General Structure
1) History

a) Nutrition

b) Bowel / bladder function

c) Sleep / Behavior

d) Allergies / medications

e) Psychosocial environment

f) Caretaker concerns

2) Physical Exam

3) Development

4) Anticipatory Guidance

5) Immunization

6) Surveillance Labs / Special concerns 

Newborn / 2-4 weeks 

1) History

a) Feeding well on breast milk/formula

b) Voiding > 4 times/day, stool since discharge

c) Nocturnal but resting comfortably without “colic”

d) Intact family unit without apparent postpartum depression or

problematic sibling rivalry

2) Development

a) Regards Face

b) Follows to midline

c) Responds to sound / bright light

d) Lifts head slightly on abdomen

e) Moves all extremities well

3) Anticipatory Guidance

a) Breatsfeeding, (Vit D), formulas,   No solids, normal urine stream/BMs

b) Thermometer use, 120⁰, car seats, smoke detectors

c) Crying, talking, music, sharing night feedings, parental respite/naps

d) Crying, talking, music, sharing night feedings, parental respite/nap

4) Physical Exam

a) Gestational age

b) Red reflex

c) palpate clavicles

d) heart murmur

e) hip dislocation

f)  femoral pulses

g)  jaundice

h) clubfoot, metatarsus adductus

i) abdominal masses 

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2 Months 

1) History

a) Feeding well on breast milk/formula – normal amount

b) Voiding straight/forceful, stooling without excess difficulty

c) 4-6 hours prone sleep/night, irritability improving, put in crib awake or rocked to sleep

d) No stresses or changes in household, sibling rivalry workable

2) Development

a) Chest up, holds head temporarily

b) Bats @ objects, briefly holds rattle

c) Differing cries and cooing

d) Social smile (6 wks)

e) Alerts  to sounds

f) Tracks objects, responds line of vision

3) Anticipatory Guidance

a) No solids, breast feeding (Vit D), formula prep

b) 120⁰, car seats, walkers, passive smoke, falls, smoke detectors, pets, toys, tub safety

c) Crying, sleep patterns, color vision

d) Cuddle time, siblings, respite, pp depression, daycare

e) More smiling, vocalizing, head control and grabbing

4) Physical Exam

a) Least intrusive first !

b) Anatomic abnormalities and congenital abnormalities

c) Occiput flattening

d) No hip dislocation, subluxation, limited abduction asymm buttocks

e) torticollis

f) murmur

g) metatarsus adductus 

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4 Months 

1) History

a) Feeding well on breast milk/formula/solids

b) Voiding, stooling without excess difficulty

c) Sleep through night,  napping well,  no temperament difficulties

d) Intact family unit

2) Development

a) Head erect, may support weight with arms or legs

b) Rolls P-S, tracks 180⁰

c) Grabs objects, puts hands together and plays with them, releases object

d) Laughs, differentiates individuals, differing cries

3) Anticipatory Guidance

a) Solid introduction, high demand periods, pacifier, dental eruption, iron, formula choices, no honey, vit D, colic gone

b) Antibiotic use, normal colds, unannounced daycare visits, respite, sibling needs, pp depression

c) Car seats, walkers, passive smoke, falls, choking, toys, no exercise/swim

d) Sleep patterns, manipulative behavior, stranger awareness

e) More laugh, vocal, sitting, responsiveness

4) Physical Exam

same as 2 month 

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6 Months 

1) History

a) Feeding well on breast milk/formula ,C-F-V

b) Voiding, stooling without excess difficulty

c) Sleep through night, no temperament difficulties,

 naps well

2) Development

a) Sit w/ support, raises body up on hands, rolls over

b) Plays with hands, holds rattle, Rakes small objects, transfers objects, reaches

c) Initiates, imitates, plays with and recognizes sounds/social contact

d) shows pleasure, excitement and displeasure

3) Anticipatory Guidance

a) Cup, no bottles in crib, iron/fluoride, dental care/eruption, no honey, make diaper change happy

b) Crawling: childproof, Ipecac, EMS, cords, outlets, passive smoke, no walker, electrical outlet / cords, sunscreen, hot liquids, appliances, unattended infant

c) Stranger anxiety, object permanence (Peek-a-boo), Sleep: separation anxiety, transition objects, comfort but don’t remove from crib

d) Shoes, play, stimulate language development

4) Physical Exam

a) Visual tracking

b) Conjugate gaze

c) Symmetrical light reflex

d) respond to sound

e) murmur, hip dislocation, abdominal mass 

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 9 Months 

1) History

a)Feeding well on breast milk/formula, solids

Using cup, finger foods

b) Voiding, stooling without excess difficulty

c) Sleep through night, no temperament difficulties

naps well, , separates, distracted from unsafe activities, tantrums/breathe holding, parental agreement re: discipline

2) Development

a) Sits well, crawls, creeps on hands, may cruise

b) Thumb / finger grasp, brings hand to mouth, feeds self, bangs object together

c) Interested in falling objects, searches for hidden objects

d) Knows name, understands words, imitates vocalizations, polysyllabic babbling

e) Stranger anxiety, participates interactive games

3) Anticipatory Guidance

a) Shoes, child care, play, reading, , modeling normal speech, “narrate your life”

b) Sleep rituals, Limits vs. Normal exploration

c) Ipecac, cords, outlets, gates, hot liquids, sharp objects, aspiration, passive smoke, toddler seat @ 20lb

d) Whole milk 1yr, dental care/eruption, bottle weaning 12-15 mo, increasing table/finger food, regular meal times, constipation, toilet training > 2years

 
 

4) Physical Exam

a) tooth erruption

b) Strabismus / red reflex

c) Hip range of motion (abduction)

d) Testicular descent

e) Parachute reflex, Bilateral Pincher grasp, muscle tone

12 Months 

1) History

unchanged from 9 months

2) Development

a) Pincher grasp, sits w/o support, crawls, pulls self up, walks with support, uses spoon

b) Plays with adult – like objects (broom, comb, telephone, cooking equipment)

c) Interactive games, Picture books, points to animals or names body parts, follows simple commands, points when asked “where’s mommy?”

3) Anticipatory Guidance

a) Variable appetite, bottle carries/tooth brushing, no nuts, popcorn, hard candy raw veggies, toilet training @ 2yrs, discourage co-sleeping, encourage cuddling

b) Childproof, burns, ipecac, foreign bodies, cords/outlets, gates, passive smoke, supervise play outside or near water, walk-climb-run, spoon

c)  Autonomy drive, limits/distraction, positive reinforcement, temper tantrums

d) Receptive>expressive, encourage simple sentences/labeling, Toys: bang, stack, place inside

4) Physical Exam

a) Don't restrain patient, most invasive first

b) Speak directly and playfully to child

c) Strabismus, red reflex

d) Pattern of tooth erruption

e) Testicular descent

f)  Hip range of motion, normal gait if ambulatory

g) Leg alignment, hip rotation for internal tibial torsion, external rotation contracture, femoral anteversion

15 Months 

1) History

no pica

2) Development

a) Better functional understanding of objects

b) 5–15 single words, jargon, gestures, follows simple commands, points to pictures / body parts, likes to have stories read to

c) Feeds with fingers / spoon, scribbles with crayons, stacks 2 blocks, usually walks

d) Gives and takes toys, plays games, communicates pleasure / displeasure, interested in novelty, tests limits

3) Anticipatory Guidance

a) Off Bottle and pacifier, 3 supervised meals/day aspiration, microwaves, decreased need for sleep/naps, child sized potty

b) Climbing stairs, throw/kick ball, car seats, passive smoke, sunscreen, plastic bags/balloons, burns, gates, outlets/cords, supervise outside/ near water

c) Discipline, limits, positive reinforcement, tantrums,  set examples: exercise, TV

d) Child care, Autonomy: eating and playing, immediate reinforcement, firm/consistent limits, demonstrate toys, encourage exploration/imitative play, encourage language development

4) Physical Exam

a) Less invasive procedures first, exam in parent's lap and allow patient to play

b) Gait and hip dysplasia

c) Hernias, strabismus, abdominal masses, teeth

18 Months 

1) History

a) appropriate / limited snacking

b) Interest in toilet training

2) Development

a) Runs, walks up stairs with hand held, walks backward, climbs onto adult chair

b) Eats with a spoon and fork, stacks blocks, scribbles with crayons

c) Finds hidden objects, pretends

d) Understands commands, points to body parts, two-word sentences

f) Likes other children

3) Anticipatory Guidance

a) Variable need for calories, regular family meals, dental care, feeding themselves, cup, don’t move with food in mouth, toilet training readiness (training after 24 – 30 mo)

b) Car seats, passive smoke, microwave, sunscreen Climbing stairs, car seats, passive smoke, sunscreen, plastic bags/balloons, burns, gates, outlets/cords, supervise outside/ near water

c) Discipline(time out), limits, consistency, self-comforting behavior, Sleep routine, bedtime stories

d) Child care, play, rarely share, Toys: no small parts, durable that can be put together, allow exploration drawers etc

4) Physical Exam

a) Resistant to exams

b) tooth decay

c) injuries

d) gait, leg and back alignment

e) Strabismus

f) inguinal hernia

2 Years 

1) History

a) spoon/fork

b) toilet training

2) Development

a) Runs, Jumps in place, walks up and down stairs (2 feet each stair), overhead throw

b) Uses spoon / fork, opens door, draws a vertical line

c) Finds hidden objects, pretends, Creates “means to an end” (pulls chair to cabinet)

d) 50 words, two-word sentences, two step commands, listens to short stories, pronouns

f) Imitates adults, parallel play Brushes teeth with help, dresses with help, feeds self

3) Anticipatory Guidance

a) Variable need for calories, need for healthy snacks, brushing teeth, , 1 quart milk/day, toilet readiness

b) Car seats, passive smoke, microwave, sunscreen Climbing stairs, car seats, passive smoke, sunscreen, smoke alarms, burns, gates, outlets/cords, supervise outside/ near water

c) TV, time out, choices, limits, consistency, self-comforting behavior,  Predictable bedtime routine with stories

d) TV, language, encourage independence, family rules

4) Physical Exam

a) don't ask questions that could be responded to with a "no"

b) Look for signs of child abuse 

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3 Years 

1) Development

a) oppositional/destructive, Pretend play

b) Jumps in place, pedals tricycle, alternating feet up steps

c) Copies circle, scribbles

d) Knows own sex, counts to 3

e) Speech 85% intelligible, short sentences

2) Anticipatory Guidance

a) Need for healthy snacks, brushing teeth, fast food, biannual dental visit, toileting, regular sleep

b) Street saftey, Bike helmet, car seats, passive smoke, sunscreen

c) TV, time out, consistency, toilet training, fears, inappropriate touch, sharing, exercise

d) Child care/preschool, time alone, choices, show affection

e) Language skills>cognitive understanding, direct conversation, Toys: blocks, puzzles, sand, water, pretend play

4 Years 

1) Development

a) Pedals tricycle, hops and balances on one foot, alternating gait on stairs

b) Copies a circle and a cross, draws a person with 3–6 parts, scissors

c) Complex pretend play (imaginary friends), Difficult to differentiate reality from imaginary,

d)   Fully intelligible, full sentences, asks complex questions, extensive vocabulary

e)  Waits, takes turns, shares, plays board / card games

f) Puts on clothes except shoes, able to button / zip, toilet trained, brushes teeth, utensils

2) Anticipatory Guidance

a) Need for healthy snacks, brushing teeth, fast food, biannual dental visit, compare growth chart with appetite, pleasant mealtimes, regression, enuresis, co-sleeping

b) Car seats, passive smoke, sunscreen booster seat, passive smoke, sunscreen, smoke alarms, burns, gates, outlets/cords, supervise outside/ near water, streets, strangers, animals, dial 911

c) TV, time out, choices, consistency, toilet training, fears, inappropriate touch, sharing, peer play, sexuality, exercise

d) Independence vs. social rules, praise 

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