Comprehensive Infant and Child Care

Introduction to Infant and Child History

The American Academy of Pediatrics recommends collecting maternal pregnancy details, including gestational age at birth, pregnancy complications, maternal medications, and substance use during pregnancy to establish baseline health status 1
The American Academy of Pediatrics suggests that growth parameters since birth, feeding history, sleep patterns, and elimination patterns should be collected to identify any potential health concerns 1
The American Academy of Pediatrics also recommends screening for substance exposure, as it may affect infant development and require specific follow-up, with a strength of evidence level of "strong recommendation" 1

The American Academy of Pediatrics recommends formal developmental screening, including assessment of motor development and language/social development 2
The American Academy of Pediatrics suggests that developmental screening should be performed even when history is incomplete, with a strength of evidence level of "strong recommendation" 2
Developmental milestones, including motor development, language development, and social-emotional development, should be recorded at well child visits 2, 3

The American Academy of Child and Adolescent Psychiatry recommends collecting family medical history, including congenital anomalies, genetic disorders, sudden unexplained deaths, cardiac conditions, metabolic disorders, and mental health conditions 4
The American Academy of Child and Adolescent Psychiatry suggests that family medical history is essential in identifying potential health risks for the infant 4
The American Academy of Child and Adolescent Psychiatry recommends assessing social and environmental factors, including primary caregivers and family structure, home environment, childcare arrangements, family support systems, parental concerns, exposure to tobacco smoke, housing stability, and resources for basic needs 4

The American Academy of Pediatrics recommends being alert for unexplained injuries, bruising in unusual locations, or inconsistent histories, which may indicate child abuse 5
The American Academy of Pediatrics suggests that careful screening for signs of child abuse is essential in preventing further harm, with a strength of evidence level of "strong recommendation" 5

The American Academy of Pediatrics recommends that a comprehensive physical examination, including assessment of dysmorphic features, neurological status, cardiovascular system, and development appropriate for age, should be performed to identify any potential health concerns 6
The American Academy of Pediatrics suggests that ongoing care and monitoring should be tailored to the individual needs of the infant, taking into account any areas requiring immediate attention, with a strength of evidence level of "strong recommendation" 6
Growth parameters (height, weight, head circumference, BMI) should be plotted and documented on appropriate growth charts at well child visits 7
Vital signs (heart rate, blood pressure, respiratory rate, temperature) and a complete physical examination should be recorded at well child visits 8, 9, 10
Vision and hearing screening results should be documented at well child visits 9, 10
Immunization status, including vaccines administered, lot numbers, and sites, should be documented at well child visits 11

The Centers for Disease Control and Prevention recommend reviewing and completing any missing adolescent vaccines, including meningococcal conjugate vaccine, HPV vaccine series, Tdap booster, and annual influenza vaccine 12
Dental health, behavior management, physical activity, nutrition counseling, sleep hygiene, and dental care should be discussed and recommended as part of a healthy lifestyle 7, 13
Depression and anxiety screening should be actively performed using validated tools, as recommended by the American Psychological Association 13
Fasting glucose or HbA1c screening is recommended for individuals with risk factors for diabetes, as stated by the American Diabetes Association 13
STI screening should be performed based on sexual history and risk factors, as recommended by the Centers for Disease Control and Prevention, and HIV testing should be offered at least once to all adolescents, according to the Clinical Infectious Diseases guidelines 12

A summary assessment, including overall health status and developmental progress, and a problem list, including any identified concerns requiring follow-up, should be documented at well child visits 14, 10
A management plan, including the plan for addressing identified issues, referrals to specialists, early intervention, or community resources, and patient and family input, should be documented at well child visits 10, 14
The American Academy of Pediatrics recommends a comprehensive preventive health visit for 18-year-old males, including screening for high-risk behaviors, appropriate immunizations, and targeted physical examination, with special attention to cardiovascular risk assessment and mental health screening, and discussions about confidentiality and privacy in adult healthcare, guidance on self-management of health conditions, and information on accessing healthcare independently 13