Components of a 2-Month Well-Child Examination

Physical Examination Components

• The American Academy of Pediatrics recommends assessment of skin color, perfusion, and presence of any rashes or lesions during the physical examination of a 2-month-old infant 1
• Examination of fontanelles, shape of head, and presence of any abnormalities is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Red reflex testing to detect abnormalities of the ocular media is recommended by the American Academy of Family Physicians and the American Academy of Ophthalmology 2, 3
• Binocular red reflex (Brückner) test to assess for symmetry of the red reflexes is recommended by the American Academy of Ophthalmology 3
• External inspection of ocular and periocular structures is recommended by the American Academy of Family Physicians and the American Academy of Ophthalmology 2, 3
• Pupillary examination and assessment of fixation and following behavior is recommended by the American Academy of Family Physicians and the American Academy of Ophthalmology 2, 3
• Examination of tympanic membranes is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Assessment of nares for patency and any discharge is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Examination of oral cavity, including palate and tongue is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Auscultation of heart for rate, rhythm, and presence of murmurs is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Auscultation of lungs for air entry and any abnormal sounds is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Assessment of respiratory rate and pattern is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Palpation for organomegaly, masses, or tenderness is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Assessment of umbilical cord site for healing and absence of infection is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Examination of external genitalia for any abnormalities is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Assessment of urinary stream in males and genital appearance in females is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Examination of hips for signs of developmental dysplasia is recommended by the American Academy of Pediatrics during the physical examination of a 2-month-old infant 1
• Assessment for Brief Resolved Unexplained Events (BRUE) risk factors in infants with concerning history is recommended by the American Academy of Pediatrics 1

Preventive Care

• The Centers for Disease Control and Prevention recommends administration of age-appropriate immunizations according to the recommended schedule 4
• For infants born to HBsAg-positive mothers, the Centers for Disease Control and Prevention ensures proper administration of hepatitis B vaccine and hepatitis B immune globulin 4

Clinical Examination and Developmental Milestones for 2-Month-Old Infants

Developmental Milestones

• By 2 months of age, infants should be able to lift head and chest when placed in prone position, according to the American Academy of Pediatrics 5, 6
• Social interaction should include making eye contact and demonstrating social smiling, as recommended by the American Academy of Pediatrics 6
• Parents should be asked specific questions about development, such as "Is there anything your child is not doing that you think he or she should be able to do?", "Is there anything your child is doing that you are concerned about?", and "Is there anything your child used to be able to do that he or she can no longer do?", as suggested by the American Academy of Pediatrics 7

Physical Examination Components

General Assessment

• A complete head-to-toe examination with careful attention to growth parameters (weight, length, head circumference) plotted on appropriate growth charts should be performed, as recommended by the American Academy of Pediatrics 7, 8
• Assessment of overall appearance, activity level, and interaction with caregivers is also important, according to the American Academy of Pediatrics 7

Neurological Examination

• Evaluation of tone, posture, primitive reflexes, and spontaneous movements should be performed, as recommended by the American Academy of Pediatrics 5, 7
• Assessing for any involuntary movements or coordination impairments is also crucial, according to the American Academy of Pediatrics 7

Vision Assessment

• Red reflex testing to detect abnormalities of the ocular media should be performed, as recommended by the American Academy of Pediatrics 6
• External inspection of ocular and periocular structures, pupillary examination, and assessment of fixation and following behavior are also important, according to the American Academy of Pediatrics 6
• Note that poor eye contact after 8 weeks warrants further assessment, as suggested by the American Academy of Pediatrics 6

Hearing Assessment

• Reviewing results of newborn hearing screening if not done previously is recommended, as suggested by the American Academy of Pediatrics 8, 9
• A formal assessment of hearing (brainstem auditory evoked potential response) should be performed if not completed or if there are concerns, according to the American Academy of Pediatrics 10

Required Screenings

• Reviewing metabolic/newborn screening results if not previously reviewed is recommended, as suggested by the American Academy of Pediatrics 6
• Assessment for risk factors that might warrant additional screening is also important, according to the American Academy of Pediatrics 6

Anticipatory Guidance

• Basic infant care including bathing, skin care, and temperature measurement should be discussed, as recommended by the American Academy of Pediatrics 9

Follow-up Recommendations

• Ensuring caregivers understand developmental expectations for the next period is crucial, as suggested by the American Academy of Pediatrics 5

Special Considerations

• For premature infants, developmental assessments should be corrected for gestational age for at least the first 24 months of life, as recommended by the American Academy of Pediatrics 5

Age Adjustment for Premature Infants

Developmental Milestone Assessment

• The American Academy of Pediatrics recommends correcting for gestational age when assessing developmental milestones for at least the first 24 months of life, and extend correction through 36 months for growth assessments in extremely and very preterm infants 11
• Developmental milestones should be corrected for prematurity for at least the first 24 months of life, by subtracting the number of weeks the infant was born early from their chronological age to calculate their "corrected age" or "adjusted age" 11
• The American Academy of Pediatrics and other medical societies recommend applying correction to all developmental domains, including motor, social, language, and cognitive functions, using corrected age 11, 12

Growth Assessment

• For extremely preterm (<28 weeks) and very preterm (28 to <32 weeks) infants, age correction is required for all growth measures (weight, length, head circumference) through 36 months of corrected age, according to the American Academy of Pediatrics 11

Special Populations Requiring Heightened Surveillance

• The American Academy of Pediatrics states that premature infants with gestational age ≥32 weeks AND postconceptional age ≥45 weeks qualify as lower-risk for Brief Resolved Unexplained Events (BRUE), while those born at less than 32 weeks gestation or who have not reached 45 weeks postconceptional age are considered higher-risk 13
• The American Heart Association recommends that premature infants with congenital heart disease face compounded neurodevelopmental risk and require heightened developmental screening, including late-preterm infants (34-36 weeks) 14

Treatment Planning Implications

• When determining need for early intervention services, the American Academy of Pediatrics recommends using corrected age to avoid unnecessary referrals in the first 24 months 11
• Infants showing delays based on corrected age warrant immediate referral, according to the American Academy of Pediatrics 11