cdc guidelines for well child visits

Family Life

AAP Schedule of Well-Child Care Visits

Parents know who they should go to when their child is sick. But pediatrician visits are just as important for healthy children.

The Bright Futures /American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the " periodicity schedule ." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.

Schedule of well-child visits

• The first week visit (3 to 5 days old)
• 1 month old
• 2 months old
• 4 months old
• 6 months old
• 9 months old
• 12 months old
• 15 months old
• 18 months old
• 2 years old (24 months)
• 2 ½ years old (30 months)
• 3 years old
• 4 years old
• 5 years old
• 6 years old
• 7 years old
• 8 years old
• 9 years old
• 10 years old
• 11 years old
• 12 years old
• 13 years old
• 14 years old
• 15 years old
• 16 years old
• 17 years old
• 18 years old
• 19 years old
• 20 years old
• 21 years old

The benefits of well-child visits

Prevention . Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.

Tracking growth & development . See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.

Raising any concerns . Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.

Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.

More information

Back to School, Back to Doctor

Recommended Immunization Schedules

Milestones Matter: 10 to Watch for by Age 5

Your Child's Checkups

• Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (periodicity schedule)

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Well-Child Visits: Parent and Patient Education

The Bright Futures Parent and Patient Educational Handouts help guide anticipatory guidance and reinforce key messages (organized around the 5 priorities in each visit) for the family. Each educational handout is written in plain language to ensure the information is clear, concise, relevant, and easy to understand. Each educational handout is available in English and Spanish (in HTML and PDF format). Beginning at the 7 year visit , there is both a Parent and Patient education handout (in English and Spanish).

For the Bright Futures Parent Handouts for well-child visits up to 2 years of age , translations of 12 additional languages (PDF format) are made possible thanks to the generous support of members, staff, and businesses who donate to the AAP Friends of Children Fund . The 12 additional languages are Arabic, Bengali, Chinese, French, Haitian Creole, Hmong, Korean, Polish, Portuguese, Russian, Somali, and Vietnamese.

Reminder for Health Care Professionals:  The  Bright Futures Tool and Resource Kit, 2nd Edition ​ is available as an online access product. For more detailed information about the Toolkit, visit  shop.aap.org . To license the Toolkit to use the forms in practice and/or incorporate them into an Electronic Medical Record System, please contact  AAP Sales .

Parent Educational Handouts

Infancy visits.

3 to 5 Day Visit

1 Month Visit

2 Month Visit

4 Month Visit

6 Month Visit

9 Month Visit

Early childhood visits.

12 Month Visit

15 Month Visit

18 Month Visit

2 Year Visit

2.5 Year Visit

3 Year Visit

4 Year Visit

Parent and patient educational handouts, middle childhood visits.

5-6 Year Visit

7-8 Year Visit

7-8 Year Visit - For Patients

9-10 Year Visit

9-10 Year Visit - For Patients

Adolescent visits.

11-14 Year Visit

11-14 Year Visit - For Patients

15-17 Year Visit

15-17 Year Visit - For Patients

18-21 Year Visit - For Patients

Last updated.

American Academy of Pediatrics

• Second Opinion

Make Time for Well-Child Visits

As a busy mom, you’re juggling it all―dashing from work to soccer practice to dance class, fitting in birthday parties, teacher conferences, and family dinners around the kitchen table. While it may feel tough to fit it all in, here’s something you don’t want to skip: well-child visits. Recommended for infants, children, and teens, these medical appointments are the time for vaccinations, important health screenings, a check of your child’s development, and for you to ask questions and voice concerns.

Kids who skip well-child visits are more likely to fall behind on the vaccines they need to stay healthy. As a result, they may face higher odds for pneumonia and other infections that need hospital treatment. 

Heed the tips below to make scheduling and keeping well-child visits easier, and to help you make the most of them.

Know when to go. The American Academy of Pediatrics (AAP) recommends well-child visits for babies and young toddlers at 3 to 5 days old, then at ages 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months. Starting at age 3, kids and teens need one preventive-care visit every year through age 21.

Make scheduling (and remembering) a cinch. Take advantage of appointment reminders―by phone, text, or email―offered by the pediatrician’s office. Schedule well-child appointments at the same time each year, such as before the start of school, to help you remember. And always say “yes” if office staff offer to schedule your child’s next well visit while you’re already there. This convenience boosts the chances you and your child will keep this important appointment.

Understand the big wellness benefits. Unlike sick visits, where the focus is on diagnosing and treating illness, every well-child visit covers a wide range of health needs, depending on your child’s age. These include:

A physical exam

Checks of vision, hearing, cholesterol, and blood pressure at recommended ages, plus autism screening

An assessment of your child’s emotional health

For teens, time for confidential conversations that may include assessments for alcohol and drug use and high-risk behavior

Keep up with your rapidly growing child. Kids’ minds and bodies grow quickly. Well visits help you keep pace with what they need now. Most of these appointments last 11 to 20 minutes or even longer. That gives you time to talk about topics like:

Healthy eating

Physical activity

How your child’s doing in school, at home, and in activities

Strengthen your partnership with the doctor. Chat away! Conversations with your child’s pediatrician or family doctor at wellness visits are a great way to build a relationship that can enhance your child’s health. By speaking freely, you’re adding more information to your child’s health history and helping the doctor better understand his or her wellness needs.

Get set for success. Make the most out of every visit. Before your appointment, jot down three to five questions about your child’s well-being that you’d like to discuss.

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The Well-Child Visit

• Original Investigation Adolescent Preventive Care and the Affordable Care Act Sally H. Adams, PhD; M. Jane Park, MPH; Lauren Twietmeyer, MPH; Claire D. Brindis, DrPH; Charles E. Irwin Jr, MD JAMA Pediatrics

Whatever name you use—check-up, well-child visit, or health supervision visit—these are important.

The benefits of well-child visits include tracking your child’s growth and development. Your pediatrician will review your child’s growth since the last visit and talk with you about your child’s development. These visits are a time to review and discuss each of the important areas of your child’s development, including physical, cognitive, emotional, and social development. Pediatricians often use a resource called Bright Futures to assess and guide discussions with parents about child development. Parents can access Bright Futures to review information relevant to their child’s age using the website at the bottom of this page.

Another benefit of a well-child visit is the opportunity to talk about prevention. For many children in the United States, the most common cause of harm is a preventable injury or illness. The well-child visit is an opportunity to review critical strategies to protect your child from injury, such as reviewing car seat use and safe firearm storage. The well-child visit is an opportunity to ensure your child is protected from infectious diseases by reviewing and updating his or her immunizations. If there is a family history of a particular illness, parents can discuss strategies to prevent that illness for their child. Healthy behaviors are important to instill at a young age, and the well-child visit is a time to review these important behaviors, such as sleep, nutrition, and physical activity.

During the teenage years, well-child visits offer adolescents an opportunity to take steps toward independence and responsibility over their own health behaviors. Every well-child visit with a teenager should include time spent alone with the pediatrician so that the adolescent has the opportunity to ask and answer questions about their health. Adolescent visits provide an opportunity for teenagers to address important questions, including substance use, sexual behavior, and mental health concerns.

Physical examination and screening tests are also a part of the well-child visit. Your child’s visit may include checking blood pressure level, vision, or hearing. Your pediatrician will do a physical examination, which may include listening to the lungs and feeling the abdomen. Screening tests can include tests for anemia, lead exposure, or tuberculosis. Some screening, such as for depression or anxiety, is done using a paper form or online assessment.

How Parents and Kids Can Get the Most Out of a Well-Child Visit

Ideally, schedule the visit ahead of time so that there is time to complete any required school or sports forms. Some parents schedule these visits to correspond with their children’s birthdays, while others schedule these during summer months to prepare for the start of a new school year.

Make a list of topics you want to discuss with your child’s pediatrician, such as development, behavior, sleep, eating, or prevention. Bring your top 3 to 5 questions with you to the visit. As your child gets older, ask your child to contribute any questions he or she would like to ask.

When going to the visit, it may be helpful to bring your child’s immunization record, a list of questions, or any school or sports forms you need completed.

For More Information

https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx .

Published Online: November 6, 2017. doi:10.1001/jamapediatrics.2017.4041

Conflict of Interest Disclosures: None reported.

See More About

Moreno MA. The Well-Child Visit. JAMA Pediatr. 2018;172(1):104. doi:10.1001/jamapediatrics.2017.4041

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Study Design and Data Source

Study population, outcomes and covariates, data analysis, characteristics of children seen at routine measurement and occasional measurement clinics, interventions by the practice of temperature measurement, interventions by fever status among well-child visits in which temperature was measured, conclusions, frequency and consequences of routine temperature measurement at well-child visits.

FINANCIAL DISLCOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Rebecca Dang , Anisha I. Patel , Julia Marlow , Yingjie Weng , Marie E. Wang , Alan R. Schroeder; Frequency and Consequences of Routine Temperature Measurement at Well-Child Visits. Pediatrics January 2022; 149 (1): e2021053412. 10.1542/peds.2021-053412

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• Ris (Zotero)
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Video Abstract

To determine the (1) frequency and visit characteristics of routine temperature measurement and (2) rates of interventions by temperature measurement practice and the probability of incidental fever detection.

In this retrospective cohort study, we analyzed well-child visits between 2014–2019. We performed multivariable regression to characterize visits associated with routine temperature measurement and conducted generalized estimating equations regression to determine adjusted rates of interventions (antibiotic prescription, and diagnostic testing) and vaccine deferral by temperature measurement and fever status, clustered by clinic and patient. Through dual independent chart review, fever (≥100.4°F) was categorized as probable, possible, or unlikely to be incidentally detected.

Temperature measurement occurred at 155 527 of 274 351 (58.9%) well-child visits. Of 24 clinics, 16 measured temperature at >90% of visits (“routine measurement clinics”) and 8 at <20% of visits (“occasional measurement clinics”). After adjusting for age, ethnicity, race, and insurance, antibiotic prescription was more common (adjusted odds ratio: 1.21; 95% CI 1.13–1.29), whereas diagnostic testing was less common (adjusted odds ratio: 0.76; 95% CI 0.71–0.82) at routine measurement clinics. Fever was detected at 270 of 155 527 (0.2%) routine measurement clinic visits, 47 (17.4%) of which were classified as probable incidental fever. Antibiotic prescription and diagnostic testing were more common at visits with probable incidental fever than without fever (7.4% vs 1.7%; 14.8% vs 1.2%; P < .001), and vaccines were deferred at 50% such visits.

Temperature measurement occurs at more than one-half of well-child visits and is a clinic-driven practice. Given the impact on subsequent interventions and vaccine deferral, the harm–benefit profile of this practice warrants consideration.

We recently reported that routine temperature measurement occurs at half of well-child visits nationally. Drivers and implications of this practice are unclear.

Temperature was measured at 59% of well-child visits; some clinics measured temperature routinely, and others measured only occasionally. The practice triggered more antibiotic prescriptions, less diagnostic testing, and detection of incidental fever, which was associated with increased interventions and vaccine deferral.

Well-child visits are the most common reason children present to ambulatory care. 1   “Bright Futures,” the American Academy of Pediatrics preventive care guidelines, provides recommendations on health supervision, anticipatory guidance, and disease and developmental screening for well-child visits from birth through adolescence. 2   It recommends 7 well-child visits within the first year of life, 5 between the ages of 1-3, then annually through adolescence. 2   Although recommendations are made for other vital signs, temperature measurement guidelines are not included. 2  

Our previous study, using publicly available national survey data (the National Ambulatory Medical Care Survey), reported that temperature is measured at almost one-half of all well-child visits. 3   The utility of routine measurement in asymptomatic children at well-child visits has yet to be determined and may have untoward consequences, such as reduced clinic efficiency, patient anxiety, and amplification of “fever phobia” (defined as exaggerated concerns about the harms of fever). 4   Additionally, incidental detection of elevated temperatures through routine measurement may drive “overdiagnosis” or the diagnosis of abnormalities that do not benefit the patient by being detected. 5   In our National Ambulatory Medical Care Survey study, we found that antibiotics and radiographs were more frequently ordered at visits in which temperature was measured, even in the absence of fever. 3   Because of limitations of these data, we were unable to determine if clinic protocols and patient symptoms contribute to temperature measurement.

To address this gap, we analyzed electronic medical record (EMR) data from well-child visits at a network of primary care clinics to determine: (1) the frequency of routine temperature measurement and associations with patient and clinic characteristics and (2) the probability of detecting incidental fever and rates of interventions by temperature measurement practice and incidental fever detection.

In this retrospective cohort study, we used well-child visit data from the Stanford Research Repository. 6   The Stanford Research Repository contains EMR data from Stanford University hospitals and clinics beginning in May 2014 and includes detailed provider and department information, billing codes, patient demographics, and clinical details such as vital signs, diagnoses, diagnostic testing, and medication prescriptions. The Stanford University Institutional Review Board approved the investigation.

We included well-child visits for children ≤18 years old seen between May 2014 and June 2019 at the Packard Children’s Health Alliance, a network of 24 Stanford-affiliated primary care clinics located throughout the northern California Bay Area. Because of the many potential Current Procedural Terminology and International Classification of Diseases (ICD) codes associated with well-child visits, well-child visits were identified by a field called “visit type” to differentiate preventive care visits from urgent care visits. To determine specificity of the data pull, we performed a random chart review on 30 visits in which a preventive care ICD-code was the primary diagnosis and 30 visits in which a preventive care ICD-code was a secondary diagnosis. All 60 notes were consistent with well-child visits (100% specificity). To assess whether visits were scheduled to address acute concerns but transitioned to well-child visits because the child was due for one, we also reviewed 20 visits scheduled within 3 days of the appointment. All notes were consistent with well-child visits. For aim 1, all well-child visits were included ( n = 274 351). For aim 2, we excluded 64 (0.02%) visits with temperature values <94°F and 3 (0.001%) visits with temperatures >105°F, because, after chart review, these values were deemed to be likely inaccurately documented.

Temperature Measurement

Temperature measurement was defined as the presence or absence of a temperature value in the vital signs section of the EMR. On preliminary analysis, we observed that clinics either measured temperatures at nearly all (>90%) well-child visits or at few (<20%) visits ( Fig 1 ). Therefore, we categorized clinics as “routine measurement” or “occasional measurement,” respectively. We investigated differences in patient demographics between routine measurement and occasional measurement clinics.

Percent of temperature measurement at well-child visits, by clinic.

Incidental Fever

We defined “incidental fever” as fever (temperature ≥100.4°F [≥38.0°C]) not previously suspected and thus, would not have been detected if not for routine temperature measurement. Because this is a subjective attribution, we classified incidental fevers as “probable” (ie, documentation in the progress note that fever was noted incidentally), “possible” (ie, no mention of preceding symptoms or chief complaint that may explain fever), or “unlikely” (ie, explicit documentation of concern that patient had infectious symptoms and/or fever preceding the encounter). The rubric is included in Supplemental Table 4 , and examples of each classification are listed in Supplemental Table 5 . “Probable” incidental fever was further classified into “noticed” or “unnoticed.” Visits with “unnoticed” fevers lacked mention of fever in the progress note (except for as a listed vital sign) and were not associated with interventions commonly linked to fever, including vaccine deferral. To classify fever, 2 of 5 board-certified pediatricians (AP, AS, MW, JM, and RD) reviewed each chart associated with fever. We a priori set a Fleiss-Cohen weighted κ at 0.80 agreement and modified the rubric until this level was achieved. Disagreements between the 2 reviewers were resolved by team consensus.

Interventions

Interventions were defined as those commonly obtained in the management of febrile pediatric patients and included diagnostic tests (C-reactive protein [CRP], complete blood cell count [CBC], rapid influenza swab, rapid strep throat swab, and urine culture) and antibiotic prescriptions. In preliminary analysis, we discovered that some clinics obtained urinalyses more frequently (∼20% of all well-child visits) than expected, so we limited our urinary tract infection testing variable to urine cultures. For well-child visits with fever, we also described rates of and reasons for vaccine deferral. Examples of reasons for deferral are listed in Supplemental Table 6 . Deferral was defined as explicit progress note wording to delay vaccination. For patients who had vaccines deferred, we reviewed subsequent well-child visit notes to determine if the deferred vaccines were given.

Post Hoc Survey

Based on our preliminary findings that the practice of temperature measurement at well-child visits may be clinic driven, we decided to conduct an informal post hoc survey of the clinic managers via Qualtrics to better elucidate protocols surrounding temperature measurement. Survey questions are detailed in Supplemental Information.

We first determined the frequency of temperature measurement at all well-child visits and examined how patient characteristics differed between routine measurement versus occasional measurement clinics. Bivariable and multivariable logistic regressions were performed to identify patient characteristics associated with being seen at routine measurement versus occasional measurement clinics, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. We also calculated standardized mean differences (SMDs) to evaluate the magnitude of the differences in patient characteristics, using cutoffs previously defined by Cohen 7   : no difference if SMD was <0.2, small if SMD was 0.2–0.49, moderate if SMD was 0.5–0.79, and large if SMD was 0.8–1.

To determine the impact of routine temperature measurement and incidental fever detection, we used χ 2 statistics and a generalized estimating equations regression to compare rates of interventions pursued at routine measurement versus occasional measurement clinics and at visits with fever versus without fever among visits in which temperature was measured at routine measurement clinics. Our multivariable model adjusted for patient characteristics determined to have moderate and large differences (SMD: ≥0.5) between routine measurement and occasional measurement clinics (age, ethnicity, race, and primary insurance) and accounted for clustering by clinic and patient. Because preliminary findings revealed that providers at each clinic did not deviate from overall clinic practice regarding temperature measurement, we did not account for clustering by provider.

Because incidental fever is a subjective attribution, we performed a sensitivity analysis to compare rates of interventions at visits with different categories of incidental fever to rates of interventions at visits lacking fever. Because of a low number of patients within each category, this sensitivity analysis was an unadjusted descriptive analysis. We performed chart review on well-child visits with documented fever for infants ≤90 days of age to better understand the impact of capturing incidental fever in this cohort, who are at higher risk for missing serious bacterial infection in the setting of fever. 8   All analyses were conducted by using R 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria).

We analyzed a total of 274 351 well-child visits in 50 571 children. Temperature was measured at 161 639 (58.9%) well-child visits. A total of 16 of the 24 clinics (67%) measured temperature at >90% of well-child visits, and the remaining 8 clinics (33%) measured temperature at <20% of well-child visits ( Fig 1 ).

Table 1 displays characteristics of patients at routine measurement versus occasional measurement clinics. The mean patient age for both groups was 5 years old. Routine measurement clinics had a lower proportion of visits for neonates and higher proportions of visits for Hispanic or Latinx, Black, and “other” race patients and patients with government insurance than occasional measurement clinics.

Patient Characteristics at Routine Measurement and Occasional Measurement Clinics

Column percentages may not add up to 100% because of rounding.

Multivariable regression model includes 274 349 of 274 351 (99.99%) visits because of missing data on sex. Binary sex data were missing for 2 well-child visits on the same patient who identifies as “other.”

Reference group for the regression model was clinics that occasionally measure temperature.

Race and ethnicity are self-reported fields. “Unknown” is the default option and includes patients who decline to answer the question. Because of small count, American Indian race was collapsed with patients who do not self-identify with any of the other listed races, classified as “other.”

“Private” includes private insurance plans. “Government” includes Managed Medicare and Medi-Cal/Medicaid. “Undocumented” includes self-pay or missing insurance data.

In multivariable analysis, Black patients and patients with government insurance were more commonly seen than White patients and patients with private insurance, respectively, at both routine measurement and occasional measurement clinics. The ORs for these characteristics were higher for routine measurement clinics.

A total of 8 of 9 (89%) clinic managers representing the 24 ambulatory clinics responded to our post hoc informal survey. The survey revealed that some clinics routinely measure temperature at all visit types (preventive and urgent care) and others routinely measure temperature on the basis of patient age, although no clear explanations for why some clinics chose to routinely measure temperature at all visit types or how age thresholds were chosen were provided. Detailed survey results are described in Supplemental Information.

In unadjusted analysis, antibiotic prescriptions were prescribed more frequently at routine measurement than occasional measurement clinics (1.7% vs 1.4%; P < .001), but ≥1 diagnostic tests were obtained marginally less commonly (1.3% vs 1.4%; P < .01). After adjustment and clustering, the odds of prescribing antibiotics at routine measurement clinics remained higher than at occasional measurement clinics (adjusted odds ratio [aOR]: 1.21; 95% CI 1.13–1.29), and the odds of obtaining diagnostic testing remained lower (aOR: 0.76; 95% CI 0.71–0.82).

At routine measurement clinics, 270 of 155 527 (0.2%) well-child visits had documented fever (≥100.4°F; 38.0°C). Of these 270 patients, 167 (61.9%) were classified as unlikely incidental fever, 56 (20.7%) were classified as possible incidental fever, 19 (7.0%) were classified as probable (noticed) incidental fever, and 28 (10.4%) were classified as probable (unnoticed) incidental fever. Table 2 shows rates of interventions by fever status. After adjustment and clustering, antibiotics and diagnostic testing had higher odds of being pursued at visits with a documented fever than visits with documented afebrile temperature (aOR: 10.2 [95% CI 7.4–14.1]; aOR: 17.6 [95% CI 12.8-24.3], respectively). Of visits with fever and associated interventions, 3 were for infants aged 0–90 days old. (The details of each case are described in Supplemental Information).

Rates of Interventions at Well-Child Visits in Which Temperature Was Measured at Routine Measurement Clinics, by Incidental Fever Category

Antibiotic classes prescribed: Penicillins, sulfonamides , cephalosporins (1st and 3rd generation only), tetracyclines, macrolides , lincosamides, anti- Mycobacterium , nitrofurantoin, and metronidazole. Italicized antibiotics were also prescribed in patients with fever.

P < .001 when comparing interventions at afebrile visits with that at the respective febrile visit;

P < .01 when comparing interventions at afebrile visits with that at the respective febrile visit;

P < .05 when comparing interventions at afebrile visits with that at the respective febrile visit.

In visits in which fever was classified as probable (noticed or unnoticed) incidental fever, vaccines were deferred at 12 of 24 (50%) visits but were given by the next well-child visit in 9 of these 12 patients (75%) ( Table 3 ). A total of 6 of 12 (50%) of vaccine deferrals were due to “parental preference,” 3 of 12 (25%) were due to “physician choice,” 2 of 12 (16.7%) had unclear progress note documentation (thus, the reason for vaccine deferral was “unable to be determined”), and 1 of 12 (8.3%) had a reason for deferral unrelated to the concurrent fever and illness (“other”). Examples of reasons for deferral are listed in Supplemental Table 6 .

Rates of Vaccine Deferral at Febrile Visits, by Incidental Fever Category

Within a large regional network of pediatric primary care clinics, we found that temperature was measured at slightly more than one-half of well-child visits, a proportion that aligns with our previous analysis using national data. 3   In this current study, we provide more granular insight into the drivers of this practice and found that two-thirds of clinics measured temperature at nearly all visits and one-third at few. Routine temperature measurement may contribute to inappropriate antibiotic prescription, in part due to incidental fever detection. Although the overall rate of incidental fever detection is low, it may trigger overuse of health care resources and unnecessary vaccine deferral.

Why clinics appear to use an “all or none” approach to temperature measurement is unclear. We noted that patients with government insurance were more likely to be seen at routine measurement clinics, which aligns with our previous findings using national data. 3   In some states, Medicaid requires temperature measurement at well-child visits. 9   Although we are not aware of such a requirement in California (J. Elliot, Staff Services Manager of the Policy Development and Analytics Team and Benefits Division at the Department of Health Services, personal communication, November 19, 2020), Medicaid requirements in other states may have influenced decisions over temperature measurement. Additionally, our post hoc survey results noted that some clinics routinely measure temperature at all visit types. Routine measurement may be perceived to improve clinic efficiency by maintaining similar intake protocols across all visits.

We noted that routine measurement clinics prescribed antibiotics more frequently than occasional measurement clinics. Although causality for the higher rates of antibiotic prescription is challenging to prove, it is possible that the detection of fevers (or even borderline temperatures that did not meet our definition of fever) that would not otherwise have been noted influences decision-making around antibiotic prescriptions. However, we also noted that, after adjustment for possible confounders and clustering by clinic and patient, diagnostic testing was slightly less common at routine temperature measurement clinics. Although it is possible that providers are opting for antibiotic prescriptions in lieu of diagnostic testing, future research should be done to confirm these findings.

Incidentally detected fever may prompt inappropriate antibiotic prescription in the setting of viral symptoms or misdiagnosed bacterial infections. A cross-sectional study on febrile children seen at 2 ambulatory clinics determined that 64% of febrile patients were managed with oral antibiotics despite frequent diagnoses of viral infections, such as upper respiratory tract infections and gastroenteritis. 10   Another study showed that pediatricians have low rates of compliance with the Centers for Disease Control and Prevention’s diagnostic criteria for acute otitis media (AOM) and that 99% of diagnosed AOM were treated with antibiotics, suggesting that overdiagnosis or misdiagnosis of AOM is contributing to excess antibiotic prescriptions. 11   In addition, fever may prompt antibiotic treatment of infections that are often self-resolving. In a study including in-person and telephone pediatric ambulatory visits, the most common diagnoses for visits associated with fever (5%) were upper respiratory infections (URIs), AOM, and tonsillitis, 12   of which the latter 2 infections often trigger antibiotic prescriptions, despite often improving without treatment. 13 – 16   Although incidental fever detection through routine temperature measurement at well-child visits is rare, the practice may contribute to overuse of resources. Of the 3 visits for infants 0–60 days old with documented fever and associated interventions, 1 visit was categorized as probable (noticed) incidental fever and had normal infectious screen results. The 2 remaining visits were categorized as unlikely incidental fever and ultimately required hospital admission. Future large-scale research should evaluate the impact of incidental fever detection through routine temperature measurement in well-appearing infants on rates of infectious diagnostic testing, antibiotic prescription, and hospital admission as well as diagnostic outcomes.

Given the high number of well-child visits that occur in the United States, even a small impact of temperature measurement on subsequent interventions could have a considerable effect at the population level. For example, if the association between routine temperature measurement and antibiotic prescription is in fact causal, the absolute risk difference in antibiotic prescriptions of 0.3% signifies that 3 additional antibiotic prescriptions are triggered by every 1000 visits in which temperatures are routinely measured. Based on an estimate of 52 million annual well-child visits from our previous US study, 3   routine temperature measurement practices at well-child visits could translate to >150 000 additional antibiotic prescriptions per year.

We also found that vaccines were deferred at more than one-half of well-child visits associated with incidental fever detection, with rates varying by the category of incidental fever. Previous literature suggests that underimmunization varies by age, community, and the type of vaccine, with up to 25% of children experiencing at least 1 missed vaccination opportunity by 2 years of age. 17 , 18   In these studies, the most common non–well-child visit diagnoses found to be associated with missed vaccine opportunities were AOM, upper respiratory tract infection, gastroenteritis, resolving illness, eczema, and impetigo. 17 , 18   Investigators for both studies also considered fever (temperature: ≥100.4°F) to be a valid contraindication to vaccination. Although the incidence of incidental fever was low in our sample, the overall population impact on vaccine deferral may be clinically significant, given the high number of well-child visits annually in the United States. Furthermore, the fact that vaccine deferral was common in the context of incidental fever has significant implications for “catch-up” vaccination strategies, such as vaccination at urgent care visits. The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices states that mild illness, including “low-grade fever, an upper respiratory infection (URI), a cold, otitis media, or mild diarrhea,” is an “invalid contraindication to vaccination.” 19   Future educational and quality improvement efforts emphasizing the Advisory Committee on Immunization Practices’ recommendations may help curtail vaccine deferral.

Our study has limitations. First, acute complaints may have prompted temperature measurement. This was not evident in limited chart review and is unlikely to explain the wide variation in temperature measurement across clinics (>90% versus <20% of the time). Second, our categorization of incidental fever was based on progress note review and relied on accurate provider documentation of patients’ infectious symptoms. Furthermore, we only performed chart review on visits associated with fever. Some patients may have had elevated temperatures that did not meet the definition of fever but still triggered interventions because of concern for infection. Third, rates of fever, antibiotic prescriptions, and diagnostic testing were determined by temperature value documentation and relevant medication and procedure codes, respectively. We did not assess previous antipyretic use, the reasons for pursuing interventions, or patient compliance with prescribed antibiotics or diagnostic testing. Finally, in this study, we only include a single network of primary care clinics and may limit generalizability to other northern California Bay Area or US clinic practices.

Despite the lack of supportive recommendations, routine temperature measurement occurred at half of well-child visits in this study and seems to be a clinic-driven practice. The harm-benefit profile of the practice warrants consideration, especially given the rise in measurement as a screening tool during the coronavirus disease 2019 pandemic.

FUNDING: All phases of this study were supported by the Maternal & Child Health Research Institute Clinical Trainee (MD) Support program and the Gerber Foundation Novice Researcher Award. The Maternal & Child Health Research Institute and the Gerber Foundation had no role in the design and conduct of the study.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-053895 .

Dr Dang conceptualized and designed the study, conducted chart review, provided detailed oversight of data analysis, interpreted the data, drafted the initial manuscript, and critically reviewed and revised the manuscript for important intellectual content; Drs Patel, Wang, and Marlow contributed to the study design and data interpretation, conducted chart review, and critically reviewed and revised the manuscript for important intellectual content; Mr Weng conceptualized and designed the study, performed data cleaning and data analysis, and participated in data interpretation, critical review, and revision of the manuscript for important intellectual content; Dr Schroeder conceptualized and designed the study, conducted chart review, interpreted the data, and critically reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Advisory Committee on Immunization Practices

acute otitis media

adjusted odds ratio

complete blood cell count

confidence interval

C-reactive protein

electronic medical record

International Classification of Diseases

standardized mean difference

upper respiratory infection

Competing Interests

Supplementary data.

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• v.18(1); 2020 Jan

Caregiver and Clinician Perspectives on Missed Well-Child Visits

Elizabeth r. wolf.

1 Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia

2 Children’s Hospital of Richmond at VCU, Richmond, Virginia

Jennifer O’Neil

3 Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia

James Pecsok

Rebecca s. etz, douglas j. opel.

4 Department of Pediatrics, University of Washington, Seattle, Washington

Richard Wasserman

5 Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont

Alex H. Krist

Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors.

We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis.

Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors.

CONCLUSIONS

Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.

INTRODUCTION

The American Academy of Pediatrics recommends 13 well-child visits before the age of 6 years. 1 These visits are an opportunity to deliver immunizations, provide anticipatory guidance, and identify and treat disease. 2 Attendance of well-child visits has been associated with reduced hospitalizations and emergency department use. 3 , 4 Despite these benefits, children miss between 30% to 50% of well-child visits. 3 – 6 Poor, uninsured, and African American children miss a greater proportion of these visits compared with upper-income, privately insured, and white counterparts. 5 – 7 Many states support safety-net practices to promote access. Despite these efforts, it is not fully understood why more disadvantaged patients miss a disproportionately larger share of well-child visits.

Few studies have explored patient and clinician perspectives on why pediatric visits are missed. Studies conducted more than 15 years ago identified transportation, 8 , 9 work, 9 wait times, 8 and lack of understanding about the reason behind the visits 8 as reasons for missed visits. Clinicians in England also identified social reasons and family belief systems as reasons. 10 Because clinicians are not always aware of the nonmedical aspects of patients’ lives, they may not fully understand or may have different perspectives on why well-child visits are missed. It is also unclear whether clinician and caregiver perspectives on missed well-child visits align. We aimed to assess current US caregiver and clinician perspectives regarding missed well-child visits in an urban, underserved health care system with a large proportion of African Americans.

We selected a purposive sample of 17 caregivers and 6 clinicians (family practice and pediatric physicians) for children aged 0 to 6 years who missed 2 or more well-child visits at Virginia Commonwealth University Health System (VCUHS) between January 1, 2011, and January 1, 2016. We chose 2 or more missed well-child visits as the cutoff in order to include caregivers of young children as well as those of older children. We hypothesized that using a higher threshold of missed visits would disproportionately select families with older children. We excluded patients without any well-child visits recorded as this group may have used a different health system as their primary care medical home. Well-child visits were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) or International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes (eg, V20.2, Z00.129) and Current Procedural Terminology (CPT) claims codes (eg, 99381). Because Spanish-speaking children make up about one-third of the pediatric population at VCUHS, we also included Spanish-speaking caregivers in this study.

Caregivers were contacted through direct mailings, while clinicians serving pediatric patients in VCUHS were contacted through e-mail. Individuals who did not respond to the initial mailings were sent another invitation.

Our research team developed a semistructured guide before the study. The included questions focused on 3 domains: the value of well-child visits (eg, “What are important aspects of well-child visits?”), barriers to attendance (“What makes it hard to attend well-child visits?”), and facilitators of attendance (eg, “What would make attendance easier?”). Interviews were conducted by telephone between November 2016 and March 2017 without the use of field notes. Two female interviewers (J.O. and Martha Gonzalez [M.G.]) conducted all the interviews; the former is a medical student, and the latter is a Spanish-speaking qualitative researcher. Both interviewers were trained in interview techniques and the use of the interview guide before the study and completed the interviews in a standardized way (ie, questions were asked in a similar manner to all of the participants). Neither interviewer had relationships with the caregivers before starting the study.

Verbal consent was obtained before the start of the interview. Participants were briefed on the goals of the study before the interviews. We did not the record demographics of the participants in order to protect their privacy and encourage forthright dialog between the participant and the interviewer. Interviews lasted between 10 and 20 minutes, and none were repeated. Interviews were conducted until saturation was reached. At the completion of each interview, caregivers were mailed a $25 gift card. Clinicians were not compensated for participation.

Interviews were digitally recorded and transcribed. Spanish-speaking families were interviewed by a native Spanish speaker (M.G.) and transcripts were translated into English for interpretation. Transcripts were not made available to participants for review after the interviews were complete.

We used a grounded theory approach when analyzing the interviews. After reviewing 5 interviews independently, the research team (E.R.W., J.O., and J.P.) met and created an initial codebook based on the interview guide and topics raised by participants. As a group, the sample of interviews was reviewed with the initial codebook, and the codebook was adjusted based on consensus. With use of an editing style of coding, 11 this final codebook was applied to the full data set (J.O., J.P., and E.R.W.) using Word (Microsoft Corp). Coded data were reviewed by coauthors (J.O., J.P., and E.R.W.) and grouped into 3 categories: (1) valuable aspects of well-child visits, (2) barriers to well-child visit attendance, and (3) facilitators of well-child visit attendance. The team then used thematic analysis 12 to highlight the significance of each grouping from the perspective of caregivers and clinicians. Participants did not provide feedback on the results of the analysis. Our study was approved by the institutional review board of Virginia Commonwealth University.

Of 205 English-speaking caregivers and 95 Spanish-speaking caregivers who were mailed invitations, 12 English-speaking and 5 Spanish-speaking caregivers agreed to participate. Of the 23 clinicians practicing at VCUHS who were contacted, 6 agreed to participate.

Both caregivers and clinicians identified immunizations, the detection of illness, and the monitoring of growth and development as important aspects of well-child care ( Table 1 ). The long-term relationship and interaction between the clinician and family was also important to both groups. Clinicians thought that their relationships with the families played a role in determining whether the family would attend future visits, as the following representative quote illustrates:

We have seen time and again that relationship and, like, connection matters for everyone when it comes to the people who take care of them and the system that takes care of them, and so if you can enhance the relationship, I think you increase your chances of helping the patients who are least likely to show up to maybe, like, improve that. (clinician participant)

Selected Quotations on the Value of Well-Child Visits

Caregivers and clinicians cited lack of transportation and difficulty taking time off from work as reasons for missed well-child visits ( Table 2 ). Caregivers said that underlying financial stress made these logistics even more difficult. Caregivers and clinicians also discussed competing priorities, such as caring for young children, older children’s school schedules, and the scheduling of the caregivers’ own medical appointments. Clinicians also thought that caregivers may prioritize attending well-child visits in which vaccinations are typically given. Clinicians expressed concern that immigration and language differences may be barriers to attendance. Spanish-speaking caregivers thought that availability of language services made them more interested in attending well-child visits.

Selected Quotations on the Barriers to Well-Child Visit Attendance

We found that this sample of caregivers and clinicians from an urban underserved health system understood the need for and valued well-child visits. Caregivers and clinicians thought these visits were important to give vaccinations, identify disease, monitor growth and development, and build the relationship between family and clinician. Caregiver and clinician perspectives on reasons behind missed well-child visits were aligned. Both groups thought that transportation, financial stress, taking time off from work, and difficulty with child care were barriers to attendance. Clinicians identified language differences and immigration status as barriers to attendance, and Spanish-speaking families thought the presence of language services facilitated attendance.

Similar to findings of older studies, 8 – 10 both groups primarily described structural and social barriers as contributing to missed well-child visits. The VCUHS is considered a safety-net health system with a large proportion of publicly insured children. Richmond also has a high proportion of single parents and parents working in low-wage jobs who may find it more difficult to take time off from work. The clinics that see pediatric patients are centrally located and on major bus lines; however, some families may feel unsafe waiting at bus stops in areas with high rates of violent crime. It should be noted that since conducting these interviews, parking has become free for patients, although we have not yet studied how this change has affected attendance.

One limitation to our study is the reliance on mailings, which may have resulted in the exclusion of families with low levels of literacy or unstable housing. In addition, the relatively low response rate (although typical for studies of this type) may have biased our sample toward those who valued well-child visits to a greater degree than those who did not respond. We plan to elicit additional perspectives from hard-to-reach families in future studies.

Our findings suggest there is a need to further explore the potential relationship between well-child visit attendance and social determinants of health. Although the importance of social determinants of health has been known to the scientific community for some time, attempts to address these determinants have been limited. There may be ways to reduce bar riers to attendance through interventions at the level of the family (eg, transportation, child care), the health care system (eg, appointment reminders, care coordination, screening for and addressing of social determinants of health), and the payer (value-based care rather than fee for service). Future research emphasis could be placed on understanding and helping the children missing the greatest number of visits.

Acknowledgments

We would like to acknowledge Martha Gonzalez, Julia Rozman, and Paulette Lail Kashiri for their assistance with the project.

Conflicts of interest: authors report none.

To read or post commentaries in response to this article, see it online at http://www.AnnFamMed.org/content/18/1/30 .

Funding support: This work was supported by a 2016 Bright Futures Young Investigator Award from the Academic Pediatric Association and by a Clinical and Translational Science Awards grant (UL1TTR002649).

Previous presentation: Qualitative Methods for Identifying Reasons Behind Missed Well Child Care Visits. Presented at the Practice Based Research Network Conference; June 22, 2017; Bethesda, Maryland.

Important Milestones: Your Baby By Nine Months

CDC’s milestones and parent tips have been updated and new checklist ages have been added (15 and 30 months). For more information about the updates to CDC’s developmental milestones, please review the Pediatrics journal article  and these  important key points .

How your child plays, learns, speaks, acts, and moves offers important clues about your child’s development. Developmental milestones are things most children (75% or more) can do by a certain age.

Check the milestones your child has reached by 9 months by completing a checklist with CDC’s free Milestone Tracker  mobile app, for  iOS  and  Android  devices, using the Digital Online Checklist , or by printing the checklist  [714 KB, 2 Pages, Print Only]  below.

“Learn the Signs. Act Early.” materials are not a substitute for standardized, validated developmental screening tools .

What most babies do by this age:

Social/emotional milestones.

Close video

Language/Communication Milestones

Cognitive milestones (learning, thinking, problem-solving), movement/physical development milestones, shows several facial expressions, like happy, sad, angry, and surprised.

Image 1 of 2

Image 2 of 2

Moves things from one hand to her other hand

Image 1 of 3

Image 2 of 3

Image 3 of 3

Smiles or laughs when you play peek-a-boo

Sits without support

Other important things to share with the doctor…

• What are some things you and your baby do together?
• What are some things your baby likes to do?
• Is there anything your baby does or does not do that concerns you?
• Has your baby lost any skills he/she once had?
• Does your baby have any special healthcare needs or was he/she born prematurely?

Concerned About Your Child’s Development? Act Early.

You know your child best. Don’t wait. If your child is not meeting one or more milestones, has lost skills he or she once had, or you have other concerns, act early. Talk with your child’s doctor, share your concerns, and ask about developmental screening. The American Academy of Pediatrics recommends that children be screened for general development using standardized, validated tools at 9, 18, and 30 months and for autism at 18 and 24 months or whenever a parent or provider has a concern.

If you or the doctor are still concerned:

• Ask for a referral to a specialist who can evaluate your child more; and
• Call your state or territory’s early intervention program to find out if your child can get services to help. Learn more and find the number at cdc.gov/FindEI .

For more on how to help your child, visit cdc.gov/Concerned .

As your baby’s first teacher, you can help his or her learning and brain development. Try these simple tips and activities in a safe way. Talk with your baby’s doctor and teachers if you have questions or for more ideas on how to help your baby’s development.

• Repeat your baby’s sounds and say simple words using those sounds. For example, if your baby says “bababa,” repeat “bababa,” then say “book.”
• Place toys on the ground or on a play mat a little out of reach and encourage your baby to crawl, scoot, or roll to get them. Celebrate when she reaches them.
• Teach your baby to wave “bye-bye” or shake his head “no.” For example, wave and say “bye-bye” when you are leaving. You can also teach simple baby sign language to help your baby tell you what he wants before he can use words.

Click here for more tips and activities

• Play games, such as peek-a-boo. You can cover your head with a cloth and see if your baby pulls it off.
• Play with your baby by dumping blocks from a container and putting them back in together.
• Play games with your baby, such as my turn, your turn. Try this by passing a toy back and forth.
• “Read” to your baby. Reading can be talking about pictures. For example, while looking at books or magazines, name the pictures as you point to them.
• Limit screen time (TV, tablets, phones, etc.) to video calling with loved ones. Screen time is not recommended for children younger than 2 years of age. Babies learn by talking, playing, and interacting with others.
• Find out about choking risks and safe foods to feed your baby. Let him practice feeding himself with his fingers and using a cup with a small amount of water. Sit next to your baby and enjoy mealtime together. Expect spills. Learning is messy and fun!
• Ask for behaviors that you want. For example, instead of saying “don’t stand,” say “time to sit.”
• Help your baby get used to foods with different tastes and textures. Foods can be smooth, mashed, or finely chopped. Your baby might not like every food on the first try. Give her a chance to try foods again and again.
• Say a quick and cheerful goodbye instead of sneaking away so your baby knows you are leaving, even if he cries. He will learn to calm himself and what to expect. Let him know when you return by saying “Daddy’s back!”
• Have routines for sleeping and feeding. Babies do better when they know what to expect.
• Stay close by as your baby explores and moves around your home so she knows that you are near.
• Make sure your baby gets enough sleep: 4- to 12-month-olds need 12 to 16 hours of sleep a day (including naps). Consistent sleep times make it easier!
• Take care of yourself. Parenting can be hard work! It is easier to enjoy your growing baby and be a loving parent when you feel good yourself.
• Make it a game when your baby drops things. Hand the item back to her so she can drop it again.
• Pay attention to the way he reacts to new situations and people; try to continue to do things that make your baby happy and comfortable.
• Describe what your baby is looking at; for example, “red, round ball.”
• Play a game that teaches your baby to look for things she sees you hide, such as a toy under a blanket.
• Give your baby safe places to explore. Baby-proof your home. For example, move sharp or breakable things out of reach. Lock away medicines, chemicals, and cleaning products. Save the Poison Help Line number, 800-222-1222, in all phones.
• Use your words, facial expressions, and voice to show what you think your baby is feeling (sad, mad, happy). For example, tell him “You are sad, let’s see if we can make you feel better.”
• Put your baby close to things that she can pull up on safely.

Special acknowledgments to the subject matter experts and others who contributed to the review of data and selection of developmental milestones, especially Paul H. Lipkin, MD, Michelle M. Macias, MD, Julie F. Pajek, PhD, Judith S. Shaw, EdD, MPH, RN, Karnesha Slaughter, MPH, Jane K. Squires,  PhD, Toni M. Whitaker, MD, Lisa D. Wiggins, PhD, and Jennifer M. Zubler, MD.

Sincere gratitude to Natalia Benza, MD and José O. Rodríguez, MD, MBA for their thoughtful review of the Spanish-language translation of these milestones.

• Developmental Disabilities
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• National Center on Birth Defects and Developmental Disabilities
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