Recommendations for Preventive Pediatric Health Care

Bright Futures/American Academy of Pediatrics

INFANCY
AGE1

EARLY CHILDHOOD

Newborn

3-5 d

By 1 mo

2 mo

4 mo

Length/Height and Weight

Head Circumference

Weight for Length

HISTORY
Initial/Interval

Prenatal

The recommendations in this statement do not indicate an exclusive course of treatment or

standard of medical care. Variations, taking into account individual circumstances, may be
appropriate.

These guidelines represent a consensus by the American Academy of Pediatrics (AAP) and
Bright Futures. The AAP continues to emphasize the great importance of continuity of care in
comprehensive health supervision and the need to avoid fragmentation of care.
Refer to the specific guidance by age as listed in Bright Futures guidelines (Hagan JF, Shaw
JS, Duncan PM, eds. Bright Futures Guidelines for Health Supervision of Infants, Children and
rd
Adolescents. 3 ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008).

Each child and family is unique; therefore, these Recommendations for Preventive Pediatric Health Care are
designed for the care of children who are receiving competent parenting, have no manifestations of any
important health problems, and are growing and developing in satisfactory fashion. Additional visits may
become necessary if circumstances suggest variations from normal.
Developmental, psychosocial, and chronic disease issues for children and adolescents may require
frequent counseling and treatment visits separate from preventive care visits.

6 mo 9 mo

Copyright 2014 by the American Academy of Pediatrics.

No part of this statement may be reproduced in any form or by any means without prior written
permission from the American Academy of Pediatrics except for one copy for personal use.

MIDDLE CHILDHOOD

ADOLESCENCE

12 mo

15 mo

18 mo

24 mo

30 mo

3y

4y

5y

6y

7y

8y

9y

10 y

11 y

12 y

13 y

14 y

15 y

16 y

17 y

18 y

19 y

20 y

21 y

MEASUREMENTS

Body Mass Index

Blood Pressure6
SENSORY SCREENING
Vision
Hearing
DEVELOPMENTAL/BEHAVIORAL ASSESSMENT

Developmental Screening9

Autism Screening10
Developmental Surveillance

Psychosocial/Behavioral Assessment

Alcohol and Drug Use Assessment11

Depression Screening12

13

PHYSICAL EXAMINATION

or 20

14

PROCEDURES

Newborn Blood Screening15

Critical Congenital Heart Defect Screening16

Immunization17

Hematocrit or Hemoglobin18

Lead Screening19

21

Tuberculosis Testing

or 20

Dyslipidemia Screening22

STI/HIV Screening23

ORAL HEALTH25
ANTICIPATORY GUIDANCE

or

1.

If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule
should be brought up to date at the earliest possible time.
2. A prenatal visit is recommended for parents who are at high risk, for first-time parents, and for those who request a conference. The prenatal visit
should include anticipatory guidance, pertinent medical history, and a discussion of benefits of breastfeeding and planned method of feeding, per the
2009 AAP statement The Prenatal Visit (http://pediatrics.aappublications.org/content/124/4/1227.full).
3. Every infant should have a newborn evaluation after birth, and breastfeeding should be encouraged (and instruction and support should be offered).
4. Every infant should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the hospital to include evaluation for
feeding and jaundice. Breastfeeding infants should receive formal breastfeeding evaluation, and their mothers should receive encouragement and
instruction, as recommended in the 2012 AAP statement Breastfeeding and the Use of Human Milk
(http://pediatrics.aappublications.org/content/129/3/e827.full). Newborn infants discharged less than 48 hours after delivery must be examined within
48 hours of discharge, per the 2010 AAP statement Hospital Stay for Healthy Term Newborns
(http://pediatrics.aappublications.org/content/125/2/405.full).
5. Screen, per the 2007 AAP statement Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and
Adolescent Overweight and Obesity: Summary Report (http://pediatrics.aappublications.org/content/120/Supplement_4/S164.full).
6. Blood pressure measurement in infants and children with specific risk conditions should be performed at visits before age 3 years.
7. If the patient is uncooperative, rescreen within 6 months, per the 2007 AAP statement Eye Examination in Infants, Children, and Young Adults by
Pediatricians (http://pediatrics.aappublications.org/content/111/4/902.abstract).
8. All newborns should be screened, per the AAP statement Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and
Intervention Programs (http://pediatrics.aappublications.org/content/120/4/898.full).
9. See 2006 AAP statement Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental
Surveillance and Screening (http://pediatrics.aappublications.org/content/118/1/405.full).
10. Screening should occur per the 2007 AAP statement Identification and Evaluation of Children with Autism Spectrum Disorders
(http://pediatrics.aappublications.org/content/120/5/1183.full).
KEY

= to be performed

Cervical Dysplasia Screening24

= risk assessment to be performed with appropriate action to follow, if positive

or

or

or

11. A recommended screening tool is available at http://www.ceasar-boston.org/CRAFFT/index.php.

12. Recommended screening using the Patient Health Questionnaire (PHQ)-2 or other tools available in the GLAD-PC toolkit and at
http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf.
13. At each visit, age-appropriate physical examination is essential, with infant totally unclothed and older children undressed and suitably draped. See
2011 AAP statement Use of Chaperones During the Physical Examination of the Pediatric Patient
(http://pediatrics.aappublications.org/content/127/5/991.full).
14. These may be modified, depending on entry point into schedule and individual need.
15. The Recommended Uniform Newborn Screening Panel
(http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders/recommendedpanel/uniformscreeningpanel.pdf), as determined by The
Secretarys Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening laws/regulations (http://genes-rus.uthscsa.edu/sites/genes-r-us/files/nbsdisorders.pdf), establish the criteria for and coverage of newborn screening procedures and programs.
Follow-up must be provided, as appropriate, by the pediatrician.
16. Screening for critical congenital heart disease using pulse oximetry should be performed in newborns, after 24 hours of age, before discharge from
the hospital, per the 2011 AAP statement Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical
Congenital Heart Disease (http://pediatrics.aappublications.org/content/129/1/190.full).
17. Schedules, per the AAP Committee on Infectious Diseases, are available at: http://aapredbook.aappublications.org/site/resources/izschedules.xhtml.
Every visit should be an opportunity to update and complete a childs immunizations.
18. See 2010 AAP statement Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and Young Children (0-3 Years of Age)
(http://pediatrics.aappublications.org/content/126/5/1040.full).
19. For children at risk of lead exposure, see the 2012 CDC Advisory Committee on Childhood Lead Poisoning Prevention statement Low Level Lead
Exposure Harms Children: A Renewed Call for Primary Prevention (http://www.cdc.gov/nceh/lead/ACCLPP/Final_Document_030712.pdf).

= range during which a service may be provided

20. Perform risk assessments or screenings as appropriate, based on universal screening requirements for patients with Medicaid or in high
prevalence areas.
21. Tuberculosis testing per recommendations of the Committee on Infectious Diseases, published in the current edition of AAP Red Book:
Report of the Committee on Infectious Diseases. Testing should be performed on recognition of high-risk factors.
22. See AAP-endorsed 2011 guidelines from the National Heart Blood and Lung Institute, Integrated Guidelines for Cardiovascular Health and
Risk Reduction in Children and Adolescents (http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm).
23. Adolescents should be screened for sexually transmitted infections (STIs) per recommendations in the current edition of the AAP Red Book:
Report of the Committee on Infectious Diseases. Additionally, all adolescents should be screened for HIV according to the AAP statement
(http://pediatrics.aappublications.org/content/128/5/1023.full) once between the ages of 16 and 18, making every effort to preserve
confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug
use, or are being tested for other STIs, should be tested for HIV and reassessed annually.
24. See USPSTF recommendations (http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm). Indications for pelvic examinations prior
to age 21 are noted in the 2010 AAP statement Gynecologic Examination for Adolescents in the Pediatric Office Setting
(http://pediatrics.aappublications.org/content/126/3/583.full).
25. Refer to a dental home, if available. If not available, perform a risk assessment
(http://www2.aap.org/oralhealth/docs/RiskAssessmentTool.pdf). If primary water source is deficient in fluoride, consider oral fluoride
supplementation. For those at high risk, consider application of fluoride varnish for caries prevention. See 2008 AAP statement Preventive
Oral Health Intervention for Pediatricians (http://pediatrics.aappublications.org/content/122/6/1387.full) and 2009 AAP statement Oral Health
Risk Assessment Timing and Establishment of the Dental Home (http://pediatrics.aappublications.org/content/111/5/1113.full).

Summary of changes made to the

2014 Bright Futures/AAP Recommendations for Preventive Pediatric Health Care
(Periodicity Schedule)
Changes to Developmental/Behavioral Assessment
Alcohol and Drug Use Assessment- Information regarding a recommended
screening tool (CRAFFT) was added.

For several recommendations, the AAP Policy has been updated since 2007 but
there have been no changes in the timing of recommendations on the Periodicity
Schedule. These include:

Depression- Screening for depression at ages 11 through 21 has been added,

along with suggested screening tools.

Footnote 2- The Prenatal Visit (2009):

http://pediatrics.aappublications.org/content/124/4/1227.full

Changes to Procedures

Footnote 4- Breastfeeding and the Use of Human Milk (2012):

http://pediatrics.aappublications.org/content/129/3/e827.full and Hospital Stay
for Healthy Term Newborns (2010):
http://pediatrics.aappublications.org/content/125/2/405.full

Dyslipidemia screening- An additional screening between 9 and 11 years of

age has been added. The reference has been updated to the AAP-endorsed
National Heart Blood and Lung Institute policy
(http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm).
Hematocrit or hemoglobin- A risk assessment has been added at 15 and 30
months. The reference has been updated to the current AAP policy
(http://pediatrics.aappublications.org/content/126/5/1040.full).
STI/HIV screening- A screen for HIV has been added between 16 and 18
years. Information on screening adolescents for HIV has been added in the
footnotes. STI screening now references recommendations made in the AAP
Red Book. This category was previously titled STI Screening.
Cervical dysplasia- Adolescents should no longer be routinely screened for
cervical dysplasia until age 21. Indications for pelvic exams prior to age 21 are
noted in the 2010 AAP statement Gynecologic Examination for Adolescents in
the Pediatric Office Setting
(http://pediatrics.aappublications.org/content/126/3/583.full).
Critical Congenital Heart Disease- Screening for critical congenital heart
disease using pulse oximetry should be performed in newborns, after 24 hours
of age, before discharge from the hospital, per the 2011 AAP statement,
Endorsement of Health and Human Services Recommendation for Pulse
Oximetry Screening for Critical Congenital Heart Disease
(http://pediatrics.aappublications.org/content/129/1/190.full).

Footnote 8- Year 2007 Position Statement: Principles and Guidelines for Early
Hearing Detection and Intervention Programs (2007):
http://pediatrics.aappublications.org/content/120/4/898.full
Footnote 10- Identification and Evaluation of Children with Autism Spectrum
Disorders (2007): http://pediatrics.aappublications.org/content/120/5/1183.full
Footnote 17- Immunization Schedules (2014):
http://aapredbook.aappublications.org/site/resources/IZSchedule0-6yrs.pdf,
http://aapredbook.aappublications.org/site/resources/IZSchedule7-18yrs.pdf,
and
http://aapredbook.aappublications.org/site/resources/IZScheduleCatchup.pdf
Footnote 19- CDC Advisory Committee on Childhood Lead Poisoning
Prevention statement Low Level Lead Exposure Harms Children: A Renewed
Call for Primary Prevention (2012):
http://www.cdc.gov/nceh/lead/ACCLPP/Final_Document_030712.pdf
Footnote 22- AAP-endorsed guideline Integrated Guidelines for Cardiovascular
Health and Risk Reduction in Children and Adolescents (2011):
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm
Footnote 25- Preventive Oral Health Intervention for Pediatricians (2008):
http://pediatrics.aappublications.org/content/122/6/1387.full and Oral Health
Risk Assessment Timing and Establishment of the Dental Home (2009):
http://pediatrics.aappublications.org/content/111/5/1113.full. Additional
information from the policies regarding fluoride supplementation and fluoride
varnish has been added to the footnote.

New references were added for several footnotes, also with no change to
recommendations in the Periodicity Schedule:
Footnote 5- Expert Committee Recommendations Regarding the Prevention,
Assessment, and Treatment of Child and Adolescent Overweight and Obesity:
Summary Report (2007):
http://pediatrics.aappublications.org/content/120/Supplement_4/S164.full
Footnote 13- Use of Chaperones During the Physical Examination of the
Pediatric Patient (2011):
http://pediatrics.aappublications.org/content/127/5/991.full
Footnote 15- The Recommended Uniform Newborn Screening Panel
(http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders/reco
mmendedpanel/uniformscreeningpanel.pdf), as determined by The Secretarys
Advisory Committee on Heritable Disorders in Newborns and Children, and
state newborn screening laws/regulations (http://genes-rus.uthscsa.edu/sites/genes-r-us/files/nbsdisorders.pdf), establish the criteria for
and coverage of newborn screening procedures and programs. Follow-up must
be provided, as appropriate, by the pediatrician.
For consistency, the title of Tuberculin Test has been changed to Tuberculosis
Testing. The title of Newborn Metabolic/Hemoglobin Screening has been
changed to Newborn Blood Screening.