-resolution techniques.

• Manage conflict nonviolently; talk to parent/trusted

adult if bullied, stalked.

EARLY ADOLESCENCE | 11 TO 14 YEAR VISITS

MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS

Observation of Parent-Youth Interaction: How

comfortably do youth and parent interact? Who asks and

answers most questions? Does youth express interest in

managing his own health?

Surveillance of Development:

• Physical, cognitive, emotional, social, and moral

competencies

• Behaviors that contribute to a healthy lifestyle

• Caring, supportive relationship with family, other adults,

and peers

• Positive engagement with community

• Self-confidence, hopefulness, well-being, and resiliency

when confronted with life stressors

• Increasingly responsible and independent decision

making

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Inspect for acne, acanthosis nigricans, atypical

nevi, tattoos, piercings, signs of abuse or self-inflicted

injury. Examine back.

Females: Assess SMR, signs of STIs.

Perform pelvic exam if warranted. Males: Observe for

gynecomastia; SMR; signs of STIs. Examine testicles for

hydrocele, hernias, varicocele, masses.

Screening (See p 61.)

Universal: Vision (once in middle adolescence)

Selective: Vision (when universal screening not per-

formed); Hearing; Anemia; Tuberculosis; Dyslipidemia;

STIs; Pregnancy; Cervical Dysplasia; Alcohol or Drug Use

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Key= Guidance for youth, questions; Guidance for parent, questions

MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS

Anticipatory Guidance

PHYSICAL GROWTH AND DEVELOPMENT

Physical and oral health, body image, healthy eating, physical

activity

• Brush teeth twice a day; floss once.

• Visit dentist twice a year.

• Protect your hearing.

• Maintain healthy weight by balancing food

choices/physical activity.

• Support healthy self-image by praising youth’s

activities/achievements, not appearance.

• Eat 3 meals a day, especially breakfast; focus on healthy

food choices; have 3+ daily servings low-fat milk/other

dairy; eat with your family.

• Encourage healthy eating.

• Be physically active 60 minutes a day; limit non-

academic screen time to 2 hours a day.

• Encourage physical activity.

SOCIAL AND ACADEMIC COMPETENCE

Connectedness with family, peers, and community;

interpersonal relationships; school performance

• Stay connected with family, help at home; get involved

with community, friends; follow family rules (cars,

curfews).

• Explore interests, new activities, including those that

help others.

• Spend time with/praise youth; show affection; agree

on limits, consequences; help youth follow interests to

new activities, increase awareness of community

issues/needs.

• Take responsibility for schoolwork; talk to parent/trusted

adult about problems at school.

• Emphasize school, praise positive efforts, help with

organization/priority setting, encourage reading.

EMO

EMOTIONAL WELL-BEING

Coping, mood regulation and mental health, sexuality

• Find ways to deal with stress; talk with parents/trusted

adult.

• Involve youth in family decision making; encourage her

to think through problems and practice independent

decision making.

• Recognize that hard times come and go; talk with

parents/trusted adult.

Have you been feeling bored, sad, or irritable most of the time?

Do you ever feel so upset that you wished you were not alive or

that you wanted to die?

• Recognize signs of depression, anxiety or other mental

health issues (irritability, changes in food/sleep habits,

not adhering to rules, substance abuse).

Do you have concerns about your youth’s emotional health?

MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS

• Get accurate information about sexuality, physical

development, sexual feelings; talk to parents/trusted

adult/me.

For females: Tell me about your periods (how often, how heavy,

painful, most recent). For females and males: Have you talked with

your parents about crushes you’ve had, about dating and relation-

ships, and about sex? Do you have any questions related to physi-

cal development, sexuality, gender identity (your identity as a male

or female), or sexual orientation? Have you had sex?

• Communicate frequently and share expectations clearly.

RISK REDUCTION

Tobacco, alcohol, or other drugs; pregnancy; STIs

• Don’t smoke, drink, use drugs; avoid situations with

drugs/alcohol; support friends who don’t use; talk with

me if you’re concerned about family member’s use.

Have you ever experimented with smoking/tobacco/alcohol/

drugs/steroids? Do you ever sniff, “huff,” or breathe anything to

get high?

• Talk with youth about tobacco/alcohol/drugs; know

youth’s friends and activities; clearly discuss rules/

expectations; praise him for not using; be a role model;

consider locking liquor cabinet, putting prescription

medicines in a place where youth can’t find them.

Do you regularly supervise your youth’s social and recreational

activities? What have you and your youth discussed about the risk

of using alcohol/tobacco/drugs?

• Abstaining from sexual intercourse, including oral sex, is

the safest way to prevent pregnancy and STIs; plan

how to avoid sex, risky situations.

• If sexually active, protect against STIs/pregnancy.

Have you had sex? Was it wanted or unwanted? Have you ever felt

pressured or forced to do something sexual that you didn’t want

to do? How many partners have you had in the past year? Were

your partners male or female or have you had both male and

female partners? Did you use a condom or other contraceptive?

• Encourage sexual abstinence; help youth make a plan

for resisting pressure; support safe activities at school;

talk about your values; have discussions with youth

as she accepts responsibility for her decisions and

relationships.

Have you shared with your youth your hopes, expectations, and

values about relationships and sex ?

VIOLENCE AND INJURY PREVENTION

Safety belt and helmet use, driving (graduated license) and

substance abuse, guns, interpersonal violence (dating

violence), bullying

• Wear safety belt, helmet, protective gear, life jacket.

• Limit night driving, driving with teen passengers.

• Wear safety belt; be involved in youth’s driving, set

limits/expectations about number of passengers, night

driving, distracted driving, high-risk situations.

Key= Guidance for youth, questions; Guidance for parent, questions

MIDDLE ADOLESCENCE | 15 TO 17 YEAR VISITS

• Don’t ride in car with driver who has used alcohol/

drugs; call parents/trusted adult for help; don’t drink

and drive.

Do you have someone you can call for a ride if you feel unsafe

riding with someone?

• Fighting, carrying weapons can be dangerous.

Do you ever carry a gun? Is there a gun at home?

• Remove guns from home; if gun necessary, store un-

loaded and locked with ammunition locked separately;

keep key inaccessible to youth.

• Manage conflict nonviolently; avoid risky situations;

healthy dating relationships are built on respect and

doing things you both like to do; saying NO is okay.

• Teach nonviolent conflict-resolution techniques.

LATE ADOLESCENCE | 18 TO 21 YEAR VISITS

Observation of Parent-Young Adult Interaction:

How comfortably do young adult and parent, if present,

interact? Is young adult appropriately encouraged to

manage own health?

Surveillance of Development:

• Physical, cognitive, emotional, social, and moral

competencies

• Behaviors that contribute to a healthy lifestyle

• Caring, supportive relationship with family, other adults,

and peers

• Positive engagement with community

• Self-confidence, hopefulness, well-being, and resiliency

when confronted with life stressors

• Increasingly responsible and independent decision

making

Physical Exam. Complete, including: Measure blood

pressure. Measure and plot height, weight. Calculate and

plot BMI. Inspect for acne, acanthosis nigricans, atypical

nevi, tattoos, piercings, signs of abuse or self-inflicted

injury.

Females: CBE routine after age 20. Assess signs of

STIs. Perform pelvic exam if warranted. Males: Assess

SMR; signs of STIs. Examine testicles for hydrocele,

hernias, varicocele, masses.

Screening (See p 61.)

Universal: Vision (once in late adolescence); Dyslipidemia

(once in late adolescence)

Selective screening: Vision (when universal screening

not performed); Hearing; Anemia; Tuberculosis;

Dyslipidemia (when universal screening not performed);

STIs; Pregnancy; Cervical Dysplasia; Alcohol or Drug Use

Immunizations

CDC: www.cdc.gov/vaccines

AAP: www.aapredbook.org

Key= Guidance for young adult, questions

LATE ADOLESCENCE | 18 TO 21 YEAR VISITS

Anticipatory Guidance

PHYSICAL GROWTH AND DEVELOPMENT

Physical and oral health, body image, healthy eating, physical

activity

• Brush teeth twice a day, floss once; visit dentist twice a

year.

• Protect your hearing.

• Eat 3 nutritious meals a day; fruits and vegetables; 3+

servings a day low-fat milk/other dairy.

• Be physically active 60 minutes a day, use protective

gear; limit nonacademic screen time to 2 hours a day.

SOCIAL AND ACADEMIC COMPETENCE

Connectedness with family, peers, and community,

interpersonal relationships, school performance

• Stay connected with family and friends; recognize some

friendships change; get involved with community.

• Take responsibility for getting to school/work on time.

• Consider future education/work plans.

What help do you need from me or your parents to help you reach

your goal?

EMOTIONAL WELL-BEING

Coping, mood regulation and mental health, sexuality

• Find ways to deal with stress; practice problem solving

and responsible/independent decision making.

• Recognize that most disappointments and setbacks are

temporary; if you find that you are so sad, depressed,

nervous, or angry that you can’t get back on track with

life, talk with parents/trusted adult/me.

Have you been feeling bored, sad, or irritable most of the time? Do

you ever feel so upset that you wished you were not alive or that

you wanted to die?

• Sexuality is important to normal development as an

adult.

Do you have any questions related to physical development, sexual-

ity, gender identity (your identity as a male or female), or sexual ori-

entation? For females: Tell me about your periods (how often, how

heavy, painful?).

RISK REDUCTION

Tobacco, alcohol, or other drugs, pregnancy, STIs

• Don’t smoke, drink, use drugs/steroids/diet pills; avoid

situations with drugs/alcohol; support friends who

don’t use.

Tell me about any experiences you’ve had with alcohol, marijuana,

or other drugs.

LATE ADOLESCENCE | 18 TO 21 YEAR VISITS

• Think through how to make sure you can carry out

your decisions about sex. Considering role of alcohol

and drug use and avoiding risky places and relation-

ships can help.

• If sexually active, protect against STIs/pregnancy; make

a plan so you can carry out your decisions about sex

(avoid alcohol/risky situations).

Have you had sex? Was it wanted or unwanted? Were your part-

ners male or female or have you had both male and female part-

ners? Did you use a condom or other contraceptive?

VIOLENCE AND INJURY PREVENTION

Safety belt and helmet use, substance abuse and riding in a

vehicle, guns, interpersonal violence (fights), bullying

• Wear safety belt, helmet, protective gear, life jacket.

• Don’t use alcohol/drugs and drive.

• Don’t ride in car with driver who has used alcohol/

drugs.

• Remove guns from home; if gun necessary, store un-

loaded and locked with ammunition separate; keep key

away from any children.

Do you ever carry a gun? Is there a gun at home?

• Manage conflict nonviolently; avoid risky situations;

leave violent relationships; healthy relationships are built

on respect, concern and mutual interests; saying NO is

okay.

Do you belong to a gang or know anyone in a gang? Have you

ever been hit, slapped, or physically hurt while on a date? Have

you ever been forced to have sexual intercourse?

Key= Guidance for young adult, questions

APPENDICES

Appendices

Developmental Milestones at a Glance — Infancy

Developmental Milestones at a Glance — Early Childhood

Social and Emotional Development in Middle Childhood

Domains of Adolescent Development

Recommended Medical Screening — Infancy

Recommended Medical Screening — Early Childhood

Recommended Medical Screening — Middle Childhood

Recommended Medical Screening — Adolescence

Tooth Eruption Chart

Sexual Maturity Ratings

Useful Web Sites

Developmental Milestones at a Glance — Infancy

AGE GROSS MOTOR FINE MOTOR COGNITIVE, LINGUISTIC, SOCIAL-EMOTIONAL

AND COMMUNICATION

2 Months Head up 45º Follow past midline Laugh Smile spontaneously

Lift head Follow to midline Vocalize Smile responsively

4 Months Roll over Follow to 180º Turn to rattling sound

Sit—head steady Grasp rattle Laugh Regard own hand

6 Months Sit—no support Look for dropped yarn Turn to voice Feed self

Roll over Reach Turn to rattling sound Work for toy (out of reach)

9 Months Pull to stand Take 2 cubes Dada/Mama, nonspecific Wave bye-bye

Stand holding on Pass cube (transfer) Single syllables Feed self

KEY

Black: 50% to 90% of children pass this item.

Green: More than 90% of children pass this item.

Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.

Developmental Milestones at a Glance — Early Childhood

AGE GROSS MOTOR FINE MOTOR COGNITIVE, LINGUISTIC, SOCIAL-EMOTIONAL

AND COMMUNICATION

1 Year •Stand a l o n e •Put b l o c k in cu p •Imitate vocalizations/sounds •Protodeclarative pointing*

•Pull to stand •Bang 2 cubes held in hands •Babbling* •Wave bye-bye

•1 word •Imitate activities

•Play pat-a-cake

15 Months •Walk backwards •Scribble •1 word* •Drink from cup

•Stoop and recover •Put block in cup •3 words •Wave bye-bye

•Walk well

18 Months •Walk up steps •Dump raisin, demonstrated •Point to at least 1 body part •Remove garment

•Run •Tower of 2 cubes •6 words •Help in house

•Walk backwards •Scribble •3 words

2 Years •Thro w ba l l ov e r h a n d •Tow e r of 6 cubes •Name 1 picture •P u t on clothin g

•Jump up •Tower of 4 cubes •Combine words •Remove garment

•Kick ball forward •Point to 2 pictures

•Walk up steps

Years •Throw ball overhand •Imitate vertical line •Know 2 actions •Wash and dry hands

•Jump up •Tower of 8 cubes •Speech half understandable •Put on clothing

•Tower of 6 cubes •Point to 6 body parts

•Name 1 picture

3 Years •Balance on each foot 1 second •Thumb wiggle •Speech all understandable •Name friend

•Broad jump • Imitate vertical line •Name 1 color •Brush teeth with help

•Throw ball overhand •Tower of 8 cubes •Know 2 adjectives

•Tower of 6 cubes •Name 4 pictures

4 Years •Hop •D r a w a pers o n wit h 3 parts •Define 5 wo rds •Copy a cross (+)

•Balance on each foot •Tower of 8 cubes •Name 4 colors •Copy a circle

2 seconds •Speech all understandable

KEY

Black: 50% to 90% of children pass this item.

Green: More than 90% of children pass this item.

*Absence of this milestone should trigger screening for autism.

Source: See the Child Development theme in

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.

Social and Emotional Development in Middle Childhood

TOPICS KEY AREAS (Key areas in italics are especially important for children with special health care needs.)

Self Self-esteem:

• Experiences of success

• Reasonable risk-taking behavior

• Resilience and ability to handle failure

• Supportive family and peer relationships

Self-image:

• Body image, celebrating different body images

• Prepubertal changes; initiating discussion about sexuality and reproduction; prepubertal changes related to physical care issues

Family What matters at home:

• Expectation and limit setting

• Family times together

• Communication

• Family responsibilities

• Family transitions

• Sibling relationships

• Caregiver relationships

Friends Friendships:

• Making friends, friendships with peers with and without special health care needs

• Family support of friendships, family support to have typical friendship activities, as appropriate

School School:

• Expectation for school performance, school performance/defined in the Individualized Education Program

• Homework

• Child-teacher conflicts, building relationships with teachers

• Parent-teacher communication

• Ability of schools to address the needs of children from diverse backgrounds

• Awareness of aggression, bullying, and victimization

• Absenteeism

Community Community strengths:

• Community organizations

• Religious groups

• Cultural groups

High-risk behaviors and environments:

• Substance use

• Unsafe friendships

• Unsafe community environments

• Particular awareness of risk-taking behaviors and unsafe environments, because children may be easily victimized

Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.

Domains of Adolescent Development

EARLY ADOLESCENCE MIDDLE ADOLESCENCE LATE ADOLESCENCE

(11 TO 14 YEARS) (15 TO 17 YEARS) (18 TO 21 YEARS)

Physiological Onset of puberty, growth spurt, Ovulation (females), growth spurt (males) Growth completed

menarche (females)

Psychological Concrete thought, preoccupation with Competence in abstract and future thought, Future orientation, emotional

rapid body changes, sexual identity, idealism, sense of invincibility or narcissism, sexual independence, unmasking of psychiatric

questioning independence, parental identity, beginning of cognitive capacity to disorders, capacity for empathy, intimacy,

controls remain strong provide legal consent and reciprocity in interpersonal

relationships, self-identity; recognized as

legally capable of providing consent,

attainment of legal age for some issues

(eg, voting) but not all issues (eg, drinking

alcohol)

Social Search for same-sex peer affiliation, Beginning emotional emancipation, increased Individual over peer relationships; transition

good parental relationships, other adults power of peer group, conflicts over parental in parent-child relationship, transition out

as role models; transition to middle control, interest in sexual relationships, initiation of home; may begin preparation for

school, involvement in extracurricular of driving, risk-taking behavior, transition to high further education, career, marriage, and

activities; sensitivity to differences school, reduced involvement in extracurricular parenting

between home culture and culture activities, possible cultural conflict as adolescent

of others navigates between family’s values and values of

broader culture and peer culture

Potential Delayed puberty, acne, orthopedic Experimentation with health risk behaviors (eg, Eating disorders, depression, suicide, auto

Problems problems, school problems, sex, drinking, drug use, smoking), auto crashes, crashes, unintended pregnancy, acne,

psychosomatic concerns, depression, menstrual disorders, unintended pregnancy, smoking, alcohol or drug dependence

unintended pregnancy; initiation of acne, short stature (males), conflicts with

tobacco, alcohol, or other drug use parents, overweight, physical inactivity, poor

eating behaviors, eating disorders (eg, purging,

binge eating, and anorexia nervosa)

Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.

Recommended Medical Screening — Infancy

UNIVERSAL ACTION NB 1W 1M 2M 4M 6M 9M

Metabolic and Done according to state law • • • •

hemoglobinopathy

Development Structured developmental screen •

Oral health Administer OH risk assessment ••

Hearing All NB before discharge; if not by discharge, in 1st month; verify documentation of

screening results and appropriate rescreening by 2M • • • •

SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + NB 1W 1M 2M 4M 6M 9M

Blood pressure Children with specific risk conditions Blood pressure • • • • • • •

or change in risk

Vision Prematurity with risk conditions, abnormal Ophthalmology referral

fundoscopic exam, parental concern (all visits);

abnormal eye alignment (4M and 6M);

abnormal cover/uncover test (9M) • • • • • • •

Hearing + on risk screening questions Referral for diagnostic audiologic • • •

assessment

Anemia Preterm/LBW; not on iron-fortified formula Hemoglobin or hematocrit •

Lead + on risk screening questions Lead screen • •

Tuberc u l o s is + on risk screening questions Tuberculin skin test • •

OH = oral health; NB = newborn; LBW = low birth weight

Recommended Medical Screening — Early Childhood

UNIVERSAL ACTION 12M 15M 18M 2Y 2

Y 3Y 4Y

Development Structured developmental screen • •

Autism Autism Specific Screen ••

Vision Objective measure with age-appropriate visual acuity measurement (using HOTV; • •

tumbling E tests; Snellen letters; Snellen numbers; or Picture tests, such as Allen

figures or LEA symbols)

Hearing Audiometry •

Anemia Hematocrit or hemoglobin •

Lead* Lead screen • •

SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + 12M 15M 18M 2Y 2

Y 3Y 4Y

Oral health No dental home Referral to dental home; if not available, • • • • •

oral health risk assessment (12M, 18M,

2Y, 2

Y). Referral to dental home (3Y).

Primary water source is deficient Oral fluoride supplementation • • • • •

in fluoride

Blood Specific risk conditions or Blood pressure • • • • •

pressure

†

change in risk

Vision Parental concern or abnormal Ophthalmology referral • • • • •

fundoscopic exam or cover/

uncover test

Hearing + on risk screening questions Referral for diagnostic audiologic assessment • • • • • •

Anemia + on risk screening questions Hematocrit or hemoglobin • • • •

Lead

‡

+ on risk screening questions Lead screen • •

Lead No previous screen or change in risk Lead screen •

No previous screen and + on Lead screen ••

risk screening questions or

change in risk

Tuberculosis + on risk screening questions Tuberculin skin test • • • • •

Dyslipidemia + on risk screening questions; not Fasting lipid profile • •

previously screened with normal

results (4Y)

*Universal lead screen = high prevalence area or on Medicaid; †Beginning at age 3, blood pressure becomes part of the physical examination; ‡Selective lead screen = low prevalence area and not on Medicaid.

Recommended Medical Screening — Middle Childhood

UNIVERSAL ACTION 5Y 6Y 7Y 8Y 9Y 10Y

Vision Objective measure with age-appropriate visual acuity measurement (using HOTV; tumbling

E tests; Snellen letters; Snellen numbers; or Picture tests, such as Allen figures or LEA symbols) • •

Snellen test ••

Hearing Audiometry •• • •

SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + 5Y 6Y 7Y 8Y 9Y 10Y

Oral health No dental home Referral to dental home •

Primary water source deficient in fluoride Oral fluoride supplementation •

Vision + on risk screening questions Snellen test • •

Hearing + on risk screening questions Audiometry • •

Anemia + on risk screening questions Hemoglobin or hematocrit • • • • • •

Lead No previous screen and + on risk Lead screen • •

screening questions or change in risk

Tuberculosis + on risk screening questions Tuberculin skin test • • • • • •

Dyslipidemia + on risk screening questions and not Fasting lipid profile • • •

previously screened with normal results

Recommended Medical Screening — Adolescence

UNIVERSAL ACTION EARLY MIDDLE LATE

(11-14Y) (15-17Y) (18-21Y)

Vision (once during Snellen test •••

each age stage)

Dyslipidemia (once A fasting lipoprotein profile (total cholesterol, LDL cholesterol high

during Late density lipoprotein [hDL], cholesterol and triglyceride). If the testing

Adolescence) opportunity is non-fasting, only total cholesterol and HDL

cholesterol will be usable. •

SELECTIVE RISK ASSESSMENT (RA) ACTION IF RA + EARLY MIDDLE LATE

(11-14Y) (15-17Y) (18-21Y)

Vision (when universal + on risk screening questions Snellen test • • •

screening not

performed)

Hearing + on risk screening questions Audiometry • • •

Anemia + on risk screening questions Hemoglobin or hematocrit •••

Tuberc u l o s is + on risk screening questions Tuberculin skin test • • •

Dyslipidemia (when + on risk screening questions and Lipid screen • • •

universal screening not previously screened with

not performed) normal results

STIs Sexually active Chlamydia and gonorrhea screen; use • • •

tests appropriate to the patient population

and clinical setting

Sexually active and + on risk Syphilis blood test • • •

screening questions HIV*

Pregnancy Sexually active without contraception, Urine hCG • • •

late menses, amenorrhea, or heavy or

irregular bleeding

Cervical dysplasia Sexually active, within 3 years Pap smear, conventional slide or liquid-based •••

of onset of sexual activity or no later

than age 21

Alcohol or drug use + on risk screening questions Administer alcohol- and drug-screening tool • • •

*The CDC has recently recommended universal voluntary HIV screening for all sexually active people, beginning at age 13. At the time of publication, the AAP and other groups had not yet commented on the CDC recom-

mendation, nor recommended screening criteria or techniques. The health care professional’s attention is drawn to the voluntary nature of screening and that the CDC allows an opt out in communities where the HIV rate is

<0.1%. The management of positives and false positives must be consider

ed befor

e testing.

Tooth Eruption Chart

Primary Dentition

Upper Teeth Erupt Exfoliate

Central incisor 8-12 months 6-7 years

Lateral incisor 9-13 months 7-8 years

Canine (cuspid) 16-22 months 10-12 years

First molar 13-19 months 9-11 years

Second molar 25-33 months 10-12 years

Lower Teeth Erupt Exfoliate

Second molar 23-31 months 10-12 years

First molar 14-18 months 9-11 years

Canine (cuspid) 17-23 months 9-12 years

Lateral incisor 10-16 months 7-8 years

Central incisor 6-10 months 6-7 years

Upper Teeth Erupt

Central incisor 7-8 years

Lateral incisor 8-9 years

Canine (cuspid) 11-12 years

First premolar (first bicuspid) 10-11 years

Second premolar (second bicuspid) 10-12 years

First molar 6-7 years

Second molar 12-13 years

Third molar (wisdom tooth) 17-21 years

Lower Teeth Erupt

Third molar (wisdom tooth) 17-21 years

Second molar 12-13 years

First molar 6-7 years

Second premolar (second bicuspid) 10-12 years

First premolar (first bicuspid) 10-11 years

Canine (cuspid) 11-12 years

Lateral incisor 8-9 years

Central incisor 7-8 years

10.

11.

12.

13.

14.

15.

16.

32.

31.

30.

29.

28.

27.

26.

17.

25.

24.

23.

22.

21.

20.

19.

18.

Permanent Dentition

Source: Reproduced with permission from the Arizona Department of Health Services, Office of Oral Health, courtesy of Don Altman, DDS, MPH.

The assistance of the American Dental Hygienists’ Association is gratefully acknowledged.

Sexual Maturity Ratings

Sexual maturity ratings (SMRs) are widely used to assess

adolescents’ physical development during puberty in 5

stages (from preadolescent to adult). Also known as

Tanner stages, SMRs are a way of assessing the degree

of maturation of secondary sexual characteristics.

The developmental stages of the adolescent’s sexual char-

acteristics should be rated separately (ie, one stage for

pubic hair and one for breasts in females, one stage for

pubic hair and one for genitals in males), because these

characteristics may differ in their degree of maturity.

Sexual Maturity Ratings: Males

SMR

PUBIC HAIR

Stage 1 None

Stage 2 Scanty, long, slightly pigmented, primarily at base of penis

Stage 3 Darker, courser, starts to curl, small amount

Stage 4 Course, curly; resembles adult type but covers smaller area

Stage 5 Adult quantity and distribution, spread to medial surface of thighs

SMR GENITALS

PENIS

TESTES

Stage 1 Preadolescent Preadolescent

Stage 2 Slight enlargement Slight enlargement of testes and

scrotum; scrotal skin reddened,

texture altered

Stage 3 Longer Further enlargement of testes and

scrotum

Stage 4 Larger in breadth, Further enlargement of testes and

glans penis develops scrotum

Stage 5 Adult Adult

Sexual Maturity Ratings: Females

SMR PUBIC HAIR

Stage 1 None

Stage 2 Sparse, slightly pigmented, straight, at medial border of labia

Stage 3 Darker, beginning to curl, increased amount

Stage 4 Course, curly, abundant, but amount less than in adult

Stage 5 Adult feminine triangle, spread to medial surface of thighs

SMR BREASTS

Stage 1 Preadolescent

Stage 2 Breast and papilla elevated as small mound; areolar diameter

increased

Stage 3 Breast and areola enlarged, no contour separation

Stage 4 Areola and papilla form secondary mound

Stage 5 Mature; nipple projects, areola part of general breast contour

Source: Tables have been adapted with permission from Daniels

1(p29)

(as drawn from Tanner

); see also Spear.

3(p4)

References

1. Daniels WA. Adolescents in Health and Disease. St Louis, MO: Mosby, Inc; 1977

2. Tanner JM.

Growth at Adolescence. 2nd ed. Oxfor

d, England: Blackwell Scientific Publications; 1962

3. Spear B.

Adolescent growth and development. In: Rickert VI, ed. Adolescent Nutrition: Assessment and Management. New York, NY: Chapman and Hall (Aspen Publishers, Inc); 1996:3-24

Useful Web Sites

American Academy of Pediatrics

www.aap.org

American Academy of Pediatrics Bright Futures

http://brightfutures.aap.org

American Academy of Pediatrics Clinical Guide:

Connected Kids

www.aap.org/ConnectedKids/ClinicalGuide.pdf

American Academy of Pediatrics Red Book Online

www.aapredbook.org

American Association of Poison Control Centers

(Poison Control: 800-222-1222 and 911)

www.aapcc.org

American College of Obstetricians and Gynecologists

www.acog.org

Automotive Safety Program

www.preventinjury.org

Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report

www.cdc.gov/mmwr/pdf/ss/ss5505.pdf

Centers for Disease Prevention and Control

National Immunization Program

www.cdc.gov/vaccines

Centers for Disease Control and Prevention

National Immunization Information Hotline

(800-CDC-INFO)

www.vaccines.ashastd.org

Centers for Disease Prevention and Control

Physical Activity for Everyone

www.cdc.gov/nccdphp/dnpa/physical/recommendations/

young.htm

Child Safety Seat Information

(866-SEATCHECK [866-732-8243])

www.seatcheck.org

Institute of Medicine of the National Academies

www.iom.edu/file.asp?id=21372

Maternal and Child Health Bureau

Accurately Weighing & Measuring: Technique

http://depts.washington.edu/growth/module5/text/

contents.htm

MyPyramid, US Department of Agriculture

www.mypyramid.gov/kids/index.html

National Association for Sport & Physical Education

www.aahperd.org/naspe/template.cfm?template=

toddlers.html

National Cancer Institute Smoking Cessation Information

(1-800-QUITNOW)

http://1800quitnow.cancer.gov

National Center for Education Statistics

www.nces.ed.gov

National Center for Health Statistics

www.cdc.gov/nchs

National Center for Health Statistics Growth Charts

www.cdc.gov/growthcharts

National Center for Homeless Education

www.serve.org/nche

National Guideline Clearinghouse

www.guideline.gov

National Institute of Mental Health

www.nimh.nih.gov

National Maternal and Child Oral Health Resource Center

www.mchoralhealth.org

National Society of Genetic Counselors

www.nsgc.org/consumer/familytree

National Youth Violence Prevention Resource Center

www.safeyouth.org

Olweus Bullying Prevention Program

www.clemson.edu/olweus/index.html

Reach Out and Read

www.reachoutandread.org

Safe Kids Worldwide

www.safekids.org/members/unitedStates.html

Statistical Abstract of the United States

www.census.gov/prod/www/statistical-abstract.html

The Cochrane Collaboration

www.cochrane.org

The National Early Childhood Technical Assistance Center

www.nectac.org/topics/earlyid/partcelig.asp

The President’s Council on Physical Fitness and Sports

http://fitness.gov

US Department of Health & Human Services

Guide to Reliable Health Information

www.healthfinder.gov

US Department of Labor

http://jobcorps.doleta.gov

Web-based Injury Statistics Query and Reporting System

www.cdc.gov/ncipc/wisqars