HEALTH SUPERVISION

VISIT GUIDELINES
SCHOOL-AGED CHILD
SUZANNE LEFEVRE MD

GENERAL APPROACH TO THE WELL

CHILD VISIT
INTERVAL HISTORY/OBSERVATION
NUTRITION
ELIMINATION
SLEEP PATTERNS
DEVELOPMENT/BEHAVIOR/SCHOOL
PERFORMANCE
PHYSICAL EXAM
ANTICIPATORY GUIDANCE
DISEASE PREVENTION/HEALTH PROMOTION
AND INJURY PREVENTION

4 YEAR OLD VISIT

Interval history/ Interview with behavioral observations
Child: How are you? How old are you? Do you go to
school? Where?

Parent: Have there been any illnesses, hospitalizations or

ED visits since our last visit? How is your child doing in
pre-school or child care? Do you have any particular
concerns youd like to discuss?

4 Year Old Visit

Nutrition
Child: What do you like to eat?
Parent:: Do you have any concerns about your childs eating habits?
Describe a typical dinner in your home?

Anticipatory Guidance:

Kids age 4-8 need 800mg of Calcium per day; one 8 oz glass of milk contains 300mg
Recommend limiting juice to no more than 6 oz of 100% fruit juice.
Food jags (favoring 1 or 2 foods) and picky eating are normal behaviors.

Explain the growth chart

Suggestions for picky eaters

Offer small portions first, then second helpings
Try to create a pleasant atmosphere at meal time
Include child in conversation at the dinner table
Offer a variety of foods and repeat them

4 YEAR OLD VISIT

Elimination
Parent:: Does the child use the toilet for urination and having
bowel movements?
Have you noticed any discomfort when the child has a bowel
movement?
By age 4, 95% of children are bowel trained
90% are dry during the day
75% are dry at night

Anticipatory Guidance
No specific interventions are warranted for night time wetting
because its so common at this age.
Stress importance of balanced diet in preventing constipation

4 Year Old Visit

Sleep Patterns
Child: Where do you sleep?
Parent:: How does your child get to sleep at night? Does your
child nap? Does your child experience nightmares, night terrors,
or sleepwalking?
Nightmares are common and involve vivid, scary or exciting
events which are easily recalled by the child upon awakening.
Night terrors are common particularly in boys ages 5-7 but can
see as early as 4. They occur in 1 3% of children and are
usually short lived. Characterized by sudden onset, usually
between midnight and 2:00am during stage 3 or 4 of slow wave
sleep. The child screams, appears frightened, tachycardic and
may hyperventilate. Child my thrash violently, there is little or no
verbalization and cannot be consoled. Sleep follows in a few
minutes and there is total amnesia of the event upon waking.

4 Year Old Visit

Sleep Patterns
Anticipatory guidance
Encourage children to sleep in their own beds if
that is compatible with the familys culture
Create a calm bedtime ritual like reading or story
telling
Reassure parents that nightmares and night terrors
are common

4 Year Old Visit

Development and Behavior
Child: What sort of things are you good at doing? Can you get yourself
dressed?
Parent: What skills do you expect of a 4 year old that your child cannot
perform?
Ages and Stages Questionnaire
Milestones
Gross motor: Pedals tricycle, hops on one foot, balances on one foot, walks up and
down stairs with alternating gate
Fine motor: Draws a circle and cross, draws a person with 3 to 6 body parts, cuts with
scissors
Cognitive skills: complex pretend play, may have imaginary friend, recognizes some of
the alphabet
Language skills: Uses full sentences of at least 6 words, 100% intelligible
Social skills: engages in interactive play, able to share, can play a board or card game.
Self-help skills: Able to put on shirt, pants, socks, able to button and zip; able to brush
teeth; toilet trained

4 Year Old Visit

Physical Exam

Height
Weight
Blood Pressure
General physical exam to include
Visual acuity- objective
Hearing screen- objective
Check for obvious dental caries
Check gait, spine and extremities
Be alert for signs of abuse
Screening: Hemoglobin if at risk for anemia (i.e., special health
needs, low iron diet or environmental factors
Immunizations: See current recommended schedule (DTaP, IPV,
MMRV)

4 Year Old Visit

Injury Prevention
Toys should be age
appropriate
Falls are common
Keep dangerous
materials out of reach;
matches, tools and
poisons
Helmets for tricycle safety
Car seats and seat belts
Start booster seat at
40lbs and 40 inches
tall

Adult supervision near

water, consider swimming
lessons
Good touch/bad touch
Careful around strange
dogs
Gun safety: AAP
recommends that they be
removed from the home
Teach child how to dial
911
UV protection

4 Year Old Visit

Close the visit

Are there any issues that we missed?
Set time and reason for next appointment

5 YEAR OLD VISIT

Interval History/ Interview with Behavioral Observations
O.K. to talk to child alone for a few minutes. As the child
grows older the time period gradually increases. This is
patient and family dependent
Child: Have you been sick since I saw you last? How many
brothers and sisters do you have?
Parent: How is your family doing? Have there been any
changes in the family?

5 Year Old Visit

Nutrition
Child: What are your favorite snacks?
Parent: Do you have any concerns about your childs weight?
Anticipatory Guidance
Same as the 4 year old visit
Discuss healthy snacking

5 Year Old Visit

Elimination
Child: do you have any problems with bowel movements
(poop) or urinating (pee)?
Parent: Does your child wet the bed at night?
At age 5 approximately 20% of children wet the bed at least
monthly.
Approximately 5% of boys and less than 1% of girls wet the bed
nightly

Anticipatory Guidance
No specific interventions are warranted for night time wetting
at this age.

5 Year Old Visit

Sleep Patterns
Same as 4 year old visit

5 Year Old Visit

Development and Behavior
Child: Can you write your name?
Parent: Can your child tie his shoes? Is your child comfortable in
speaking to others?
ASQ (Ages and Stages Questionnaire)
Milestones
Gross motor: balances on one foot, hops, skips
Fine motor: able to tie a knot, has mature pencil grasp, draws a person
with at least 6 body parts, able to copy squares and triangles.
Language: Names at least 4 colors, counts to 10, tells a simple story
using full sentences, appropriate tenses, pronouns.
Social skills: follows simple directions, able to listen and attend, dresses
and undresses with minimal assistance.

5 Year Old Visit

Physical Exam
Same as the 4 year old visit

Screening
Urinalysis
Other screening as indicated by risk: lead,
hemoglobin, PPD

5 Year Old Visit

Anticipatory Guidance
Injury Prevention/Health Promotion
Fire safety (alarms,
fire escapes, home
plan for emergencies)
Dealing with strangers
Discourage skate
boarding or in-line
skating unless
helmets, wrist, elbow
and knee pads are
used
Violence prevention
Pedestrian and bicycle
safety

Regular exercise/family
activities
Brush teeth at least 2
times per day. See
dentist 2 times per year.
TV viewing should be
limited and monitored
Encourage interaction
with other kids,
grandparents and adults
Spend time playing with
child every day

6-7 Year Old Visit

Interval History/Interview with Behavioral

Observations
Child: What grade are you in? Have you been sick
since our last visit? Any broken bones or stitches?
Parent: Have there been any family crisis or stressors?
Is your child on any medications?

6 7 Year Old Visit

Nutrition
Child: Do you eat fruits and
vegetables?
Parent: What does your child
eat for protein? How much
milk does your child drink?
Anticipatory Guidance:
Continue to promote wellbalanced diet.
Avoid junk foods
Consider need for vitamins,
iron supplements
Encourage regular exercise

Elimination
Child: Do you have a
bowel movement every
day? Is it hard or soft?
Does it hurt?
Parent: Does your child
have problems with day
time wetting, night time
wetting or soiling?
Anticipatory Guidance
By age 6 only 10% of
children will wet the bed
If problems are
identified, enuresis,
constipation and
encopresis.

6 7 Year Old Visit

Development and Behavior
Child: Can you ride a bike? Show me your left hand?
Parent:: How would you evaluate your childs abilities in sports?
How are your childs abilities to draw and write?
Milestones:
Gross motor: skip
Fine motor: Draw a picture of a person with 8 to 10 features
Language/Cognitive: Recount a personal story about a
recent event, count to 20

6 7 Year Old Visit

Physical Exam:
Same as 5 year old

Screening:
Same as 5 year old

Injury Prevention/Health promotion:

Same as 5 year old

School Readiness
Years from 3 to 6 are historically called preschool because of
their importance for preparing the child for the tasks of school
Determine any parental concerns about school readiness by
asking trigger questions

How does your child feel about going to school?

How are you feeling about John/Jane going to school?
When you were Johns/Janes age, did you enjoy school?
How did John/Jane do in preschool?
Is there anything you would like checked before he/she goes to
school?
Is there anything the school or teacher should know?

School Readiness
Parental concerns regarding developmental milestones

Communication/Language
Knowledge of letters,
words and symbols
Ability to recognize letters
and numbers
Articulate speech
Behavioral/Emotional Skills
Ability to take another
persons point of view and
follow rules
Separation anxiety
Social shyness
Temper tantrums and
tendency to be aggressive
when fearful are indicators
of emotional immaturity

Gross motor/Fine motor

Ability to print letters and
numbers
Good gross motor
coordination can provide
important status with peers
and is a source of selfesteem through athletics.
This is least predictive of
school achievement when
compared with other areas
of development.
Physical size and stature

Developmental milestones necessary for

Elementary School Success
Cognitive
Long term memory, storage and recall
This is the ability to acquire skills that are automatic
Deficit: Delayed mastery of the alphabet, slow handwriting and the
inability to progress past basic mathematics

Selective Attention
Ability to attend to important stimuli and ignore distractions
Deficit: Difficulty following multi-step instructions, completing assignments
and behaving well

Sequencing
Ability to remember things in order
Deficit: Difficulty organizing assignments, planning, spelling and telling
time
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004

Developmental Milestones necessary for

Elementary School Success
Perception
Visual Analysis
Ability to break a complex figure into components and
understand spatial relationships
Deficit: Persistent letter confusion (between b,d and g),
difficulty with basic reading and writing and limited sight
vocabulary

Proprioception and fine motor control

Ability to obtain information about body position by feel and
unconsciously program complex movements
Deficit: Poor handwriting often with overly tight pencil grasp,
difficulty with timed tasks
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004

Developmental Milestones necessary for

Elementary School Success
Language
Receptive
Ability to comprehend constructive function words like: if, when, only,
except. Ability to understand nuances of speech and extended blocks of
language (e.g. paragraphs)
Deficit: Difficulty following directions, wandering during lessons and
stories, problems with reading comprehension, problems with peer
relationships

Expressive
Ability to recall required words effortlessly (word finding), to control
meanings by varying position and word endings, to construct meaningful
paragraphs and stories
Deficit: Difficulty expressing feelings and using words for self-defense,
with resulting frustration and physical acting out; struggling during circle
time and language based subjects
Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004

References
Bright Futures, Health Supervision III
Guidelines 2008 AAP Publication
Caring for your Baby and Young Child
AAP Publication
Nelsons Textbook of Pediatrics 2004
Pediatrics: A Primary Care Approach,
Carol Berkowitz, MD, FAAP, 2008

General Approach to the Well Child Visit

Interval History/Behavioral Observation

Nutrition
Elimination
Sleep Patterns
Development/Behavior/School Performance
Physical Exam
Anticipatory Guidance
Disease Prevention, Health Promotion, Injury Prevention

8 9 Year Old Visit

Interval History/Interview with Behavioral Observations

Child: How are things going?

Parent: Have there been any changes in your childs health?

Middle childhood is marked by considerable development in academic skills,

physical abilities, social interactions and emotional regulation. School
success and home life are both important for self-esteem.

Nutrition

Child: How is your appetite? What do you eat for breakfast?

Parent: How is your childs appetite?

Encourage child to eat breakfast daily

Reinforce need for balanced diet avoiding junk food
With a balanced diet and exercise there should be no need for dieting

8 9 Year Old Visit

Elimination
Child: How often do you have bowel movements?
Parent: Do you have any concerns about your childs toilet habits?

Enuresis: Defined as normal voiding that occurs at an inappropriate

time or involuntarily in a socially unacceptable setting.
Defined as occurring at least 2 per week for at least 3 consecutive months
Diagnosis is reserved for girls older than 5 and boys older than 6
Diurnal enuresis occurs during the day
Nocturnal enuresis occurs at night
Primary enuresis refers to kids who have never achieved sustained
dryness
Secondary enuresis refers to kids whose urinary incontinence occurs after
3 to 6 months of dryness
75% to 80% of kids with enuresis have primary enuresis
Incidence of secondary enuresis increases with age and makes up 50% by
age 12
Causes of primary enuresis include faulty toilet training, maturational delay,
small bladder capacity, sleep disorders, nocturnal polyuria
Causes of secondary enuresis include UTIs, diabetes mellitus and
insipidus, genitourinary anomalies, seizure disorder, medication use

8 9 Year Old Visit

Sleep Patterns
Child: What time do you go to bed at night? How many hours do you
sleep on a school night?
Children age 8 frequently sleep 9 to 12 hours per night.

School
Child: What subjects do you like? What do you think about your
grades?
Parent: How are your childs reading and writing skills? What did you
learn at the parent-teacher conference?
If school failure is suspected discuss need for comprehensive approach
involving parents, school and pediatrician.

8 9 Year Old Visit

Development and Behavior
Child: What do you like to do for fun? How many hours each day do
you watch T.V?
Parent: What are your expectations for your child in terms of sports and
extracurricular activities? How does your child get along with friends
and peers at school?
Parents should encourage peer play outside the home, i.e. clubs,
camps or athletic teams.
Parents should consider giving an allowance to encourage
independence and responsibility.
Recommend fair, understandable rules about chores, T.V., outside
activities, homework and bedtime.
Encourage follow through with stated consequences when rules are
broken.
Consider discussing puberty.

8 9 Year Old Visit

Physical Exam

Height
Weight
Blood Pressure
Look for signs of puberty

Screening
Hemoglobin, PPD if high risk

Injury Prevention/ Health promotion/ Disease Prevention

Discuss participation in team sports where emphasis is fun and not
winning
For those children that dont like team sports, encourage individual
sports like swimming, tennis, dance or gymnastics
Trampoline use should be discouraged
Children can learn CPR at this age
Gun Safety
Smoke detectors in the home

10 11 Year Old Visit

Interval History/ Interview with Behavioral Observations

Speak to child alone during some portion of the visit

Explain confidentiality to the child and parents
At this age peer groups become an increasingly important influence on
style, attitudes and values. They may begin risk-taking behaviors such
as cigarette smoking or drinking alcohol.

Nutrition

Child: What is meant by a well balanced diet?

Parent: Is there a history of elevated cholesterol in your family?
Encourage child to eat breakfast before school
Encourage regular exercise
Advise parent and child about adequate hydration during warm climate
sports or outdoor activities

10 11 Year Old Visit

Elimination
Child: Do you experience pain or burning with urination?

Sleep Patterns

Child: How do you feel when you wake up in the morning?

Parent: How much sleep does your child get at night?
Children this age should still get at least 9 hours of sleep per night

Development/ Behavior
Child: Where do you spend your time after school?
Parent: What are the most enjoyable activities you do together? What
activities are most likely to cause friction or problems?
Age 10 is a prime year for sports competition. Year round participation in
multiple sports my reduce over-use injuries of same muscle groups.
Strength training is appropriate with proper supervision.
Parents should discuss tobacco, alcohol and illicit drug use.
Encourage parents to prepare girls for menarche.

10 11 Year Old Visit

Physical Exam

Height
Weight
Blood Pressure
Make sure to include assessment for scoliosis, Tanner staging and
exam of genitalia

Screening
Hemoglobin for menstruating females
Urine dipstick should be done between 11 and 21
Cholesterol and PPD for high risk kids

Injury Prevention

Seat belts
No power tools unless supervised
Water activities should be supervised
Children this age should not operate personal watercraft
Sunburn protection

School Failure
Failure in school can have lifelong consequences. The causes of
school failure are often multiple including: chronic illness,
behavioral, emotional and social issues
Background
10 15% of school age children repeat or fail a grade
More likely among males, minorities, low socio-economic status and
single parent households
Children with disabilities are nearly 3 times as likely to repeat a grade as
those with no disability
Disability
Learning
Speech or language impairment
Mental retardation
Emotionally disturbed

Children who are small for gestational age are nearly twice as likely to
experience school failure

School Failure
Background
Grade failure is linked strongly to subsequent dropping out of high
school
10% of drop-outs had no failures
22% of drop-outs failed one grade
39% of drop-outs failed 2 grades

Grade failure causes children to be older than their same-grade peers

Old for grade high school students are more likely to report smoking
regularly, chewing tobacco, alcohol use, driving in a car with someone who
has been drinking, using alcohol prior to a sexual experience and using
cocaine or other illicit drugs.
They have more suicidal ideations, risky sexual behavior and violent
behaviors
Grade retention alters peer group formation
Grade retention has a negative impact on self-esteem, social adjustment,
behavior, self-confidence, attitudes towards school and is stressful for
children

School Failure
Conditions and Associated Factors
Endogenous Factors

Chronic disease
Anemia
Asthma
Sleep Apnea
Cystic Fibrosis
SLE
Crohns Disease
Acute conditions causing school absence
Sensory impairment
Vision
Hearing
Perinatal conditions
Prematurity
FAS
In utero drug exposure
Maternal conditions affecting pregnancy
Neurologic disorders
Brain injury
Tic disorders
Seizure disorders
Toxic exposures

Endogenous Factors

Learning disability
Language and Speech Disorder
Phonologic language
Expressive language
Receptive language
Stuttering
Learning disorder
Reading
Writing
Mathematics
Mental Retardation
Communication disorders
ADHD
Autistic spectrum disorders
Genetic disorders: Fragile x
Endocrine disorders: Hypothyroidism
Psychiatric disorders
Oppositional defiant disorder
Conduct disorder
OCD
Anxiety disorders: phobias, panic
Substance abuse

School Failure
Conditions and Associated Factors
Exogenous Factors

Family
Divorce/Separation/conflict
Poverty
Frequent moves
Substance abuse
Depression
Attitudes towards education
Low level of family support
Inadequate accommodations
for studies at home
Neglect/Abuse
Environment
Neighborhood/housing
TV/computers
Peers
Peer pressure for low performance
Substance abuse

Exogenous Factors

Competing priorities: excessive

extramural activities
Social
Work
Sports
School
Mismatch between student and
teacher
Unrealistic expectations
Inadequate school environment
Violence/safety
Classroom size
Transitions
Third grade
Elementary school to middle
school
Increases in testing standards without
increasing educational support
Excessive testing

School Failure
Medical Assessment and Subsequent Interventions
History
School history
Details of current difficulties
School setting
Educational support
School absences
Achievement
Onset of problems
Results of educational testing
Preschool performance
Communication with the school
Attention profile
Attention
Hyperactivity
Impulsivity
Family history
Educational achievement and difficulties
Mental retardation
ADHD
General conditions
Tic disorders
PKU
Thyroid disease
Psychiatric disorders
Pregnancy complications
Birth complications
Prematurity
Hypoxia
Low Birth weight

History
Developmental history
Motor milestones
Language milestones
Regression
Social skills
Temperament
Current Medical Conditions
Acute
Chronic
Medications
Past medical history
Head trauma
CNS conditions
Sleep history
Social history
Peer group
Family stress: poverty, conflict, single
parent
Family orientation toward education
Mobility
Extracurricular activities
Substance abuse
Sexual behavior
Nutrition: diet
Strengths
Developmental Assessment
Vision and Hearing Screen
Physical Exam
Laboratory screening

School Failure
Medical Assessment and Subsequent Interventions
School Failure Interventions
As indicated by assessment
(e.g., treatment of
hypothyroidism)
Advocate for more complete
assessment
Attend school meetings
Advocate for IEP that consists
of more than simply having a
child repeat the grade that
was failed
Advocate for alternatives to
grade retention
Mixed-age classes
Individualized instruction
Tutoring
Home assistance program
Smaller class size
Alternative education settings
Guidance counseling

Help families get more

involved in their childs
education
Assist families with peer group
issues
Improve environment for
learning at home
Limit amount of television
watching
Provide a quiet place to do
homework

Help develop childs strengths

Assess siblings for school
problems and take the
opportunity to promote school
readiness prior to the failure of
a younger sibling

School Failure
Medical Assessment and Subsequent Interventions

Prevention
Promote school readiness during health supervision visits
Assess childrens strengths and weaknesses
Assess educational progress at all health supervision visits
Implement some interventions listed previously before failure occurs
Assess peers, activities, and health-impairing behaviors