Well child care

Presented by

Dr. marwa sayed mohamed

lecturer of family medicine
Cairo university
Visit schedules are set according to age groups :
Neonate: within 1-2 Weeks of birth
Infant: at 2, 4, 6, 9, and 12 months
Toddler: at15, and 18 months; 2 and 3 years old
Preschool: annual visits beginning at 3 years old
Primary school age: annual visits 5 through 10
years old
Middle school age: annual visits 10 through 13
years old
Teenager: annual visits 13 through 18 years old
Birth history and key highlights should be documented
Prenatal course
Labor and delivery method (cesarean section,
normal spontaneous vaginal delivery, instrument-
assisted delivery)
Gestational age (full term/preterm)
Birth weight
Apgar scores
Immunization history
Bonding: postpartum depression, substance use,
sibling jealousy
 Growth and Development
• A continuous process starts by fertilization till
the end of adolescence

• Growth: increase in the mass and dimensions

of the body

• Development: functional maturation and

acquisition of new skills
 Stages of growth and
development
• Prenatal
1. Embryonic period (first 8 weeks)
2. Fetal period (9-40 weeks)
• Postnatal
1. Neonatal period (first 28 days)
2. Infant (till 2 years)
3. Early childhood 2-6 years
4. Late childhood (6-10)
5. Adolescent (10-20)
• Neonate (0 – 30 days)
• Infant (till 12 months)
• Toddler (1 – 3 years)
• Primary school age (4-12)
• Adolescence and puberty (13 – 19 years)
 Knowing the normal pattern is essential to
differentiate between normal and abnormal
 Physical growth
Main parameters
• Weight
• Length (height)
• Head circumference
Others
• Body proportions :upper/lower ratio
• Dentition
• Vital signs
 Four developmental areas

• Gross motor,
• Fine motor
• Speech and language,
• Social development
 Sexual development
• Thelarche and pubarche may starts at age of 9
and menarche follow 2-3 years

• The first manifestation of boys =enlargement

of testes

• Growth spurt 1 year after breast bud in girls

and 2 years after genital enlargement in boys
 Puberty

On average, girls begin puberty at ages 10–11;

boys at ages 11–12. Girls usually complete
puberty by ages 15–17, while boys usually
complete puberty by ages 16–17
Sexual development
 Development and developmental
assessment
• Parents are always interested in their child’s
developmental progress and are usually concerned if
any aspect is delayed.

• It is an important indicator of a child’s wellbeing

• Any delay or abnormal development may indicate

serious limitations for later life.
 Advanced development of
language and fine motor skills
may be a sign of intelligence
 Patterns of weight gain
- At birth : 3 Kg (average)
- In first 4 months : Increase by ¾ kg/month (The child
doubles his weight by four months = 6 kilos)

- In the second fourth months : Increase by

½kg/month ( reaches 8 kilos by 8th month)

- In the last four months of the first year : Increase by

¼ kg/month (triple his weight by the end of first
year)
• 1 month 3750 gm
• 2 month 4500 gm
• 3 month 5250 gm
• 4 month 6000 gm (2 times birth weight)
• 5 month 6500 gm
• 6 month 7000 gm
• 7 month 7500 gm
• 8 month 8000 gm (8kg at 8 months)
• 9 month 8250 gm
• 10 month 8500 gm
• 11 month 8750 gm
• 12 month 9000 gm (3 times birth weight)
 Early childhood weight gain
• About 2kg/year

• 2 years :12 kg
• 3 years :14 kg
• 4 years :16 kg
• 5 years :18 kg
• 6 years :20 kg
 Late childhood weight gain
About 2.5 kg/year

• 7 years :22.5 kg
• 8 years: 25 kg
• 9 years: 27.5 kg
• 10 years : 30 kg (10 times birth weight)
Then following formula can be used to
calculate weight above 2 years:

(Age in years x2) +8 = Weight in kg

Length / height
Length /Height monitoring for children

• Average length / height for age:

• First 4 years

- At birth 50 cm
- End of first year 75cm
- End of second year 87cm
- End of third year 95cm
- End of fourth year 100cm (2 times
birth length)
Length /Height monitoring for children

• Average length / height for age:

between 4-8 years height increase 7cm/year

• 5 years : 107 cm
• 6 years : 114 cm
• 7 years: 121 cm
• 8 years: 128 cm
Length /Height monitoring for children

• Average length / height for age:

between 9-12 years height increase 5 cm/year

• 9 years : 135 cm
• 10 years : 140 cm
• 11 years: 145 cm
• 12 years: 150 cm (3 times birth height)
- The following formula can be used as a
rough estimate of the height up to
puberty

(age in year x 5) + 80= height in cm

 Head circumference monitoring for
children
• At birth 35 cm
• 6 months 43 cm
• 1 year 47 cm
• 2 years 49 cm
• 6 years 51 cm
• 12 years 53 cm
How to perform a developmental
assessment?

• Young children often will not co-operate so

make the most of observing them informally.

• You may have to rely heavily on parental

report
 Gross motor development
The baby should be placed prone; At 2 months
normally he will lift his head for a few seconds,
though some infants may take a few minutes to
do so.

Infants who usually sleep prone are more

advanced in lifting their heads than others.

If the infant does not eventually lift his head he

needs to be re-examined two weeks later.
 Gross motor development

Pull to sit
• Birth
• Complete head lag
• 6 weeks
• Head control developing
• 3-4 months
• No head lag
No head lag
Gross motor development
Sitting Position
• 6 weeks
• Curved back, needs support from
adult
• 9 months
• Gets into sitting position alone
 Gross motor development
• Standing and walking

• 9 months
• crawling
• 10 months
• Pulls to Standing and stands holding on
• 12 months
• Stands, and walks with one hand held
• 15 month
• Walks independently And stoops to pick up
objects
10-12 months old
15 months
 Gross motor development
• Standing and walking

• 1and ½ years
• Ascending stairs in a child manner
• 2 years
• Descending stairs in a child manner
• 3 years
• Ascending stairs in an adult manner
• 4 years
• Decending stairs in a adult manner
• 5 years
• Hop on one foot
 Fine motor development
Grasping and reaching
• 4 months
• Holds a ring purposefully
• 5 months
• Reaches for object
• 6 months
• Transfers object from hand to hand
• 7 months
• Finger feeds
 Fine motor development
• Building blocks
• 12 months
• Gives blocks to examiner
• 15 months
• Builds a tower of two cubes
• 18 months
• Builds a tower of three to four cubes
 Fine motor development
Manipulation
• 5 months
• Whole hand grasp
• 9 months
• Immature pincer grasp
• 12 months
• Mature pincer grasp
 Fine motor development
Pencil skills
• 18 months
• Scribbles with a pencil
• 3 years
• Draws a circle
• 4 years
• Draws a cross
• 5 years
• Draws a triangle
 Speech and language development
Speech
• 3 months
• Vocalizes
• 8 months
• Double babble
• 12 months
• Two or three words with meaning
• 18 months
• 10 words
• 24 months
• Linking two words
• 3 years
• Full sentences
 Social development
• 1 month • 6 months
• Follow moving objects • Mother recognition
• 2 months • 7 months
• Social smile • Stranger anxiety
• 3 months • 9 months
• Listen to music • Respond to own name
• 4 months • 12 months
• Laugh • Wave bye bye
 Milestones that are
essential to remember
Growth monitoring of children
Two types of growth charts were developed

- Home based growth charts –given to parents.

This is a simple chart for both sexes with two
weight curves and with space for
identification and health information
- Health center based growth chart. This is a
more complex weight and height chart for
boys and girls which should be retained in
PHCs.
 The WHO Prototype
(Home based growth chart)

This chart has two reference curves. The upper

one represents the (50th percentile) and the
lower one represents the 3rd percentile)
LOW WEIGHT FOR AGE
The 50th percentile normally corresponds to the
median; it gives the value of the 50th child of a
group of 100 when they are arranged in
ascending or descending order and when
equal number of children will have
measurements smaller or larger than the 50th
value
The third percentile means that only 3 percent
(3 in each 100) of children weighed had values
which fall below that line
 The chart is designed to enable the health worker to

- Assess normal growth

- Determine deviations in individuals
- To interpret findings in terms of health status
- To decide regarding alternative types of care and
referral procedures if required
- Monitor growth at community level as contribution
to health surveillance
 Tools for monitoring growth
The growth chart
Are standards for growth of normal infants,
children and adolescence available in
percentile values:
50th percentile represents average or the mean
25th, 10th and 5th percentile are law normal value
75th, 90th and 95th are high normal values
 Types of growth curves

• Charts for weight

• Charts for height
• Charts for head
circumference

For each parameter there are charts for

boys and girls and according to age
 Tools for growth monitoring

Growth charts
Weight for age growth charts

- These are charts for monitoring growth of

children according to age

- They provide simple and inexpensive way of

monitoring weight gain and child health over
time
• Growth charts

- In the weight for age chart , the height of the

child is not taken into consideration. This is
because the weight is the most sensitive
measure of growth, and any deviation from
“normal” can be detected easily by
comparison with reference curves.
A child can lose weight ,but
not height.
 How to use the growth charts

- Weight the child

- Register the weight by putting a dote on the line
corresponding to weight according to age of the child
- Weigh the child and register his weight
- By connecting the dotes of child weights we obtain what
is called growth curve
 Interpretation of weight for age growth
curves
- Weights of healthy children lie between upper
and lower lines
- Weights of underweight children lies below
the lower line (3rd percentile)
- Weights of overweight or obese children lie
above the upper line (97th percentile)
- Continuous weight gain of the child is more
important than his position between lines
The upper one
for head
circumference in
cm for boys from
birth till
36 months

The second one

for boy’s length
from birth till 36
months
 Height in
cm for boys
2-21 years
 Weight
for boys
from
birth till
36
months
 Weight
for boys
2-21
years
The upper one
for head
circumference
in cm for girls
from birth till
36 months

The second one

for girls length
from birth till
36 months
Height in cm
for girls 2-21
years
Weight for
girls from
birth till 36
months
Weight for
girls 2-21
years
 Direction of the curve

- ascending curve: healthy childe

- horizontal curve: failure to thrive
Acute malnutrition
- decreased velocity curve: Chronic
malnutrition, Chronic conditions
 Factors affecting growth and
development
• Genetic and hereditary
• Race
• Sex
• Nutrition
• Chronic illness
• Socioeconomic factors
No television recommended under 2
years old.

A recommendation from the American

Academy of Pediatrics (AAP) that kids
2 and older watch TV no more than
one to two hours daily. And kids under
2 watch no television at all
• can lead to attention problems, school
difficulties, sleep and eating disorders, and
obesity. The Internet and cell phones can
provide platforms for illicit and risky
behaviors.

• A child's brain develops rapidly during these

first years, and young children learn best by
interacting with people, not screen
 Obesity in children

• USPSTF recommends for screening for obesity

in children specially above age of 6 years by
plotting BMI better than weight and height
separately (recommendation B)
Childhood obesity

BMI for
boys 2-21
years
Childhood obesity

BMI for
girls 2-21
years
• Teething usually begins around 6 months of
age. But it is normal for teething to start at
any time between 3 months and 12 months of
age. By the time your child is about 3 years
old, he or she will have all 20 primary teeth.
Permanent teeth
 Dental health
• Daily brushing
• Tooth paste when the child old enough
not to swallow
• Fluoride drops
• Bottle feeding during sleep
 Recommended childhood prevention
screening
Test/ Screening recommendation
examination
Blood At age of 3 and every 1-2 year
pressure

Hearing Subjective assessment at all visit :

1. checking for a response to noise
produced outside an infant field of
vision.
2. Absent of babbling at age of 6
months
3. Assessing speech development
Test/ examination Screening recommendation
u
Vision During Red reflex and corneal light
1st week reflex
and at
6 months
At 3 yr Visual acuity and cover-
and 5- 6 uncover test
yr
Anemia At age of 9 months and repeated at 2-
3 yr
Urine analysis In preschool children : AAP
Recommend screening at age of 4-5
 Anemia
• Anemia screening still controversial

• Universal supplementation with iron and

multivitamines for high risk infants is a more
effective strategy
 Vitamin D chemoprophylaxis

• 400 IU for all infants and children who

are formula fed and breast fed