pediatric healthcare visits

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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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Preventive care benefits for children

Coverage for children’s preventive health services.

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• Alcohol, tobacco, and drug use assessments  for adolescents
• Autism screening  for children at 18 and 24 months
• Behavioral assessments for children: Age  0 to 11 months ,  1 to 4 years ,  5 to 10 years ,  11 to 14 years ,  15 to 17 years

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• Blood pressure screening for children: Age  0 to 11 months ,  1 to 4 years  ,  5 to 10 years ,  11 to 14 years ,  15 to 17 years
• Blood screening  for newborns
• Depression screening  for adolescents beginning routinely at age 12
• Developmental screening  for children under age 3
• Fluoride supplements  for children without fluoride in their water source
• Fluoride varnish  for all infants and children as soon as teeth are present
• Gonorrhea preventive medication  for the eyes of all newborns
• Hematocrit or hemoglobin screening  for all children
• Hemoglobinopathies or sickle cell screening  for newborns
• Hepatitis B screening  for adolescents at higher risk
• HIV screening  for adolescents at higher risk
• Hypothyroidism screening  for newborns
• PrEP (pre-exposure prophylaxis) HIV prevention medication  for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
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• Obesity screening and counseling
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• Sexually transmitted infection (STI) prevention counseling and screening  for adolescents at higher risk
• Tuberculin testing for children at higher risk of tuberculosis: Age  0 to 11 months ,  1 to 4 years ,  5 to 10 years ,  11 to 14 years ,  15 to 17 years
• Vision screening  for all children
• Well-baby and well-child visits

More information about preventive services for children

• Preventive services for children age 0 to 11 months
• Preventive services for children age 1 to 4 years
• Preventive services for children age 5 to 10 years
• Preventive services for children age 11 to 14 years
• Preventive services for children age 15 to 17 years

More on prevention

• Learn more about preventive care from the CDC .
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Home / Parenting, Kids & Teens / Quick guide to your infant’s first pediatrician visits

Quick guide to your infant’s first pediatrician visits

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Frequent checkups with a health care provider are an important part of your baby’s first few years. These checkups — often called well-child visits — are a way for you and your child’s health care provider to keep tabs on your child’s health and development, as well as spot any potential problems. Well-child visits also give you a chance to discuss any questions or concerns you might have and get advice from a trusted source on how to provide the best possible care for your child.

The benefit of seeing your child’s provider regularly is that each visit adds critical information to your child’s health history. Over time, you and the provider will get a good idea of your child’s overall health and development.

In general, the provider will be more attentive to your child’s pattern of growth over time, rather than to specific one-time measurements. Typically what you’ll see is a smooth curve that arcs upward as the years go by. Regularly reviewing your child’s growth chart can also alert you and the provider to unexpected delays in growth or changes in weight that may suggest the need for additional monitoring.

Each health care provider does things a bit differently, but here’s what will generally be on the agenda during your first well-child exams.

Body measurements

Checkups usually begin with measurements. During first-year visits, a nurse or your baby’s health care provider will measure and record your baby’s length, head circumference and weight.

Your child’s measurements will be plotted on his or her growth chart. This will help you and the provider see how your child’s size compares with that of other children the same age. Try not to fixate on the percentages too much, though. All kids grow and develop at different rates. In addition, babies who take breast milk gain weight at a different rate than do babies who are formula-fed.

Keep in mind that a child who’s in the 95th percentile for height and weight isn’t necessarily healthier than a child who’s in the fifth percentile. What’s most important is steady growth from one visit to the next. If you have questions or concerns about your child’s growth rate, discuss them with your child’s provider.

Physical exam

Your child’s health care provider will give your child a thorough physical exam and check his or her reflexes and muscle tone. Be sure to mention any concerns you have or specific areas you want the doctor to check out.

Here are the basics of what providers commonly check for during an exam:

• Head — In the beginning, your child’s health care provider will likely check the soft spots (fontanels) on your baby’s head. These gaps between the skull bones give your baby’s brain plenty of room to grow in the coming months. They’re safe to touch and typically disappear within two years, when the skull bones fuse together. The health care provider may also check baby’s head for flat spots. A baby’s skull is soft and made up of several movable plates. If his or her head is left in the same position for long periods of time, the skull plates might move in a way that creates a flat spot.
• Ears — Using an instrument called an otoscope, the health care provider can see in your child’s ears to check for fluid or infection in the ears. The provider may observe your child’s response to various sounds, including your voice. Be sure to tell the provider if you have any concerns about your son’s or daughter’s ability to hear or if there’s a history of childhood deafness in your family. Unless there’s cause for concern, a formal hearing evaluation isn’t usually needed at a well-child exam.
• Eyes — Your child’s health care provider may use a flashlight to catch your child’s attention and then track his or her eye movements. The provider may also check for blocked tear ducts and eye discharge and look inside your child’s eyes with a lighted instrument called an ophthalmoscope. Be sure to tell the provider if you’ve noticed that your child is having any unusual eye movements, especially if they continue beyond the first few months of life.
• Mouth — A look inside your baby’s mouth may reveal signs of oral thrush, a common, and easily treated, yeast infection. The health care provider might also check your baby’s mouth for signs of tongue-tie (ankyloglossia), a condition that affects the tongue’s range of motion and can interfere with a baby’s oral development as well as his or her ability to breast-feed.
• Skin — Various skin conditions may be identified during the exam, including birthmarks, rashes, and jaundice, a yellowish discoloration of the skin and eyes. Mild jaundice that develops soon after birth often disappears on its own within a week or two. Cases that are more severe may need treatment.
• Heart and lungs — Using a stethoscope, your child’s health care provider can listen to your child’s heart and lungs to check for abnormal heart sounds or rhythms or breathing difficulties.
• Abdomen, hips and legs — By gently pressing a child’s abdomen, a health care provider can detect tenderness, enlarged organs, or an umbilical hernia, which occurs when a bit of intestine or fatty tissue near the navel breaks through the muscular wall of the abdomen. Most umbilical hernias heal by the toddler years without intervention. The provider may also move your child’s legs to check for dislocation or other problems with the hip joints, such as dysplasia of the hip joint.
• Genitalia — Your child’s care provider will likely inspect your son’s or daughter’s genitalia for tenderness, lumps or other signs of infection. The provider may also check for an inguinal hernia, which results from a weakness in the abdominal wall.

For girls, the doctor may ask about vaginal discharge. For boys, the provider will make sure a circumcised penis is healing well during early visits. The provider may also check to see that both testes have descended into the scrotum and that there’s no fluid-filled sac around the testes, a condition called hydrocele.

Your child’s provider will likely ask you about your child’s eating habits. If you’re breastfeeding, the provider may want to know how often you’re feeding your baby during the day and night and whether you’re having any problems. If you’re pumping, the provider may offer suggestions for managing pumping frequency and storing breast milk. If you’re formula-feeding, the provider will likely want to know how often you feed and how many ounces of formula your baby takes at each feeding. In addition, the provider may discuss with you your baby’s need for vitamin D and iron supplements.

Bowel and bladder function

In the first few visits, your child’s health care provider will likely also ask how many wet diapers and bowel movements your baby produces a day. This information offers clues as to whether your baby is getting enough to eat.

Sleeping status

Your child’s health care provider may ask you questions about your child’s sleep habits, such as your regular bedtime routine and how many hours your child is sleeping during the day and night. Don’t hesitate to discuss any concerns you may have about your child’s sleep, such as getting your baby to sleep through the night. Your child’s provider may also help you figure out how to find rest for yourself, especially in the early baby months.

Development

Your child’s development is important, too. The health care provider will monitor your child’s development in the following five main areas.

• Gross motor skills — These skills, such as sitting, walking and climbing, involve the movement of large muscles. Your child’s health care provider may ask you how well your baby can control his or her head. Is your baby attempting to roll over? Is your baby trying to sit on his or her own? Is your child starting to walk or throw a ball? Can your toddler walk up and down steps?
• Fine motor skills — These skills involve the use of small muscles in the hand. Does your baby reach for objects and bring them to his or her mouth? Is your baby using individual fingers to pick up small objects?
• Personal and social skills — These skills enable a child to interact and respond to his or her surroundings. Your child’s health care provider may ask if your baby is smiling. Does your baby relate to you with joy and enthusiasm? Does he or she play peekaboo?
• Language skills — These skills include hearing, understanding and use of language. The health care provider may ask if your baby turns his or her head toward voices or other sounds. Does your baby laugh? Is he or she responding to his or her name?
• Cognitive skills — These skills allow a child to think, reason, solve problems and understand his or her surroundings. Your child’s provider might ask if your baby can bang together two cubes or search for a toy after seeing you hide it.

Vaccinations

Your baby will need a number of scheduled vaccinations during his or her first years. The health care provider or a nurse will explain to you how to hold your baby as he or she is given each shot. Be prepared for possible tears. Keep in mind, however, that the pain caused by a shot is typically short-lived but the benefits are long lasting.

Your child’s provider may talk to you about safety issues, such as the importance of placing your baby to sleep on his or her back and using a rear-facing infant car seat as long as possible.

Questions and concerns

During your son’s or daughter’s checkups, it’s likely that you’ll have questions, too. Ask away! Nothing is too trivial when it comes to caring for your baby. Write down questions as they arise between appointments so that you’ll be less likely to forget them when you’re at your child’s checkup.

Also, don’t forget your own health. If you’re feeling depressed, stressed-out, run-down or overwhelmed, describe what’s happening. Your child’s provider is there to help you, too.

Before you leave the health care provider’s office, make sure you know when to schedule your child’s next appointment. If possible, set the next appointment before you leave the provider’s office. If you don’t already know, ask how to reach your child’s provider in between appointments. You might also ask if the provider has a 24-hour nurse information service. Knowing that help is available when you need it can offer peace of mind.

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Preventive Health Care Visits in Infants

Healthy infants should be seen by their doctor often during the first year of life. Preventive health care visits (also called well-child visits) typically take place within a few days after birth or by 2 weeks of age and at 1, 2, 4, 6, and 9 months of age. During these visits, the doctor uses age-specific guidelines to monitor the infant's growth and development and asks the parents questions about various developmental milestones (see table Developmental Milestones From Birth to Age 12 Months ). Tests are sometimes done, and during many visits, the doctor vaccinates the infant against various illnesses (see Childhood Vaccination Schedule ).

Health care visits also allow the doctor to educate the parents about eating, sleeping, behavior, child safety, nutrition, exercise, and good health habits. In addition, the doctor advises the parents what developmental changes to expect in their infant by the next visit.

Examination

The infant's length and height , weight , and head circumference are measured at every visit. The doctor examines the infant for various abnormalities, including signs of hereditary disorders or birth defects .

The eyes are examined, and vision is tested. Infants who were born very prematurely (before the completion of 32 weeks of development in the uterus) usually need more frequent eye examinations by an eye specialist to look for retinopathy of prematurity , which is an eye disease that occurs when infants are born before the blood vessels in their eyes are fully developed and may result in blindness, and for the development of refractive errors , which result in blurring of vision. These disorders are more common among infants who were born very prematurely.

The doctor checks the infant’s hips for signs that the hip joints are loose or dislocated ( developmental dysplasia of the hip ). The doctor checks the infant's teeth , if they are present, for cavities and the mouth for thrush , which is a common yeast infection among infants.

The doctor also examines the heart, lungs, abdomen, arms and legs, and genitals.

Screening tests are done to assess whether infants are at risk of certain disorders.

Blood tests are done to detect anemia , sickle cell disease , and exposure to lead .

Hearing tests are done shortly after birth to determine whether an infant has a hearing disorder or hearing loss (see Newborn Screening Tests ) and are repeated later if new concerns about the infant's hearing develop (see also Hearing Impairment in Children ).

Infants are screened for tuberculosis (TB) risk factors with a questionnaire at all well-child visits, usually beginning in infancy. Risk factors include exposure to TB, being born in or having traveled to areas of the world where TB is common (countries other than the United States, Canada, Australia, and New Zealand and Western and North European countries), having a family member with TB, and having parents or close contacts who are recent immigrants from an area where TB is common or who have recently been in jail. Those with risk factors usually have tuberculosis screening tests done.

At these visits, the doctor gives parents age-appropriate safety guidelines.

The following safety guidelines apply to infants from birth to age 12 months:

Use a rear-facing car seat and place it in the back seat of the vehicle.

Set the hot water heater to 120° F or less.

Prevent falls from changing tables and around stairs.

Place infants on their back to sleep on a firm, flat mattress for every sleep, do not share a bed, and do not place pillows, bumper pads, nonfitted sheets, stuffed animals or other toys, quilts, comforters, or weighted or loose blankets in the crib. (See also sidebar Safe to Sleep: Reducing the Risk of SIDS .)

Do not give infants foods and objects that can cause choking or be inhaled into the lungs.

Do not use baby walkers.

Place safety latches on cabinets and cover electrical outlets.

Remain alert when watching infants in the bathtub or near a pool or any body of water and when they are learning to walk.

Image courtesy of the Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control ( Transportation Safety Resources ). This guidance from the CDC is for the United States, and regulations may differ in other countries.

Nutrition and exercise

For infants, recommendations for nutrition are based on age. The doctor can help parents weigh the benefits of breastfeeding versus formula-feeding and give guidance regarding solid foods .

Parents should provide infants with a safe environment they can roam in and explore. Outdoor play should be encouraged from infancy.

Screen time (for example, television, video games, cell phones and other handheld devices, and noneducational computer time) may result in inactivity and obesity. Limits on the time a child spends using devices with screens should start at birth and be maintained throughout adolescence.

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Well-Care Visits

What is a well-care visit?

It's important to take your child to the healthcare provider when your child is ill. Or when you child needs an exam to take part in a sport. But routine well-care visits are also recommended.

Well-care, well-baby, or well-child visits are routine visits to your child's healthcare provider for the following:

Physical exam

Immunization updates

Tracking growth and development

Finding any problems before they become serious

Providing information on health and safety issues

Providing information on nutrition and physical fitness

Providing information on how to manage emergencies and illnesses

Your child's healthcare provider can also provide guidance on other issues, such as the following:

Behavioral problems

Learning problems

Emotional problems

Family problems

Socialization problems

Puberty and concerns about teenage years

When should well-care visits be scheduled?

Your child's healthcare provider will give you a schedule of ages when a well-care visit is suggested. The American Academy of Pediatrics recommends well-care visits at the following ages:

Before a newborn is discharged from the hospital, or at 48 to 72 hours of age

3 to 5 days

2 to 4 weeks

Annually, between ages 6 and 21

• Pediatric Brain Tumors
• Pediatric Heart Surgery
• Aerodigestive and Airway Reconstruction Center
• Pediatric Neurosurgery
• Pediatric Oncology (Cancer)
• Cleft and Craniofacial Center

Related Topics

When to Call Your Child's Healthcare Provider

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Guidance on Providing Pediatric Well-Care During COVID-19

Last updated.

The American Academy of Pediatrics (AAP) strongly supports the continued provision of health care for children during the COVID-19 pandemic. Specifically, well-child care should be provided consistent with the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (4th Edition) and the corresponding Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule).

Since the onset of the pandemic, a significant drop in well-child visits has resulted in delays in vaccinations, delays in appropriate screenings and referrals and delays in anticipatory guidance to ensure optimal health. Pediatricians rapidly adapted to provide appropriate elements of well examinations through telehealth when clinically warranted and also implemented measures to provide in-person care as safely as possible. Despite these efforts and a rebound increase in outpatient visits to near pre-pandemic levels, a significant cohort of children remain behind on regular well-child care and routine immunizations. Concern exists that delays in vaccinations may result in secondary outbreaks with vaccine-preventable illnesses.

Primary care pediatricians are prepared to ensure all newborns, infants, children and adolescents are up to date on their comprehensive well-child care, inclusive of appropriate screenings, complete physical examination, laboratory examinations, fluoride varnish and vaccines. Pediatric practices can also serve as COVID-19 vaccination sites.

See below for additional guidance.

• Consistent with previous guidance, all well-child care should occur in person whenever possible and within the child’s medical home, where continuity of care may be established and maintained. For practices that have successfully implemented telehealth to provide appropriate elements of the well examination virtually, these telehealth visits should continue to be supported, followed by a timely in-person visit .
• Outpatient newborn care should not be compromised because of COVID-19, and newborn visits should take place in person. See AAP interim guidance FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19 and Post-Hospital Discharge Guidance for Breastfeeding Parents or Newborn Infants With Suspected or Confirmed SARS-CoV-2 Infection . If the mother is positive for SARS-CoV-2 and still in her recommended isolation period and the infant is negative, an alternate caregiver (if available) who is SARS-CoV-2 negative and masked should accompany the infant to their visit to minimize risk of transmission. If no alternate caregiver is available, the mother should accompany the infant to the visit if she is not too ill to do so. Appropriate PPE should be used in the ambulatory care setting, per AAP interim guidance . If the infant is positive for SARS-CoV-2, close outpatient follow-up beyond the initial in-person visit via telephone, telemedicine, and/or additional in-office visits through 14 days after birth is recommended. Additionally, pediatricians should continue to follow federal and state guidelines on newborn screening and ensure timely follow-up for out-of-range results per AAP interim guidance on newborn screening .
• Pediatricians should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule appointments inclusive of newborns, infants, children and adolescents. Pediatricians should work with families to bring children up to date as quickly as possible, particularly confirmed decreases in childhood and adolescent immunization rates and the potential for other vaccine preventable disease outbreaks. State-based immunization information systems and electronic health records may be able to support any catch-up immunizations.
• Pediatricians should inquire about any SARS-CoV-2 infections and vaccination status since the last evaluation and should document it within the patient’s medical record. Patients with a history of SARS-CoV-2 infection should be monitored for ongoing symptoms per the AAP interim guidance on post-COVID conditions . Pediatricians should encourage eligible infants, children, and adolescents to receive the COVID-19 vaccine .
• Pediatricians should integrate surveillance and screening for social, emotional and behavioral concerns into every office visit and provide age-appropriate anticipatory guidance as part of well-child care. Special consideration should be given to populations with higher baseline risk, such as populations of color, communities living in poverty, historically under-resourced communities, children who are refugees and seeking asylum, children and youth with special health care needs, and children and youth involved with the child welfare or juvenile justice systems. Pediatricians should continue surveillance for children and youth at risk for abuse and neglect. In addition to screening for signs of maltreatment, an assessment of family well-being and the potential need for additional resources and supports that promote family strengths and decrease the risk of abuse and neglect should occur.
• Pediatricians should ensure timely referral to pediatric medical subspecialists and pediatric surgical specialists, inclusive of regularly recommended dental and eye examinations.
• Regular cleaning and disinfecting.
• Promotion of physical distancing of both staff and patients in the office.
• Use of source control (face masks) by all patients, families, clinicians, and staff if SARS-CoV-2 Community Transmission level is high.
• Providers and staff who are up to date on COVID-19 vaccination.
• Use of personal protective equipment by providers and staff.
• Upgraded ventilation system or installation of HEPA filters.
• Scheduling well visits and sick visits at different times of the day or using telehealth.
• Separating patients spatially, such as by placing patients there for sick visits in different areas of the primary care clinic, outdoors, or another location from patients attending well visits.

Additional Information 

• Providing Acute Care in the Ambulatory Setting During the COVID-19 Pandemic
• Face Masks and Other Prevention Strategies
• Infection Control Guidance for Health Care Professionals About COVID-19 (CDC)

Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing.

American Academy of Pediatrics

KATHERINE TURNER, MD

Am Fam Physician. 2018;98(6):347-353

Related letter: Well-Child Visits Provide Physicians Opportunity to Deliver Interconception Care to Mothers

Author disclosure: No relevant financial affiliations.

The well-child visit allows for comprehensive assessment of a child and the opportunity for further evaluation if abnormalities are detected. A complete history during the well-child visit includes information about birth history; prior screenings; diet; sleep; dental care; and medical, surgical, family, and social histories. A head-to-toe examination should be performed, including a review of growth. Immunizations should be reviewed and updated as appropriate. Screening for postpartum depression in mothers of infants up to six months of age is recommended. Based on expert opinion, the American Academy of Pediatrics recommends developmental surveillance at each visit, with formal developmental screening at nine, 18, and 30 months and autism-specific screening at 18 and 24 months; the U.S. Preventive Services Task Force found insufficient evidence to make a recommendation. Well-child visits provide the opportunity to answer parents' or caregivers' questions and to provide age-appropriate guidance. Car seats should remain rear facing until two years of age or until the height or weight limit for the seat is reached. Fluoride use, limiting or avoiding juice, and weaning to a cup by 12 months of age may improve dental health. A one-time vision screening between three and five years of age is recommended by the U.S. Preventive Services Task Force to detect amblyopia. The American Academy of Pediatrics guideline based on expert opinion recommends that screen time be avoided, with the exception of video chatting, in children younger than 18 months and limited to one hour per day for children two to five years of age. Cessation of breastfeeding before six months and transition to solid foods before six months are associated with childhood obesity. Juice and sugar-sweetened beverages should be avoided before one year of age and provided only in limited quantities for children older than one year.

Well-child visits for infants and young children (up to five years) provide opportunities for physicians to screen for medical problems (including psychosocial concerns), to provide anticipatory guidance, and to promote good health. The visits also allow the family physician to establish a relationship with the parents or caregivers. This article reviews the U.S. Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) guidelines for screenings and recommendations for infants and young children. Family physicians should prioritize interventions with the strongest evidence for patient-oriented outcomes, such as immunizations, postpartum depression screening, and vision screening.

Clinical Examination

The history should include a brief review of birth history; prematurity can be associated with complex medical conditions. 1 Evaluate breastfed infants for any feeding problems, 2 and assess formula-fed infants for type and quantity of iron-fortified formula being given. 3 For children eating solid foods, feeding history should include everything the child eats and drinks. Sleep, urination, defecation, nutrition, dental care, and child safety should be reviewed. Medical, surgical, family, and social histories should be reviewed and updated. For newborns, review the results of all newborn screening tests ( Table 1 4 – 7 ) and schedule follow-up visits as necessary. 2

PHYSICAL EXAMINATION

A comprehensive head-to-toe examination should be completed at each well-child visit. Interval growth should be reviewed by using appropriate age, sex, and gestational age growth charts for height, weight, head circumference, and body mass index if 24 months or older. The Centers for Disease Control and Prevention (CDC)-recommended growth charts can be found at https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts . Percentiles and observations of changes along the chart's curve should be assessed at every visit. Include assessment of parent/caregiver-child interactions and potential signs of abuse such as bruises on uncommonly injured areas, burns, human bite marks, bruises on nonmobile infants, or multiple injuries at different healing stages. 8

The USPSTF and AAP screening recommendations are outlined in Table 2 . 3 , 9 – 27 A summary of AAP recommendations can be found at https://www.aap.org/en-us/Documents/periodicity_schedule.pdf . The American Academy of Family Physicians (AAFP) generally adheres to USPSTF recommendations. 28

MATERNAL DEPRESSION

Prevalence of postpartum depression is around 12%, 22 and its presence can impair infant development. The USPSTF and AAP recommend using the Edinburgh Postnatal Depression Scale (available at https://www.aafp.org/afp/2010/1015/p926.html#afp20101015p926-f1 ) or the Patient Health Questionnaire-2 (available at https://www.aafp.org/afp/2012/0115/p139.html#afp20120115p139-t3 ) to screen for maternal depression. The USPSTF does not specify a screening schedule; however, based on expert opinion, the AAP recommends screening mothers at the one-, two-, four-, and six-month well-child visits, with further evaluation for positive results. 23 There are no recommendations to screen other caregivers if the mother is not present at the well-child visit.

PSYCHOSOCIAL

With nearly one-half of children in the United States living at or near the poverty level, assessing home safety, food security, and access to safe drinking water can improve awareness of psychosocial problems, with referrals to appropriate agencies for those with positive results. 29 The prevalence of mental health disorders (i.e., primarily anxiety, depression, behavioral disorders, attention-deficit/hyperactivity disorder) in preschool-aged children is around 6%. 30 Risk factors for these disorders include having a lower socioeconomic status, being a member of an ethnic minority, and having a non–English-speaking parent or primary caregiver. 25 The USPSTF found insufficient evidence regarding screening for depression in children up to 11 years of age. 24 Based on expert opinion, the AAP recommends that physicians consider screening, although screening in young children has not been validated or standardized. 25

DEVELOPMENT AND SURVEILLANCE

Based on expert opinion, the AAP recommends early identification of developmental delays 14 and autism 10 ; however, the USPSTF found insufficient evidence to recommend formal developmental screening 13 or autism-specific screening 9 if the parents/caregivers or physician have no concerns. If physicians choose to screen, developmental surveillance of language, communication, gross and fine movements, social/emotional development, and cognitive/problem-solving skills should occur at each visit by eliciting parental or caregiver concerns, obtaining interval developmental history, and observing the child. Any area of concern should be evaluated with a formal developmental screening tool, such as Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, Parents' Evaluation of Developmental Status-Developmental Milestones, or Survey of Well-Being of Young Children. These tools can be found at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx . If results are abnormal, consider intervention or referral to early intervention services. The AAP recommends completing the previously mentioned formal screening tools at nine-, 18-, and 30-month well-child visits. 14

The AAP also recommends autism-specific screening at 18 and 24 months. 10 The USPSTF recommends using the two-step Modified Checklist for Autism in Toddlers (M-CHAT) screening tool (available at https://m-chat.org/ ) if a physician chooses to screen a patient for autism. 10 The M-CHAT can be incorporated into the electronic medical record, with the possibility of the parent or caregiver completing the questionnaire through the patient portal before the office visit.

IRON DEFICIENCY

Multiple reports have associated iron deficiency with impaired neurodevelopment. Therefore, it is essential to ensure adequate iron intake. Based on expert opinion, the AAP recommends supplements for preterm infants beginning at one month of age and exclusively breastfed term infants at six months of age. 3 The USPSTF found insufficient evidence to recommend screening for iron deficiency in infants. 19 Based on expert opinion, the AAP recommends measuring a child's hemoglobin level at 12 months of age. 3

Lead poisoning and elevated lead blood levels are prevalent in young children. The AAP and CDC recommend a targeted screening approach. The AAP recommends screening for serum lead levels between six months and six years in high-risk children; high-risk children are identified by location-specific risk recommendations, enrollment in Medicaid, being foreign born, or personal screening. 21 The USPSTF does not recommend screening for lead poisoning in children at average risk who are asymptomatic. 20

The USPSTF recommends at least one vision screening to detect amblyopia between three and five years of age. Testing options include visual acuity, ocular alignment test, stereoacuity test, photoscreening, and autorefractors. The USPSTF found insufficient evidence to recommend screening before three years of age. 26 The AAP, American Academy of Ophthalmology, and the American Academy of Pediatric Ophthalmology and Strabismus recommend the use of an instrument-based screening (photoscreening or autorefractors) between 12 months and three years of age and annual visual acuity screening beginning at four years of age. 31

IMMUNIZATIONS

The AAFP recommends that all children be immunized. 32 Recommended vaccination schedules, endorsed by the AAP, the AAFP, and the Advisory Committee on Immunization Practices, are found at https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Immunizations are usually administered at the two-, four-, six-, 12-, and 15- to 18-month well-child visits; the four- to six-year well-child visit; and annually during influenza season. Additional vaccinations may be necessary based on medical history. 33 Immunization history should be reviewed at each wellness visit.

Anticipatory Guidance

Injuries remain the leading cause of death among children, 34 and the AAP has made several recommendations to decrease the risk of injuries. 35 – 42 Appropriate use of child restraints minimizes morbidity and mortality associated with motor vehicle collisions. Infants need a rear-facing car safety seat until two years of age or until they reach the height or weight limit for the specific car seat. Children should then switch to a forward-facing car seat for as long as the seat allows, usually 65 to 80 lb (30 to 36 kg). 35 Children should never be unsupervised around cars, driveways, and streets. Young children should wear bicycle helmets while riding tricycles or bicycles. 37

Having functioning smoke detectors and an escape plan decreases the risk of fire- and smoke-related deaths. 36 Water heaters should be set to a maximum of 120°F (49°C) to prevent scald burns. 37 Infants and young children should be watched closely around any body of water, including water in bathtubs and toilets, to prevent drowning. Swimming pools and spas should be completely fenced with a self-closing, self-latching gate. 38

Infants should not be left alone on any high surface, and stairs should be secured by gates. 43 Infant walkers should be discouraged because they provide no benefit and they increase falls down stairs, even if stair gates are installed. 39 Window locks, screens, or limited-opening windows decrease injury and death from falling. 40 Parents or caregivers should also anchor furniture to a wall to prevent heavy pieces from toppling over. Firearms should be kept unloaded and locked. 41

Young children should be closely supervised at all times. Small objects are a choking hazard, especially for children younger than three years. Latex balloons, round objects, and food can cause life-threatening airway obstruction. 42 Long strings and cords can strangle children. 37

DENTAL CARE

Infants should never have a bottle in bed, and babies should be weaned to a cup by 12 months of age. 44 Juices should be avoided in infants younger than 12 months. 45 Fluoride use inhibits tooth demineralization and bacterial enzymes and also enhances remineralization. 11 The AAP and USPSTF recommend fluoride supplementation and the application of fluoride varnish for teeth if the water supply is insufficient. 11 , 12 Begin brushing teeth at tooth eruption with parents or caregivers supervising brushing until mastery. Children should visit a dentist regularly, and an assessment of dental health should occur at well-child visits. 44

SCREEN TIME

Hands-on exploration of their environment is essential to development in children younger than two years. Video chatting is acceptable for children younger than 18 months; otherwise digital media should be avoided. Parents and caregivers may use educational programs and applications with children 18 to 24 months of age. If screen time is used for children two to five years of age, the AAP recommends a maximum of one hour per day that occurs at least one hour before bedtime. Longer usage can cause sleep problems and increases the risk of obesity and social-emotional delays. 46

To decrease the risk of sudden infant death syndrome (SIDS), the AAP recommends that infants sleep on their backs on a firm mattress for the first year of life with no blankets or other soft objects in the crib. 45 Breastfeeding, pacifier use, and room sharing without bed sharing protect against SIDS; infant exposure to tobacco, alcohol, drugs, and sleeping in bed with parents or caregivers increases the risk of SIDS. 47

DIET AND ACTIVITY

The USPSTF, AAFP, and AAP all recommend breastfeeding until at least six months of age and ideally for the first 12 months. 48 Vitamin D 400 IU supplementation for the first year of life in exclusively breastfed infants is recommended to prevent vitamin D deficiency and rickets. 49 Based on expert opinion, the AAP recommends the introduction of certain foods at specific ages. Early transition to solid foods before six months is associated with higher consumption of fatty and sugary foods 50 and an increased risk of atopic disease. 51 Delayed transition to cow's milk until 12 months of age decreases the incidence of iron deficiency. 52 Introduction of highly allergenic foods, such as peanut-based foods and eggs, before one year decreases the likelihood that a child will develop food allergies. 53

With approximately 17% of children being obese, many strategies for obesity prevention have been proposed. 54 The USPSTF does not have a recommendation for screening or interventions to prevent obesity in children younger than six years. 54 The AAP has made several recommendations based on expert opinion to prevent obesity. Cessation of breastfeeding before six months and introduction of solid foods before six months are associated with childhood obesity and are not recommended. 55 Drinking juice should be avoided before one year of age, and, if given to older children, only 100% fruit juice should be provided in limited quantities: 4 ounces per day from one to three years of age and 4 to 6 ounces per day from four to six years of age. Intake of other sugar-sweetened beverages should be discouraged to help prevent obesity. 45 The AAFP and AAP recommend that children participate in at least 60 minutes of active free play per day. 55 , 56

Data Sources: Literature search was performed using the USPSTF published recommendations ( https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations ) and the AAP Periodicity table ( https://www.aap.org/en-us/Documents/periodicity_schedule.pdf ). PubMed searches were completed using the key terms pediatric, obesity prevention, and allergy prevention with search limits of infant less than 23 months or pediatric less than 18 years. The searches included systematic reviews, randomized controlled trials, clinical trials, and position statements. Essential Evidence Plus was also reviewed. Search dates: May through October 2017.

Gauer RL, Burket J, Horowitz E. Common questions about outpatient care of premature infants. Am Fam Physician. 2014;90(4):244-251.

American Academy of Pediatrics; Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics. 2010;125(2):405-409.

Baker RD, Greer FR Committee on Nutrition, American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010;126(5):1040-1050.

Mahle WT, Martin GR, Beekman RH, Morrow WR Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2012;129(1):190-192.

American Academy of Pediatrics Newborn Screening Authoring Committee. Newborn screening expands: recommendations for pediatricians and medical homes—implications for the system. Pediatrics. 2008;121(1):192-217.

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898-921.

Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or = 35 weeks' gestation: an update with clarifications. Pediatrics. 2009;124(4):1193-1198.

Christian CW Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse [published correction appears in Pediatrics . 2015;136(3):583]. Pediatrics. 2015;135(5):e1337-e1354.

Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for autism spectrum disorder in young children: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;315(7):691-696.

Johnson CP, Myers SM American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215.

Moyer VA. Prevention of dental caries in children from birth through age 5 years: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2014;133(6):1102-1111.

Clark MB, Slayton RL American Academy of Pediatrics Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134(3):626-633.

Siu AL. Screening for speech and language delay and disorders in children aged 5 years and younger: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2015;136(2):e474-e481.

Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics . 2006;118(4):1808–1809]. Pediatrics. 2006;118(1):405-420.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for lipid disorders in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;316(6):625-633.

National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. October 2012. https://www.nhlbi.nih.gov/sites/default/files/media/docs/peds_guidelines_full.pdf . Accessed May 9, 2018.

Moyer VA. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(9):613-619.

Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published correction appears in Pediatrics . 2017;140(6):e20173035]. Pediatrics. 2017;140(3):e20171904.

Siu AL. Screening for iron deficiency anemia in young children: USPSTF recommendation statement. Pediatrics. 2015;136(4):746-752.

U.S. Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women. Pediatrics. 2006;118(6):2514-2518.

Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials . Atlanta, Ga.: U.S. Public Health Service; Centers for Disease Control and Prevention; National Center for Environmental Health; 1997.

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and post-partum women: evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;315(4):388-406.

Earls MF Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039.

Siu AL. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.

Weitzman C, Wegner L American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics; Committee on Psychosocial Aspects of Child and Family Health; Council on Early Childhood; Society for Developmental and Behavioral Pediatrics; American Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems [published correction appears in Pediatrics . 2015;135(5):946]. Pediatrics. 2015;135(2):384-395.

Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children aged 6 months to 5 years: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;318(9):836-844.

Donahue SP, Nixon CN Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Academy of Pediatrics; American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

Lin KW. What to do at well-child visits: the AAFP's perspective. Am Fam Physician. 2015;91(6):362-364.

American Academy of Pediatrics Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339.

Lavigne JV, Lebailly SA, Hopkins J, Gouze KR, Binns HJ. The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol. 2009;38(3):315-328.

American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment of infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

American Academy of Family Physicians. Clinical preventive service recommendation. Immunizations. http://www.aafp.org/patient-care/clinical-recommendations/all/immunizations.html . Accessed October 5, 2017.

Centers for Disease Control and Prevention. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Accessed May 9, 2018.

National Center for Injury Prevention and Control. 10 leading causes of death by age group, United States—2015. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2015_1050w740h.gif . Accessed April 24, 2017.

Durbin DR American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):788-793.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Reducing the number of deaths and injuries from residential fires. Pediatrics. 2000;105(6):1355-1357.

Gardner HG American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics. 2007;119(1):202-206.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003;112(2):437-439.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics. 2001;108(3):790-792.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Falls from heights: windows, roofs, and balconies. Pediatrics. 2001;107(5):1188-1191.

Dowd MD, Sege RD Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416-e1423.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics. 2010;125(3):601-607.

Kendrick D, Young B, Mason-Jones AJ, et al. Home safety education and provision of safety equipment for injury prevention (review). Evid Based Child Health. 2013;8(3):761-939.

American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134(6):1224-1229.

Heyman MB, Abrams SA American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967.

Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591.

Moon RY Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162940.

American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.

Wagner CL, Greer FR American Academy of Pediatrics Section on Breastfeeding; Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents [published correction appears in Pediatrics . 2009;123(1):197]. Pediatrics. 2008;122(5):1142-1152.

Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics. 2011;127(3):e544-e551.

Greer FR, Sicherer SH, Burks AW American Academy of Pediatrics Committee on Nutrition; Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.

American Academy of Pediatrics Committee on Nutrition. The use of whole cow's milk in infancy. Pediatrics. 1992;89(6 pt 1):1105-1109.

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Child well visits, birth to 15 months

• Child well visit checklist
• Quiz: Child well-being and immunizations

Checking in: Questions to ask at your child's well visits

Welcoming a new child is exciting. But caring for a baby can also leave you with a lot of unanswered questions. Your baby’s care provider can help. From giving immunizations to offering you feeding tips, care providers help your baby grow up healthy. That includes making sure you have the answers and support you need.

A note about immunizations at child well visits

Your child’s care provider will give your baby immunizations during most visits. Immunizations work better and reduce the risk of infection by working with the body's natural defenses to help safely develop immunity to disease. Keeping your baby on schedule is also key, so don’t forget to schedule visits on time.

Learn what to ask at your child's well visits

Preparation is key for a stress-free appointment. Your baby should go to at least 8 child well visits before they are 15 months old. Knowing what will happen at each of these appointments can help you get ready. Knowing what to pack for your visit and questions you might ask when you get there can make your life easier. Watch the videos and view the questions below to get ready for each early child well visit.

Child Well Visits: Newborn

Video transcript.

Screen 1: What to expect at your baby’s appointment – Newborn

Screen 2:  Your newborn will need a checkup before going home.

Screen 3:  What to expect before you leave the hospital:

• Physical checkup (measurements, vitals).
• Screenings: Critical congenital heart defect, vision, hearing, newborn bilirubin, blood (check for disorders).
• Developmental and behavioral assessment.
• Immunizations:  HepB.

Screen 4:  Before you leave:

• Make sure your contact information is current.
• Schedule your next appointment.

Screen 5:  In light of COVID-19, remember to practice social distancing at your well-child visits. Wash your hands often and wear a mask. Contact your care provider with questions about your visit.

Screen 6:  UnitedHealthcare Logo

Your newborn will need a checkup before going home from the hospital. Watch the video to learn what screenings and immunizations you can expect at your child’s first appointment.

3 to 5-day visit

Child well visits: 3 to 5-day visit.

Screen 1: What to expect at your baby’s appointment – 3-5 Days

Screen 2:  Early well-child visits and immunizations set your baby up for a healthy future.

Screen 3:  What to expect at your child’s appointment:

• Physical checkup: Measurements, vitals.
• Umbilical cord examination.
• Screenings: Vision, hearing, blood (check for disorders).
• Review screenings done at birth.

Screen 4:  You’ll also talk about if baby can:

• Suck to eat
• Grasp your finger
• React when startled

Screen 5:  Before you leave:

Screen 6:  In light of COVID-19, remember to practice social distancing at your well-child visits. Wash your hands often and wear a mask. Contact your care provider with questions about your visit.

UnitedHealthcare Logo

Watch the video to get an idea of what to expect at your appointment

In addition, here are some questions you may want to ask:

• How can I keep my baby comfortable and safe from seasonal weather?
• What can I do to make breastfeeding more comfortable for me and baby?
• When will my baby gain more weight?
• Should I always put my baby to sleep on their back?
• How do I care for my baby’s umbilical cord?
• How often should my baby get a bath?
• How do I calm and soothe my baby?

1-month visit

Child well visits: 1 month appointment.

Screen 1: What to expect at your baby’s appointment – 1 Month

• Immunizations: HepB.
• Postpartum depression screening (for mothers).
• Raise hands
• Focus on your face

Screen 7:  UnitedHealthcare Logo

• When will my baby sleep through the night?
• What should I do for the peeling skin on my baby’s head?
• How do I care for my infant's skin?
• What is a normal number of wet or soiled diapers I should change every day?
• Are there programs to help me buy formula or breast pumps?

2-month visit

Child well visits: 2 month appointment.

Screen 1: What to expect at your baby’s appointment – 2 Months

• Physical checkup: (measurements, vitals).
• Screenings: Vision, hearing.
• Immunizations: DTaP, Hib, IPV, RV, HepB, PCV13.
• Developmental assessment.
• Turn and lift head
• Kick while laying on back
• Notice hands
• Follow objects with eyes
• How often should my baby be eating?
• Should I be using formula in addition to breastfeeding?
• How can I keep my baby comfortable after immunizations?
• How can I find childcare I can trust?
• When should I stop swaddling my baby?
• I’ve been feeling sad and anxious since delivering my baby. What should I do?
• What is “tummy time”?

4-month visit

Child well visits: 4 month appointment.

Screen 1: What to expect at your baby’s appointment – 4 Months

• Roll onto tummy
• Reach for objects
• Watch an object move
• Laugh and giggle

Screen 7: UnitedHealthcare Logo

• Is Tylenol safe to give my baby for a fever?
• How can I help my baby have healthy teeth?
• How can I soothe my baby during teething?
• How can we begin to create a sleeping routine?
• How long should my baby spend doing “tummy time” each day?
• How long should my baby nap each day?

6-month visit

Child well visits: 6 month appointment.

Screen 1: What to expect at your baby’s appointment – 6 Months

• Screenings: Vision, hearing, oral health.
• Immunizations: DTaP, Hib, IPV, RV, HepB, PCV13, IIV.
• Roll in both directions
• Play with toes
• Hold a bottle
• Sit with good head control
• When and how should I introduce foods other than breastmilk or formula?
• How can I wean my baby off night feedings?
• How long should my baby use a pacifier?
• Can my baby sleep with a favorite blanket or toy?
• When can my baby start drinking from a sippy cup?

9-month visit

Child well visits: 9 month appointment.

Screen 1: What to expect at your baby’s appointment – 9 Months

• Screenings: Vision, hearing, anemia, lead, oral health.
• Immunizations: IIV.
• Sit unassisted
• Crawl and pull up to stand
• Work to get toys that are out of reach
• I think my baby is behind in development (e.g., crawling). What can I do to help?
• What do I need to babyproof in my home once my baby can crawl?
• Should I be brushing my baby’s new teeth?
• How long should my baby be sleeping at night?
• How long should I let my baby cry at night?

12-month visit

Child well visits: 12 month appointment.

Screen 1: What to expect at your baby’s appointment – 12 Months

• Screenings: Vision, hearing, lead, oral health.
• Immunizations: MMR, HepA, Varicella, PCV13, IIV.
• Walk while holding onto something
• Use gestures to get things
• Eat solid foods with fingers
• Say more than one word
• Respond to name
• What should I do when baby pulls my hair or bites?
• Are my baby’s sleep patterns normal?
• How can I treat diaper rash?
• What can I do about sore arms and back from holding my baby?
• Should my baby nap at the same time each day?
• How do I keep my child safe as they learn to walk and explore?

15-month visit

Child well visits: 15 month appointment.

Screen 1: What to expect at your baby’s appointment – 15 Months

• Immunizations: DTaP, Hib, IIV.
• Walk and run
• Squat and stand back up
• Throw or kick a ball
• Point for things 
• When should my baby switch from a crib to a bed?
• How much juice or milk should my baby be drinking?
• Should my baby have screen time?
• When should my baby go to the dentist?
• When should I switch to a front-facing car seat?

Wellness visits are also important for your child after 15 months

As your child grows, it’s important to continue to have regular checkups with your health care provider. You can view checklists for preventive care visits at every age, from 1 month to adulthood.

Looking for resources to help support you and your child?

• Most health insurance plans cover early child well visits or provide assistance. Call the number on your insurance card for more details.
• If you are a UnitedHealthcare Community Plan member, you may have access to our Healthy First Steps program , which can help you find a care provider, schedule well-child visits, connect with educational and community resources and more. To get started, call 1-800-599-5985 , TTY 711, Monday through Friday, from 8 a.m. to 5 p.m. 1
• If you need help getting to an appointment, or getting formula or healthy food, call the number on your insurance card.
• If you are having a hard time getting food or are experiencing unemployment, your care provider may be able to connect you with resources that can help.

Related content

• Preventive care

More like this:

• What’s preventive care and what’s covered?
• Children's health

Developmental Surveillance Resources for Healthcare Providers

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 recent updates to CDC’s developmental milestones, please review the Pediatrics journal article and these important key points .

In addition to early childhood screenings, the American Academy of Pediatrics also recommends developmental surveillance , a flexible, longitudinal, continuous, and cumulative process, at each health supervision visit to help identify children with developmental concerns. CDC’s “Learn the Signs. Act Early.” program has FREE parent-friendly milestone checklists and other resources for children 2 months to 5 years of age to support healthcare providers with this process. Watch a webinar hosted by the American Academy of Pediatrics , that focuses on understanding and incorporating Developmental Surveillance into your practice.

• CDC’S Free Milestone Checklists
• How to Use CDC’S Checklists in Your Practice
• How Surveillance Supports Screening
• Steps for Surveillance and Screening
• Resources for Free CME, MOC, and QI
• Additional Resources for Surveillance and Screening
• Developmental Monitoring and Screening for Health Professionals

Print Milestone Checklist

English [4 MB, 24 Pages, 508] Spanish [5.7 MB, 24 Pages, 508]

Order free materials

CDC’s  Learn the Signs. Act Early.  materials include developmental milestone checklists to help parents track milestones between visits and provide guidance about what steps to take if they have concerns, like talking with their child’s healthcare provider. They have been tested for clarity, ease of understanding, have an engaging design and are written at a fifth grade reading level. Encouraging parents to complete checklists can help with developmental surveillance during health supervision visits.

The checklists are

• Available within CDC’s free Milestone Tracker app
• Free to download and print in your office
• Available to order in limited quantities
• Available in English and Spanish, with some in simplified Chinese, Vietnamese and Korean, and  other languages
• Able to be customized by adding your practice’s logo

View, print, or order milestone checklists pdf icon , CDC’s Milestone Tracker  app, and other free resources to help with developmental surveillance at  www.cdc.gov/ActEarly/Materials .

“Learn the Signs. Act Early.” One Doctor’s Story

Janet Siddiqui, M.D., is a pediatrician and office medical director at Johns Hopkins Community Physicians in Odenton, Maryland.

Support routine developmental surveillance in your practice with the help of CDC’s free materials.

• Review the app’s milestone summary during health supervision visits
• For families who prefer to use paper or speak languages other than English or Spanish, print and give the milestone checklists . Laminate the checklists and reuse as needed.
• Use a web button to link your practice website to Learn the Signs. Act Early. resources
• Use prepared social media content  to promote developmental monitoring at home
• Share the Healthcare Provider Primer , that explains the benefits of using LTSAE materials in pediatric settings and how to access materials and easily integrate them within practices. Primer in English [233 KB, 2 pages, 508] Primer in Spanish [242 KB, 2 Pages, 508]
• Include a PowerPoint slide [PPT – 3.11 MB] featuring the Milestone Tracker app during your next presentation and share how it can be used to help with developmental surveillance.
• AAP’s Family Friendly Referral Guide This free, printable handout is available in English [629 KB, 2 pages, 508] and Spanish to use with families and/or caregivers to support them in taking the next steps when developmental referrals are needed. Healthcare providers can fill in the types of referrals being made and let families know how to communicate any barriers they may be experiencing in the referral process.
• Birth to 5: Watch Me Thrive Screening Passport to print and use with families.
• Brazelton Touchpoints Development is a Journey Roadmap This roadmap is designed for pediatric primary care providers to facilitate  conversations if there are developmental concerns and/or after developmental screening using seven short and simple steps to actively engage parents and other caregivers in planning for their child’s developmental needs and enhance the provider-parent partnership. Development is a Journey conversation roadmap | Roadmap Background and Guidance

Prioritizing and Facilitating Developmental Referrals

Referrals to appropriate resources should be considered if any person on the patient’s care team has concerns about the patient’s current development or identifies the patient to be at increased risk of developmental delays.

Our practice uses the ‘Learn the Signs. Act Early.’ milestone checklists and they have significantly improved our ability to conduct developmental surveillance with our patients. Our parents and providers love these resources!

– Michelle Grier-Hall MD, FAAP, Medical Director of Pediatrics, Escambia Community Clinics, Inc., Pensacola, FL

I regularly use Learn the Signs. Act Early. milestone checklists for developmental surveillance at well visits to help identify children with developmental concerns.

– Cecily Kelly, MD, FAAFP, Kelly Family Clinic, New Braunfels, TX

Developmental surveillance and screening together are more likely to identify the 1 in 6 children with a developmental disability than either one alone. Identifying these children is important so they can receive early intervention services that help improve skills, abilities, future school performance, and later success in life.

Overview of Developmental Surveillance and Screening

Developmental surveillance is a continuous process that is recommended at least at every well-child/health supervision visit through early childhood. Developmental screening, on the other hand, is done with validated screening tools with appropriate sensitivity and specificity at strategic time points in early childhood.

• This video from the AAP discusses developmental surveillance recommendations, tips, and resources.
• This study showed that children receiving developmental monitoring and screening together were more likely to receive early intervention.

This video from AAP shows how obtaining developmental information from early childhood professionals, and sharing information back, can improve early identification.

• 1.) review checklists/developmental history;
• 2.) ask about concerns;
• 3.) assess strengths and risks;
• 4.) observe the child;
• 5.) document; and
• 6.) obtain and share results with others ( early childhood educators , WIC providers , home visitors , etc.).
• Print and post FREE Milestone Tracker app posters [617 KB, 1 Page, 508] in exam rooms; encourage families to download the app and complete a checklist.
• Print and give milestone checklists [4 MB, 24 Pages, 508] to families who prefer paper or speak languages other than English or Spanish; laminate and reuse them as needed.
• Conduct early childhood screenings as recommended by the AAP, using validated screening tools at recommended ages and if surveillance reveals a concern.
• Refer children with concerning results for further evaluation AND to your state’s early intervention program .

These free resources can help healthcare providers obtain Continuous Medical Education (CME) and Maintenance of Certification (MOC), and implement a Quality Improvement (QI) project in healthcare settings.

Milestones Matter: Don’t Underestimate Developmental Surveillance

The AAP offers this FREE online PediaLink course that highlights the importance of developmental surveillance as an essential component of the new recommendations in the clinical report titled, “Promoting Optimal Development: Identifying Infants and Young Children with Developmental Disorders Through Developmental Surveillance and Screening.” You do not need to be an AAP member to register and receive credit. This course will help pediatricians recognize the value of early identification and intervention when developmental delays are suspected, and to identify the key surveillance and screening steps to incorporate into practice. Participants are eligible for 1 AMA PRA Category 1 Credit™ and 1 Maintenance of Certification (MOC) Part 2 point.

Identifying and Caring for Children with Autism Spectrum Disorder: A Course for Pediatric Clinicians

The AAP offers this FREE, self-paced, online PediaLink course to educate pediatric clinicians about evidence-based practices in caring for children with autism spectrum disorder (ASD). You do not need to be an AAP member to register and receive credit. The course consists of 7 units, each grounded in recommendations from the AAP clinical report, “ Identification, Evaluation and Management of Children with Autism Spectrum Disorder .” Learners may complete all units or select specific units they would like to complete based on their needs, capacity, and professional interests. Units within the course are eligible for  AMA PRA Category 1 Credit™  and Maintenance of Certification (MOC) Part 2 points.

Toolkit to Implement Your Own Quality Improvement (QI) Project

This toolkit was developed by CDC and AAP to assist providers with implementing a MOC part 4 project on developmental surveillance and screening in the office.

Developmental Surveillance Mini (Spark)-Training for Pediatric Clinicians and Practices

Identify and discuss developmental surveillance best practices in your office setting.  This free training, developed with support from the Centers for Disease Control and Prevention, includes a ready-to-use PowerPoint presentation , facilitator script , and case study . The training can be facilitated by providers or staff in various roles and is specifically designed to “spark” discussion and reflection. Facilitators can anticipate the training to last approximately 15-30 minutes and can be presented anywhere from staff meetings to professional development opportunities. Content in the training is grounded in the recently published AAP clinical report, “Promoting Optimal Development: Identifying Infants and Young Children with Developmental Disorders Through Developmental Surveillance and Screening.” Download a copy to present to your team today!

AAP Chapter Resource Guide

The chapter resource guide, Support for Pediatric Clinicians Conducting Developmental Surveillance, Screening, Referral, and Follow-up , is based on feedback received from chapters focused on early identification of developmental delays and disabilities. It covers how to assess community assets, discovering potential community partners, collaborating with your state’s CDC Act Early Ambassador, and finding resources to facilitate developmental surveillance and screening.

Identifying Risks, Strengths, and Protective Factors for Children and Families : A Resource for Clinicians Conducting Developmental Surveillance

A study from the Journal of Developmental & Behavioral Pediatrics indicates LTSAE may improve developmental surveillance by increasing parent’s awareness of and discussion about milestones.

A study from the Journal of Developmental & Behavioral Pediatrics suggests that LTSAE materials may help improve developmental surveillance by increasing parent-physician communication about development.

Early Intervention Early intervention contact information by state.

Physical Developmental Delays: What to Look For

A tool developed by AAP and CDC on physical developmental delays and what to look for.

STAR Center American Academy of Pediatrics’ Screening Technical Assistance and Resource Center for information on screening tools, practice resources, and technical assistance.

Birth to 5: Watch Me Thrive! .

• A Healthcare provider guide to encourage healthy child development, universal developmental and behavioral screening for children, and support for the families.

AAP’s Clinical Reports Recommending Developmental Surveillance and Screening

• Promoting Optimal Development: Identifying Infants and Young Children with Developmental Disorders Through Developmental Surveillance and Screening
• Identification, Evaluation, and Management of Children with Autism Spectrum Disorder

Identify and discuss developmental surveillance best practices in your office setting. This free training, developed with support from the Centers for Disease Control and Prevention, includes a ready-to-use PowerPoint presentation , facilitator script , and case study .

Establishing Trusting Relationships with Families and Caregivers through Developmental Surveillance and Screening [467 KB, 2 Pages, 508]

The Well Visit Planner ® (WVP) is a brief family-completed, online pre-visit planning tool, available in English and Spanish, carefully aligned with national  Bright Futures  Guidelines that covers all 15 recommended well visits between a child’s first week of life through age six. The WVP supports a comprehensive, strengths-based, and personalized approach to well-child visits and can be used to document completion of required screenings (including but not limited to developmental and maternal depression) while prioritizing trust and family-centered care.

Watch this overview video of the Cycle of Engagement Well Visit Planner Approach to learn more. Download CAHMI’s COE WVP Getting Started Toolkit and visit the CAHMI website to create your COE account and customized Well Visit Planner tool today.

Milestones in Action is a FREE library of photos and videos of children showing developmental milestones.

If a child has a developmental delay, it is important to identify it early so that the child and family can receive needed intervention services and support. Healthcare providers play a critical role in monitoring children’s growth and development and identifying concerns as early as possible.  The American Academy of Pediatrics (AAP) recommends that healthcare providers do the following:

• Monitor the child’s development during regular well-child visits.
• Screen all children with validated tools at recommended ages to identify any areas of concern that may require a further examination or evaluation.
• Ensure that more comprehensive developmental evaluations are completed if risks are identified.

Developmental monitoring and screening can be done by a number of professionals in healthcare, community, and school settings in collaboration with parents and caregivers. Pediatric primary care providers are in a unique position to promote children’s healthy development because they have regular contact with children before they reach school age, and their families. The AAP encourages pediatric care providers to provide family-centered , comprehensive, and coordinated care.

Developmental Monitoring

Developmental monitoring, also called developmental surveillance, is the process of recognizing children who might be at risk for developmental delays. The AAP recommends that developmental monitoring should be a part of every well-child preventive care visit. Monitoring can include using a brief checklist of milestones , but is less formal than developmental screening. Developmental monitoring should include the following:

• Asking about parents’ concerns.
• Obtaining a developmental history.
• Observing the child.
• Identifying risk and protective factors.
• Documenting the findings.
• Share information with early childhood professionals.

If concerns are identified through developmental monitoring, they should be addressed promptly with validated screening tools to identify and refine any risk or concern that has been noticed.

Developmental Screening

Developmental screening is more in-depth than monitoring and may identify children with a developmental risk that was not identified during developmental monitoring.

The American Academy of Pediatrics (AAP) recommends developmental and behavioral screening for all children during regular well-child visits at these ages:

In addition, AAP recommends that all children be screened specifically for autism spectrum disorder (ASD) during regular well-child visits at:

Developmental screening with a validated test is recommended for all children at these ages even if there are no concerns. Healthcare providers may screen a child more frequently if there are additional risk factors, such as preterm birth , low birthweight, and lead exposure , among others.

Evidence-based screening tools that include reports from parents and early childhood professionals can help parents and healthcare professionals talk about the child’s development in a systematic way. A number of good screening tools designed for a variety of settings, ages, and purposes are available (e.g., Ages and Stages Questionnaire, 3rd edition, Parents’ Evaluation of Developmental Status with Developmental Milestones, and Child Development Inventory). Screening tools can be specific to a disorder (for example, autism), an area (for example, cognitive development, language, or gross motor skills), or they can be about development in general, addressing multiple areas of concern. More information is available from the AAP’s Screening Technical Assistance and Resource Center (STAR Center). A list of examples of validated screening tools is available from the American Academy of Pediatrics .

If the screening test identifies a potential developmental problem, further developmental and medical evaluation is needed. Screening tools do not provide conclusive evidence of developmental delays and do not result in diagnoses. A positive screening result should be followed by a thorough assessment done by a trained provider. A more detailed evaluation will show whether the child needs treatment and early developmental intervention services. Medical examinations can identify whether the problems are related to underlying medical conditions that need to be treated.

Children aged 0-3 years can be referred to early intervention programs and children aged 3 years and older can be referred to special education services for developmental evaluation and services. Learn more about early intervention and special education . Children with behavior problems can also benefit from parent behavior therapy  and may need a referral to a mental health provider.

Teaching Parents and Caregivers to Recognize Developmental Milestones

Parents can monitor a child’s development as well. Research studies have confirmed that parents are reliable sources of information about their child’s development. Parents who are aware of developmental milestones can observe their child and inform their healthcare provider about any concerns they may have about their child’s development. Pediatric healthcare providers can provide parents with milestone checklists  to track their child’s milestones at home. CDC’s “ Learn the Signs. Act Early .” campaign was designed to give parents and professionals the tools they need to track healthy child development and move toward evaluation and intervention if concerns are noted.

Early care and education providers can also be a valuable source of information on how the child is developing.

• Learn the Signs. Act Early. Developmental Milestone checklists
• Birth to 5: Watch Me Thrive – Families
• Motor Delay Tool

Ensuring All Children Have a Medical Home

Quality of care is best when children receive coordinated care and services. Having a medical home means having consistent access to health care that is comprehensive, well-coordinated, and of high quality, and that provides an ongoing relationship with personal providers who treat the whole child. The AAP describes a family-centered medical home  as an approach in which the pediatric care team works in partnership with a child and a child’s family to assure that all of the medical and non-medical needs of the patient are met.

In a medical home approach, developmental monitoring and screening includes the following:

• Identifying children with diagnosed developmental disorders as children with special healthcare needs and managing their care as a chronic condition. 1
• Coordinating with specialists about additional evaluation that the child may need.
• Integrating feedback from early childhood providers who can monitor and screen the children in the early childhood setting.

Integrating Developmental Screening into Pediatric Primary Care

The following are resources to integrate screening services into primary care efficiently and at low cost, while ensuring thorough coordination of care:

• The CDC’s Learn the Signs. Act Early program has FREE resources and recommendations for integrating developmental surveillance into health supervision visits .
• The  AAP’s Screening Technical Assistance and Resource Center (STAR Center) has resources for implementing surveillance, screening, referral, follow-up and continuing education.
• The AAP’s Developmental Surveillance and Screening webpage has resources for pediatric clinicians, providers, and families including free courses provided by the AAP .
• Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
• Lipkin PH, Macias MM, Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics (2020). Promoting optimal development: Identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics , 145(1), e20193449.
• Developmental Disabilities
• Child Development
• Positive Parenting Tips
• National Center on Birth Defects and Developmental Disabilities

English [233 KB, 2 Pages, 508]

Spanish [242 KB, 2 Pages, 508]

Use and share this presentation tailored for healthcare providers to:

• Describe the difference between developmental monitoring and developmental surveillance
• How to use CDC’s Milestone Checklists
• Background on the 2022 milestone revisions
• How to improve early identification of developmental delay or disability in the medical home.

Presentation Download [PDF – 3 MB, Print only]

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• Introduction
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• Article Information

Emergency department visit rates are per 1000 person-years in children younger than 2 years are shown. Symbols are the crude annual (April 1 to March 31) rates from April 1, 2004, to March 31, 2022, among groups. Trends were quantified using the Joinpoint regression program, version 5.0.5 (National Cancer Institute). Annual percent change (APC) was estimated for years 2004-2005 to 2019-2020. There was no evidence of a significant joinpoint for sex, residence location, or material resources quintile (Q), indicating that the observed increases in emergency department visit rates were linear.

a The average APC was significantly different from zero at P  < .001.

b The average APC was significantly different from zero at P  < .01.

Hospitalization rates are per 1000 person-years in children younger than 2 years are shown. Symbols are the crude annual (April 1 to March 31) rates from April 1, 2004, to March 31, 2022, among groups. Trends were quantified using the Joinpoint regression program, version 5.0.5 (National Cancer Institute). Annual percent change (APC) was estimated for years 2004-2005 to 2019-2020. There was no evidence of a significant joinpoint for sex and residence location. For material resources, in quintile (Q) 4, there was an initial decrease in hospitalization rate from 2004 to 2008 (trend 1: APC, −5.72; 95% CI, −14.10 to 3.49; P  = .19) followed by an increase from 2008 to 2019 (trend 2: APC, 1.72; 95% CI, −0.28 to 3.76; P  = .09). In Q5, there was an initial decrease in hospitalization rate from 2004 to 2012 (trend 1: APC, −3.05; 95% CI, −6.51 to 0.53; P  = .09) followed by an increase from 2012 to 2019 (trend 2: APC, 3.81; 95% CI, −0.70 to 8.53; P  = .09). However, these trends for Q4 and Q5 were not statistically significant. The average annual percent change (AAPC) for each of the Q1 to Q5 subgroups was not significantly different from zero at the α = .05 level. The AAPC difference between Q2 to Q5 and referent Q1 were not significantly different from zero at the α = .05 level.

eMethods. Supplemental Methods

eTable 1. Trends in Bronchiolitis Emergency Department Visit Rates Among Equity Stratifiers: Female vs. Male, 2004-2005 to 2021-2022

eTable 2. Trends in Bronchiolitis Emergency Department Visit Rates Among Equity Stratifiers: Rural vs. Urban, 2004-2005 to 2021-2022

eTable 3. Trends in Bronchiolitis Emergency Department Visit Rates Among Equity Stratifiers: Material Resources Quintile, 2004-2005 to 2021-2022

eTable 4. Trends in Bronchiolitis Hospitalization Rates Among Equity Stratifiers: Female vs. Male, 2004-2005 to 2021-2022

eTable 5. Trends in Bronchiolitis Hospitalization Rates Among Equity Stratifiers: Rural vs. Urban, 2004-2005 to 2021-2022

eTable 6. Trends in Bronchiolitis Hospitalization Rates Among Equity Stratifiers: Material Resources Quintile, 2004-2005 to 2021-2022

eAppendix. Canadian Paediatric Inpatient Research Network Members

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Mahant S , Borkhoff CM , Parkin PC, et al. Sociodemographic Factors and Trends in Bronchiolitis-Related Emergency Department Visit and Hospitalization Rates. JAMA Netw Open. 2024;7(4):e248976. doi:10.1001/jamanetworkopen.2024.8976

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Sociodemographic Factors and Trends in Bronchiolitis-Related Emergency Department Visit and Hospitalization Rates

• 1 Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
• 2 Division of Pediatric Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
• 3 Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
• 4 Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, Ontario, Canada
• 5 ICES, Ottawa, Ontario, Canada
• 6 The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Question   Have inequalities based on sex, residence location, and material resources in bronchiolitis emergency department visits and hospitalizations improved over time?

Findings   In a population-based cohort study of 2 921 573 children from 2004 to 2022 in Ontario, Canada, bronchiolitis emergency department and hospitalization rates were highest for boys, those with rural residence, and those with lowest material resources. There were no between-group differences in the average annual percentage change in bronchiolitis emergency department visit and hospitalization rates for sex (female vs male), residence (rural vs urban), and material resources (greatest vs least).

Meaning   These findings indicate that inequalities in bronchiolitis emergency department visit and hospitalization rates did not improve over time.

Importance   Bronchiolitis is the most common and most cumulatively expensive condition in pediatric hospital care. Few population-based studies have examined health inequalities in bronchiolitis outcomes over time.

Objective   To examine trends in bronchiolitis-related emergency department (ED) visit and hospitalization rates by sociodemographic factors in a universally funded health care system.

Design, Setting, and Participants   This repeated cross-sectional cohort study was performed from April 1, 2004, to March 31, 2022, using population-based health administrative data from children younger than 2 years in Ontario, Canada.

Main Outcome and Measures   Bronchiolitis ED visit and hospitalization rates per 1000 person-years reported for the equity stratifiers of sex, residence location (rural vs urban), and material resources quintile. Trends in annual rates by equity stratifiers were analyzed using joinpoint regression and estimating the average annual percentage change (AAPC) with 95% CI and the absolute difference in AAPC with 95% CI from April 1, 2004, to March 31, 2020.

Results   Of 2 921 573 children included in the study, 1 422 088 (48.7%) were female and 2 619 139 (89.6%) lived in an urban location. Emergency department visit and hospitalization rates were highest for boys, those with rural residence, and those with least material resources. There were no significant between-group absolute differences in the AAPC in ED visits per 1000 person-years by sex (female vs male; 0.22; 95% CI, −0.92 to 1.35; P  = .71), residence (rural vs urban; −0.31; 95% CI −1.70 to 1.09; P  = .67), or material resources (quintile 5 vs 1; −1.17; 95% CI, −2.57 to 0.22; P  = .10). Similarly, there were no significant between-group absolute differences in the AAPC in hospitalizations per 1000 person-years by sex (female vs male; 0.53; 95% CI, −1.11 to 2.17; P  = .53), residence (rural vs urban; −0.62; 95% CI, −2.63 to 1.40; P  = .55), or material resources (quintile 5 vs 1; −0.93; 95% CI −3.80 to 1.93; P  = .52).

Conclusions and Relevance   In this population-based cohort study of children in a universally funded health care system, inequalities in bronchiolitis ED visit and hospitalization rates did not improve over time.

Quantifying and assessing health inequalities in a population is important as health care systems seek to reduce health inequities. 1 - 3 The World Health Organization defines health inequalities as “differences in health status or the distribution of health determinants between different population groups.” 4 Health inequalities are assessed by comparing differences in health outcomes among population groups. Health inequalities may be due to biological variations, personal preferences, or an individual’s environment and conditions outside their control. When the differences in health outcomes are avoidable or deemed unfair and unjust, they are termed health inequities. 5 Equity stratifiers, also called dimensions of inequality, are characteristics chosen to investigate perceived inequalities. The PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) framework summarizes the equity stratifiers most frequently used when grouping individuals into population subgroups to measure health inequalities 6

Bronchiolitis is a common cause of childhood emergency department (ED) visits and hospitalizations and is among the costliest conditions in pediatric hospital care. Health inequalities in bronchiolitis may occur for several reasons. 7 , 8 Material hardship, rural residence, and male sex have been associated with greater health care use and poorer outcomes. 6 , 9 - 14 Although several studies have examined health inequalities in bronchiolitis outcomes, 15 - 19 few studies have examined bronchiolitis ED visit and hospitalization inequalities over time using population-based data. 20 Such research is important to understand trends in inequality and whether the inequality gap is narrowing or widening. Therefore, the objective of this study was to conduct a population-based cohort study within a universally funded health care system in Ontario, Canada, to examine temporal trends in bronchiolitis-related ED visit and hospitalization rates from 2004 to 2022. Specifically, we examined trends in bronchiolitis outcomes by equity stratifiers: sex, residence location, and material resources.

We conducted a population-based cohort study using a repeated cross-sectional study design to examine trends in bronchiolitis-related ED and hospitalization rates by sociodemographic factors in Ontario, Canada. In a similar approach to previous studies, 13 , 14 the data sources were provincial health administrative databases housed at ICES (formerly known as the Institute for Clinical Evaluative Sciences), an independent, nonprofit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health data for health system evaluation without patient consent. Data were collected from children younger than 2 years from April 1, 2004, to March 31, 2022. Annual (April 1 to March 31) rates of bronchiolitis ED visits and hospitalizations were determined for the entire study period. The trend analysis, which determined the average annual percentage change (AAPC) in rates and differences in AAPC for the equity stratifiers, focused on April 1, 2004, to March 31, 2020. We did not include the period from April 1, 2020, to March 31, 2022 (the last 2 annual time points), in the trend analysis given the unprecedented reduction in bronchiolitis incidence during the early COVID-19 pandemic period. Research ethics board approval was obtained from The Hospital for Sick Children. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. 21

All children younger than 2 years who were residents of Ontario and enrolled in the provincially funded Ontario Health Insurance Plan (OHIP) were included. Data from all children’s and community hospitals in the province were included. Bronchiolitis encounters were identified using International Statistical Classification of Diseases and Related Problems, Tenth Revision, Canada ( ICD-10-CA ) discharge diagnosis codes for bronchiolitis, including both respiratory syncytial virus (RSV) and non-RSV causes, and whether bronchiolitis was the primary or secondary discharge diagnosis (eMethods in Supplement 1 ). Viral pneumonia diagnosis codes (eg, RSV, influenza, and adenovirus pneumonia) were also included because viral pneumonia presents similarly and is managed similarly to bronchiolitis in children younger than 2 years.

Health administrative databases, 22 linked using unique encoded identifiers derived from the OHIP number of every resident in Ontario with public health insurance, were used (eMethods in Supplement 1 contains information on the databases). The Registered Persons Database includes demographic information on all Ontarians registered for public health insurance and was used to obtain age, sex, and residence postal code. The National Ambulatory Care Reporting System database was used to obtain ED visit data, the Canadian Institute for Health Information Discharge Abstract Database was used for hospitalization data, and the MOMBABY database was used to capture birth records for inpatient births (the database captures more than 97% of all births in Ontario). 23

The study population was described by the following characteristics: sex, gestational age, and comorbidity status. Comorbidity status was determined by the presence of a comorbidity ICD-10-CA discharge diagnosis code on a hospital encounter from birth to 2 years. Additionally, procedural codes were used for children with a complex chronic condition (eg, gastrostomy), following the Canadian Institute for Health Information methods. 24 Comorbidities were not mutually exclusive and included complex chronic condition, 24 , 25 chronic lung disease or bronchopulmonary dysplasia arising from the perinatal period, 18 congenital heart disease, 26 neurologic impairment, 27 immunodeficiency, and trisomy 21. 26

Health inequalities were determined for the following equity stratifiers: sex (male or female), geography (rural or urban residence), and material resources quintile. Race and ethnicity data are not available through Ontario health administrative databases. The primary residence location was assessed using the Rurality Index of Ontario, which defines neighborhoods into urban (score of <40) or rural (score of ≥40). 28 The Rurality Index of Ontario score is calculated using community population size, density, and travel time to the nearest basic and advanced health care referral centers. We used the 2008 version of the rurality index, which is the most recent version available and currently used by the Ontario government. Material resources is 1 of 4 dimensions of the Ontario Marginalization Index that is used as a comprehensive area-based measure of socioeconomic status and poverty at the neighborhood level. 29 It is based on level of education (proportion of population 25 years or older without a certificate, diploma, or degree), family structure (proportion of lone-parent families), housing quality (proportion of homes needing a major repair), employment (proportion of population 15 years or older who are unemployed), and income (proportion of population below the low-income cutoff and proportion receiving government transfer payments). Material resources quintiles were created at the dissemination area level and assigned to individual records, with quintile 1 representing the most resourced (ie, least deprived) and quintile 5 representing the least resourced (ie, most deprived). The material resources index is available for 2001, 2006, 2011, 2016, and 2021 for tracking changes over time.

Bronchiolitis outcomes included the population-based bronchiolitis ED visit and hospitalization rate. Outcomes were estimated annually (April 1 to March 31) and for the entire study period (April 1, 2004, to March 31, 2022). The population-based ED visit rate was estimated per 1000 person-years with 95% CIs. The numerator was the total number of bronchiolitis ED visits for all children younger than 2 years, and the denominator was the number of person-years contributed by all children younger than 2 years in that period. The hospitalization rate was estimated per 1000 person-years with 95% CIs. The numerator was the total number of bronchiolitis hospitalizations for all children younger than 2 years, and the denominator was the number of person-years contributed by all children younger than 2 years in that period. Crude rates were estimated because the focus was on understanding the health system and population burden of bronchiolitis hospital use.

We used joinpoint regression analysis to examine temporal trends in bronchiolitis ED visit rates and hospitalization rates by sex, residence location, and material resources quintile from April 1, 2004, to March 31, 2020. 30 The joinpoint regression software calculates the number and temporal location of points representing a statistically significant change in trend (ie, a joinpoint). 31 We used Joinpoint, version 5.0.2 (National Cancer Institute) to run the joinpoint regression models, starting with a model with 0 joinpoints (a linear relationship) and testing whether 1 or more joinpoints should be added to the final model. We selected the grid search method for fitting the model and the permutation test (n = 4499 permutations) for determining the optimal number of joinpoints. We selected log transformation to calculate annual average percent change (AAPC), the average rate of change in ED rate (or hospitalization rate) per year during the study period. The AAPC was tested against the null hypothesis that the percent change was zero (no increase or decrease over time). A pairwise comparison between trends (with the null hypothesis that the 2 lines are parallel) was performed to examine whether the rate of change (AAPC) differed between groups. A 95% CI around the absolute difference in the AAPC between groups (eg, male vs female) that includes 0 indicates no increase or decrease in the inequality gap over time between groups. Statistical significance was defined as P  < .05; all statistical tests were 2-sided.

The study cohort included 2 921 573 children, of whom 1 499 485 (51.3%) were male and 1 422 088 (48.7%) were female, 545 378 (18.7%) were preterm and/or had a comorbidity, 105 189 (3.6%) had a chronic complex condition, and 2 619 139 (89.6%) lived in an urban location ( Table 1 ). Bronchiolitis ED visits occurred at 214 hospitals (185 [86.4%] community and 29 [13.6%] pediatric or teaching) and hospitalizations at 151 hospitals (134 [88.7%] community and 17 (11.2%) pediatric or teaching).

During the study period, there were 141 045 bronchiolitis ED visits for an overall population-based ED visit rate of 27.8 (95% CI, 27.6-27.9) per 1000 person-years. eTables 1-3 in Supplement 1 provide the annual ED visit rates by equity stratifier and rate ratios with 95% CIs. The ED visit rates were lower for girls than boys, greater for children living in a rural location than an urban location, and greater for children with the least material resources. The ED visit rates increased from years 2004-2005 to 2019-2020. The 2020-2021 rates saw a marked reduction associated with the pandemic; in 2021-2022 rates showed an increase but not to prepandemic rates. There was no evidence of a significant joinpoint for sex, residence location, or material deprivation quintile, indicating that the observed increases in ED visit rates were linear over time to 2019-2020 ( Figure 1 ).

The ED visit rates increased over time for both boys (AAPC, 2.38 [95% CI, 1.48-3.30] visits per 1000 person-years; P  < .001) and girls (AAPC, 2.60 [95% CI, 1.76-3.45]) visits per 1000 person-years; P  < .001), with no significant between-group difference in the rate of change (0.22 [95% CI, −0.92 to 1.35] visits per 1000 person years; P  = .71) ( Figure 1 and Table 2 ).

The ED visit rates increased over time for both children with an urban (AAPC, 2.53 [95% CI 1.72-3.34] visits per 1000 person-years; P  < .001) and rural (AAPC, 2.22 [95% CI, 0.94-3.52]) visits per 1000 person-years; P  = .002) residence, with no significant between-group difference in the rate of change (−0.31 [95% CI, −1.70 to 1.09] visits per 1000 person-years; P  = .67) ( Figure 1 and Table 2 ).

The ED visit rates increased for all material resources quintiles, with the greatest increase for the group with greatest material resources (quintile 1) (AAPC, 3.07 [95% CI, 1.83-4.32] visits per 1000 person- years; P  < .001) and lowest for the group with lowest material resources (quintile 5) (1.89 [95% CI, 1.00-2.79] visits per 1000 person-years; P  < .001) ( Figure 1 and Table 2 ). However, there were no statistically significant between-group differences in the rate of change for each quintile compared with the group with the greatest material resources (eg, quintile 5 vs 1: −1.17; 95% CI, −2.57 to 0.22; P  = .10) ( Table 2 ).

There were 58 215 bronchiolitis hospitalizations during the study period for an overall hospitalization rate of 11.4 (95% CI, 11.4-11.6) hospitalizations per 1000 person-years. As displayed in Figure 2 , there was no evidence of a significant joinpoint for sex and residence location, indicating that the observed stable hospitalization rates were linear over time to 2019-2020. There was 1 joinpoint for material resources quintiles 4 and 5, which was not statistically significant. Similar to ED rates, hospitalization rates in 2020-2021 saw a marked reduction associated with the pandemic, and then the 2021-2022 rates showed an increase, but not to prepandemic rates.

Hospitalization rates were lower for girls compared with boys (eTables 4-6 in Supplement 1 ). Hospitalization rates were stable over time for both boys (AAPC, 0.22 [95% CI, −0.94 to 1.40] visits per 1000 person-years) and girls (AAPC, 0.75 [95% CI, −0.60 to 2.12] visits per 1000 person-years), with no significant between-group difference in the rate of change (0.53 [95% CI, −1.11 to 2.17] visits per 1000 person-years; P  = .53) ( Figure 2 and Table 3 ).

Hospitalization rates were greater for children living in a rural location compared with an urban location (eTable 5 in Supplement 1 ). Hospitalization rates were stable over time for both children with an urban (AAPC, 0.52 [95% CI, −0.65 to 1.70] visits per 1000 person-years) and rural (AAPC, −0.10 [95% CI, −1.95 to 1.79] visits per 1000 person-years) residence, with no significant between-group difference in the rate of change (−0.62 [95% CI, −2.63 to 1.40] visits per 1000 person-years; P  = .55) ( Figure 2 and Table 2 ).

During the study period, the hospitalization rate was lowest for the group with the greatest material resources (quintile 1) (eTable 6 in Supplement 1 ). The hospitalization rate was stable for all material resources quintiles, and there were no statistically significant between-group differences in the rate of change for each quintile compared with the group with greatest material resources (eg, quintile 5 vs 1: −0.93; 95% CI −3.80 to 1.93; P  = .52) ( Figure 2 and Table 2 ).

This population-based cohort study examined trends in bronchiolitis-related ED visit and hospitalization rates by sociodemographic factors in a universally funded health care system from 2004 to 2022. Crude rates were highest for boys, rural residents, and those with the least material resources. We found no significant differences in the AAPC in the ED visit and hospitalization rates between groups based on sex, residence, and material resources. These data indicate that health inequalities among children with bronchiolitis in Ontario (based on an examination of sex, location of residence, and material resources as potential equity stratifiers) did not improve over time. Although health inequalities also did not get worse over time, the existence of inequalities suggests that we need to reallocate effort and resources to those groups experiencing poorer outcomes to improve children’s health.

Few previous studies 15 , 20 have examined trends in bronchiolitis inequalities to examine whether the inequality gap is narrowing or widening. Fujiogi et al 15 examined bronchiolitis hospitalizations in the US from 2000 to 2016 in a serial cross-sectional analysis using the Kids’ Inpatient Database. In contrast to our data source, the Kids’ Inpatient Database does not contain data on the denominator of at-risk children. Thus, Fujiogi et al 15 could not determine population-based hospitalization rates by equity stratifiers to examine temporal trends. Chung et al 20 reported increasing hospitalization rates in Scotland from 2001 to 2016, with a hospitalization rate of 45 per 1000 children in the most deprived group vs 23 per 1000 in the least deprived group. In contrast to our findings, Chung et al 20 found a greater increase in the hospitalization rate in the most deprived compared with the least deprived group during 5 years, comparing 2011 with 2015. Other studies 16 , 19 , 20 , 32 - 35 quantify inequalities at one time point rather than examining trends in inequalities. These studies found higher rates of bronchiolitis ED visits or hospitalization based on race, Indigenous status, material deprivation, health care insurance provider, and maternal age in the US, Canada, New Zealand, and the UK.

Health system or bronchiolitis-specific interventions implemented during the study period might have affected bronchiolitis ED or admission rates. Between 2001 and 2006, the Ontario government introduced new primary care models characterized by group-based care, physician remuneration by salary (vs fee for service), pay for performance, and a requirement for after-hours services. 36 These primary care interventions are aimed at increasing primary care access and reducing ED visits and hospitalizations. However, we observed an increase in bronchiolitis-related ED visits over time.

For this 18-year study, we observed persistent health inequalities in bronchiolitis ED visit and hospitalization rates. Several underlying factors may contribute to the sustained inequality. Disparities in bronchiolitis outcomes based on sex have been reported in previous studies. 11 , 13 , 15 , 37 Both biological (ie, smaller airways in males and hormonal and immunologic difference) and possibly social factors have been suggested as explanations for higher rates of ED visits, hospitalizations, and severity of illness in males. 37 - 39 Residents of rural areas often face chronic health care infrastructure limitations from primary to tertiary care, leading to inadequate health care access and/or delayed medical care. 40 Socioeconomic disparities, including material deprivation, remain a pervasive issue, creating barriers to access and timely use of health care services. 41 , 42 Emerging preventive interventions hold promise in addressing inequalities in sex, residence location, material resources, and other equity stratifiers (eg, race and/or ethnicity). Vaccination for RSV and new RSV monoclonal antibodies (eg, nirsevimab) could prevent a substantial proportion of RSV-related bronchiolitis and, if implemented equitably, may narrow the health inequalities gap. 43 - 46 Evaluation of inequalities after implementation is important because it is possible that these interventions could also increase disparities in bronchiolitis outcomes if access to them is not equitable.

Several limitations to this study are important to consider. Data on individuals’ race, ethnicity, or indigeneity were unavailable in the data source; thus, we could not describe trends in health inequalities based on these important strata. Children with comorbidities are at risk for severe bronchiolitis and may not have been equally distributed across the groups examined. Rurality was measured using the most recent version of the rurality index of Ontario from 2008. It is possible that some jurisdictions moved from rural to urban since 2008. Such misclassification could bias the results toward finding less inequality. Our study focused on ED visits and hospitalization outcomes. Further studies examining inequalities in other important outcomes, such as length of stay and intensive care unit admission, are needed. Lastly, the findings of this study may not be generalizable to jurisdictions without universal health care coverage.

This population-based cohort study in a universally funded health care system found that inequalities in bronchiolitis ED and hospitalization rates from 2004 to 2022 did not improve. Future research should evaluate whether emerging preventive interventions, such as RSV vaccination and newer monoclonal antibodies, narrow the bronchiolitis inequalities gap.

Accepted for Publication: February 28, 2024.

Published: April 29, 2024. doi:10.1001/jamanetworkopen.2024.8976

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Mahant S et al. JAMA Network Open .

Corresponding Author: Sanjay Mahant, MD, MSc, Department of Pediatrics and Institute for Health Policy, Management, and Evaluation, University of Toronto, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay St, Toronto, ON M5G 0A4, Canada ( [email protected] ).

Author Contributions: Drs Mahant and Borkhoff had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mahant and Borkhoff made equal contributions to the manuscript as first authors.

Concept and design: Mahant, Borkhoff, Parkin, Imsirovic, Gill.

Acquisition, analysis, or interpretation of data: Mahant, Borkhoff, Parkin, Imsirovic, Tuna, Macarthur, To.

Drafting of the manuscript: Mahant, Borkhoff, Macarthur, Gill.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Borkhoff, Imsirovic, Tuna, Gill.

Administrative, technical, or material support: Mahant, Tuna, To.

Supervision: Mahant, Tuna.

Conflict of Interest Disclosures: Dr Parkin reported receiving grants from The Hospital for Sick Children Foundation and Canadian Institutes of Health Research and nonfinancial support from Mead Johnson outside the submitted work. Dr Tuna reported receiving grants from The Ottawa Hospital Research Institute during the conduct of the study. Dr Gill reported receiving grants from Physicians’ Services Incorporated Foundation, Canadian Institutes of Health Research, grants from The Hospital for Sick Children, serving as a member of the Canadian Institutes of Health Research’s Institute of Human Development Child and Youth Health advisory board, and serving on the EBMLive Steering Committee outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the Ontario Child Health Support Unit and by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. This manuscript used data adapted from the Statistics Canada Postal Code Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from Canada Post Corporation and Statistics Canada.

Role of the Funder/Sponsor: The Ontario Child Health Support Unit provided methodologic support for the study; otherwise, the funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The members of the Canadian Paediatric Inpatient Research Network are listed in the eAppendix in Supplement 1 .

Disclaimer: Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information and the Ontario Ministry of Health. The analyses, conclusions, opinions, and statements expressed herein are those of the authors and do not necessarily reflect those of the funding or data sources; no endorsement is intended or should be inferred.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Shan Dhaliwal, BSc, ICES, Ottawa, Ontario, Canada, made substantial contributions to the data analysis and did not receive payment for this work.

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New bipartisan bill seeks to tackle national child care shortage with help from the Pentagon

WASHINGTON — As the country faces a shrinking supply of child care workers and higher costs of care, a bipartisan duo of senators is taking steps to address the shortage, specifically targeted at helping service members who face unique challenges trying to access reliable child care.

Sens. Jeanne Shaheen, D-N.H., and Joni Ernst, R-Iowa, will introduce the Expanding Child Care for Military Families Act on Thursday, proposing a first-of-its-kind Defense Department-led pilot program to help child care providers near military installations train, recruit and retain staff members. The goal would be to boost the availability of care, for both military members and local civilians, by increasing workforce development opportunities for workers in the industry, using the Defense Department’s already existing resources.

“We have a workforce shortage, and to the extent that people look at the challenges of family life in the military — child care is one of those challenges, and that’s a deterrent for people to join the military. Anything we can do to address that is really important,” Shaheen said in an interview Wednesday.

The legislation would enable the Defense Department to enter into partnerships with both private and public child care centers on or near military installations and require it to participate in recruitment and retention programs for child care providers at participating centers.

Ernst, the first female combat veteran in the Senate, said the legislation is personal. “As a mom and a new grandma, I know it takes a village to raise a child and that our military members need high-quality, affordable child care for their young ones,” she said. “By boosting training and recruitment efforts, this bipartisan bill will ensure military kids are safe and loved while their parents diligently train and prepare to protect our nation.”

To further close the worker gap, the bill would also allow the Pentagon to work with AmeriCorps, a government agency for national service, to place its volunteers at participating child care facilities, and it would encourage the Pentagon to train and recruit military spouses to join the industry.

“That’s one of the biggest challenges right now,” Shaheen said of the staffing shortage. “One of the reasons that’s such a challenge is because the pay scale for child care teachers is so low, and often benefits are not provided for people, as well. So I think we need to think about all the ways that we can be creative to figure out how to get more people in the field.”

During the Covid-19 pandemic, the federal government spent $24 billion to help keep child care facilities afloat, but the funding expired in September, leaving many providers who relied on it unable to make ends meet .

A recent survey from the National Association for the Education of Young Children found that more than half of child care centers’ directors and operators reported staffing shortages.

Cora Hoppe, the director of Rochester Child Care Center, a nonprofit center in New Hampshire that would partner with the Defense Department if the new bill passes, said the provider shortage is particularly felt among families of service members, who deal with frequent moves that bring a unique set of challenges for parents.

“It can be harder for service members because of how far away [child care] can be from a base or if they don’t have access to it on an active base,” Hoppe said in an interview Tuesday. “It’s just an extremely important partnership, because when you have uncertainty everywhere else, it’s nice to have a certain partnership to help support you through that.”

The Rochester Child Care Center serves five to 10 military families at a given time and takes in military subsidies to help with expenses, but Hoppe said budgetary constraints and high operating costs recently caused her to have to let go of a quarter of her staff.

“There’s no wiggle room. There’s absolutely none. I’m in the classroom constantly. I have workers call out because they have sick kids. It’s all over the place,” she said.

Hoppe said that if she had access to additional resources from the Defense Department, she would have been able to hold on to her staff.

“The DoD’s backing would be huge, because then it would allow us to build our capacity,” she said.

“Right now, we’re all in silos. So to have a DoD program available, I think it could bring together more of the child care industry. It would bring us in less siloed positions and give us opportunities to work more together in order to collaborate to support these types of families.”

Shaheen, who has pushed for several measures to ease the burden for both parents and child care facilities, said she will continue to advocate for more accessible and affordable child care.

“We’ve got to be flexible in thinking about how we respond to the child care needs of families, that we need to provide options. There’s not a one-size-fits-all, and I think that’s particularly true for military families,” she said.

“I think this is an issue that there is no one magic silver bullet answer, and so we need to look at a whole variety of things. That’s why this kind of a pilot program would be really helpful,” she said.

Kate Santaliz is an associate producer for NBC News’ Capitol Hill team.

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