12 month well baby visit ontario

Ages & Stages

Checkup checklist: first birthday (12 months old).

​​​​​​Happy first birthday to your baby! That little bundle you first held is now a budding toddler, soon to take their first steps (if they haven't already). Be sure to share all your proud-parent moments with your pediatrician. Here's what you can expect at the 12-month checkup:

✅ Immunizations

At the 12-month visit, your baby may receive vaccines for measles, mumps and rubella (MMR), Hepatitis A , and Varicella (chickenpox). They may also be due for a booster shot for earlier vaccines. If it's flu season, your doctor will also recommend an influenza (flu) vaccine.

✅ Screenings

The doctor will check your child for anemia at this visit. Based on your child's risk, they may also test blood lead level, hearing, vision, and blood pressure. If your child may have been exposed to tuberculosis , they can do a skin test.

✅Feeding & development

Your pediatrician will measure and weigh your baby to make sure their growth is on track. They will also observe their development and behavior, and perform a physical exam.

Questions your pediatrician may ask

Has your baby tried to stand or take their first steps without support?

How is your baby doing with feeding themselves during meals and snacks?

If your baby is formula fed, have you started to switch to whole milk ?

Questions you may have

Why is the best way to react to a tantrum ? Are time-outs OK when my child isn't following directions?

How can I help my child fall asleep at bedtime?

How can I encourage my child to try new foods?

Is it normal for my baby's appetite​  to change a lot from meal to meal?

Do you have stair guards and window guards​ ? Where is the mattress positioned in the crib?

Do you apply sunscreen and put a hat on your child when they play outside?

Are there swimming pools or other potential water dangers near or in your home? Are you thinking about starting your child in a swimming program ?

How long do I need to keep pillows and other soft objects out of the crib?

Should I use a baby walker ?

Can I put the car safety seat in the front seat of my car?

✅ Communication tips

Never hesitate to call your pediatrician's office with any questions or concerns—even if you know the office is closed. If your pediatrician is unable to see you but believes your baby should be examined, they will advise you on the most appropriate place for your baby to receive care and how quickly your baby should be seen.

More information

• AAP Schedule of Well-Child Care Visits

The Hub – Family Medicine

Well child visit.

• Conduct an age-appropriate well child visit that includes physical exam, assessment of growth, nutrition, development, and education regarding injury prevention and safety risks.
• Address parental concerns, social context, and safety, and provide relevant anticipatory guidance (e.g. dental caries, family adjustment and sleeping position).
• Know the current childhood immunization schedule, be able to assess vaccination status of a child, and counsel parents on the risks and benefits of vaccinations.
• Use an evidence-based tool to help guide a well child visit, e.g. Rourke Baby Record, Greig Health Record.
• Identify common presenting concerns in newborns and children (e.g. jaundice, murmurs, autism), identify patients who require further assessment and perform the initial steps in management of these common presenting conditions.

Core Resources

Rourke baby record: evidence-based infant/child health maintenance.

Rourke L, Leduc D, Rourke J. Rourke Baby Record. Revised January 22, 2020.

18 Month Clinical Card

Rourke L, Leduc D, Li, P, Riverin B, Rourke J, Englert S, Power L. 18 Month Enhanced Visit. Canadian Family Medicine Clinical Card. 2016. Available at: https://sites.google.com/site/sharcfm/

Feeding your baby in the first year

Feeding your baby in the first year. Caring for your kids website. https://www.caringforkids.cps.ca/handouts/feeding_your_baby_in_the_first_year. Updated January 2020.

Greig Health Record 2016 Guidelines page 1

Greig A. Greig Health Record 2016: Selected Guidelines and Resources – Page 1. Canadian Paediatric Society. 2016. Available at http://www.cps.ca/

Greig Health Record 2016 Guidelines page 3

Greig A. Greig Health Record 2016: Selected Guidelines and Resources – Page 3. Canadian Paediatric Society. 2016. Available at http://www.cps.ca/

Greig Health Record 2016 Guidelines page 5

Greig A. Greig Health Record 2016: Selected Guidelines and Resources – Page 5. Canadian Paediatric Society. 2016. Available at http://www.cps.ca/

Newborn and Early Child Assessment E-Module

Law M, Mardimae A, Moaveni A et al. Newborn and Early Child Assessment: Family and Community Medicine Clerkship Core Curriculum Module. University of Toronto.

Publicly Funded Immunization Schedules for Ontario

Ontario Ministry of Health and Long-Term Care. Publicly Funded Immunization Schedules for Ontario. June 2022.

Supplemental Resources

Greig executive summary.

Greig AA, Constantin E, LeBlanc CM, et al. An update to the Greig Health Record: Executive summary. Paediatr Child Health. 2016;21(5):265-272.

Greig Health Record 2016 Guidelines page 2

Greig A. Greig Health Record 2016: Selected Guidelines and Resources – Page 2. Canadian Paediatric Society. 2016. Available at http://www.cps.ca/

Greig Health Record 2016 Guidelines page 4

Greig A. Greig Health Record 2016: Selected Guidelines and Resources – Page 4. Canadian Paediatric Society. 2016. Available at http://www.cps.ca/

Nutrition Healthy Term Infants 6 to 24 Months

Critch JN, Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Nutrition for healthy term infants, six to 24 months: An overview. Paediatr Child Health 2014;19(10):547-49. For a wealth of information  on child and youth health and well-being, visit www.cps.ca

Jaundice Clinical Practice Guideline

Canadian Paediatric Society The Hospital for Sick Children (‘SickKids’). Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants. Paediatr Child Health 2007;12(Suppl B):1B-12B. Available at https://cps.ca/en/

Child Obesity Recommendation

Canadian Task Force on Preventive Health Care. Child Obesity Recommendation. Copyright 2015 by University of Calgary. Available at http://canadiantaskforce.ca/

Enhanced 18-Month Well-Baby Visit

Role of the health care professional during an 18-month well-baby visit.

• Complete the Rourke Baby Record 2020 Ontario Version , an evidence-based guide to be used by primary health care workers in delivery of the enhanced well-baby visit
• Promote the LookSee Checklist by NDDS (previously Nipissing District Developmental Screen), a parent-completed developmental checklist designed to identify areas of concern requiring further attention
• Discuss healthy child development, and the provision of information about local parenting and community programs to promote healthy child development, with all parents
• Facilitate referrals to specialists for children with developmental concerns, and other community-based services for families with more complex needs

Additional recommended interventions

• Promote early literacy activities (reading, speaking and singing to babies) for all families
• Read, Speak, Sing: Promoting early literacy in the health care setting
• Support positive parenting in the early years
• Relationships matter: How clinicians can support positive parenting in the early years
• Screen for parental well-being, and offer support or referrals as needed for mental health, family conflict, anger, abuse / neglect, substance misuse, physical illness, housing / food insecurity and other adverse childhood experiences
• General and Family Practitioners: A002
• Pediatrics: A268

Accredited courses

• Supporting Healthy Child Development with Ontario's Enhanced 18-Month Well-Baby Visit
• Optimizing Well-Baby Care: Conducting an Enhanced 18-Month Well-Baby Visit
• Early Literacy Promotion: The A-B-Cs for busy clinicians

To learn more and register, visit professional development opportunities .

For use in practice

• Machealth provides a number of resources and tools to help you implement the enhanced 18-month well-baby visit in your practice

For parents

• 18-Month Well-Baby Visit Planner 
• Play & Learn
• Look and See Checklists
• Nutrition Screen
• Early Years Check-In

For more information, visit Ontario’s Enhanced 18-Month Well-Baby Visit .

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Healthy Babies Healthy Children program

Learn about the support available while you are pregnant, after your baby is born and as your child grows. Read parenting tips for your child’s first months.

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About healthy babies healthy children.

If you are pregnant or if your family has young children, Healthy Babies Healthy Children is a free and voluntary program that can help your family learn about:

• having a healthy pregnancy and birth
• connecting with your baby
• how you can help your child grow and develop
• breastfeeding, food and healthy nutrition
• taking care of yourself and your family
• services available for you and your child in your community

The Healthy Babies Healthy Children program is funded by the government of Ontario and delivered by your local public health unit.

Get a fact sheet about the Healthy Babies Healthy Children program . Chinese simplified | Arabic | Punjabi | Spanish | Tamil | ASL | LSQ

If you are pregnant , you can find a Health Babies Healthy Children program by asking your:

• family doctor
• other service provider

If you have a child who hasn't started school yet, contact your local public health unit .

To find out more about the program contact your local public health unit .

Parenting tips for the first few months

The early years of your child's life are a very exciting time. Your baby is learning about you and the world around them. You are your baby's best teacher. How you care, talk and play with your infant will influence how your child learns and grows.

Here are some suggestions to help you enjoy your time with your new baby in the first year:

• Babies love to be held. Take time to cuddle and hold your child.
• Comfort your baby when they cry.
• Learn your baby's cues — when they are hungry, sleepy or want to play with you.
• Breast milk provides all the nutrition your baby needs for the first six months. Feeding can be a special way to feel close to your baby.
• Speak in a soft, gentle voice to your baby.
• Talk to your baby about the things that are around them.
• Help your child explore safely. Share different textures, colours, sounds and smells.
• Share picture books and read simple stories, including in your first language.
• Babies learn naturally through play. Have fun through music, singing and dance.

Support for new parents

Having the right support in place during pregnancy and as a new parent can make the transition to parenting easier.

Find information to help during this time in your life. You can:

• read useful parenting information from the Canadian Paediatric Society
• do the Early Years Check-In questionnaire to identify concerns about how your child is developing
• try activities to help your child learn, grow and thrive (by Play and Learn )

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Getting it right at 18 months: In support of an enhanced well-baby visit

Evolving neuroscience reveals an ever-strong relationship between children’s earliest development/environment and later life experience, including physical and mental health, school performance and behaviour. Paediatricians, family physicians and other primary care providers need to make the most of well-baby visits—here a focus on an enhanced 18-month visit—to address a widening ‘opportunity gap’ in Canada. An enhanced visit entails promoting healthier choices and positive parenting to families, using anticipatory guidance and physician-prompt tools, and connecting children and families with local community resources. This statement demonstrates the need for measuring/monitoring key indicators of early childhood health and well-being. It offers specific recommendations to physicians, governments and organizations for a universally established and supported assessment of every Canadian child’s developmental health at 18 months.

L’évolution des neurosciences révèle une relation toujours solide entre le développement et les milieux de la petite enfance et les expériences plus tard dans la vie, y compris la santé physique et mentale, le rendement scolaire et le comportement. Les pédiatres, les médecins de famille et les autres dispensateurs de soins de premier recours ont besoin de mettre le plus à profit possible les bilans de santé, dans ce cas-ci le bilan de santé amélioré à 18 mois, afin de compenser une « inégalité des chances » croissante au Canada. Un bilan amélioré comprend la promotion de choix plus sains et de rôles parentaux positifs auprès des familles, l’utilisation de conseils préventifs et d’outils gérés par le médecin ainsi que l’établissement de liens entre les ressources communautaires locales et les enfants et leur famille. Le présent document de principes démontre la nécessité de mesurer et de surveiller les principaux indicateurs de la santé et du bien-être de la petite enfance. Il contient des recommandations destinées aux médecins, aux gouvernements et aux organismes visant une évaluation universelle et subventionnée de la santé développementale de chaque enfant canadien à 18 mois.

THE 18-MONTH WELL-BABY VISIT

Neuroscience has dramatically increased our understanding of the importance of the quality of early child development and its inextricable link to children’s behaviours, their capacity to learn and later health outcomes ( 1 – 4 ). This has increased attention on how the structure and process of well-baby visits can promote long-term health and well-being. There is tremendous potential for primary care providers to positively affect outcomes through regular contact with children and families in the early years. To fully realize this potential, paediatricians and family physicians must assess their current practice, updating where necessary with enhanced clinical practices and skills. Primary care providers—paediatricians, family physicians and others—must also play a stronger role as advocates within the child health system.

No longer are well-baby visits limited to immunization and early identification of variance or abnormality. Increasingly, the primary care role is to proactively recognize and help enhance the unique assets of all children and their families. Primary care providers promote a wide variety of positive behaviours (such as breastfeeding, quality parenting, child management, injury prevention, and pro-literacy activities), using anticipatory guidance and connecting children and their families to local community resources. For these interventions to be effective, the literature supports using a physician-prompt health supervision guide, having found that clinical judgment alone is not enough ( 5 ).

Although primary care providers have an opportunity to work with families and children to enhance early childhood development at each well-baby visit, some jurisdictions have selected a pivotal visit as a starting point for universal, system-focused improvements. The 18-month encounter offers many opportunities: Not only is it seen as a crucial time in children’s development, but it is also a time when families face issues such as child care (especially centre-based care, which typically starts at this age), behaviour management, nutrition/eating and sleep. Screening for parental morbidities (mental health problems, abuse, substance misuse, physical illness) is an important task at all well-child visits, and particularly at this one.

The 18-month visit is often the final regularly scheduled visit (involving immunizations) with a primary care provider before school entry. Apart from illness-related visits, it may be the last time a child and family see their primary care provider until the child is four years of age or starts school. It is critical that families know how to promote healthy development during this important period of life and be alert to signs of difficulty, including problems with self-regulation, communication and language. They need to know when to consult their primary care provider, and how to connect with supportive community resources.

Primary care providers must be aware of available services and be involved in identifying barriers and facilitating access to assessment and care for their patients.

THE OPPORTUNITY GAP

Measurement of the sensitive indices of early child development in senior kindergarten (age 5) across Canada, through the use and analysis of the Early Development Instrument (EDI), shows that significant numbers of children are not adequately prepared for their school experience. Approximately 27% of Canadian kindergarten children score as ‘vulnerable’ on the EDI, when vulnerability rates greater than 10% can be considered ‘excessive’. In other words, approximately two-thirds of the developmental vulnerabilities (language/cognitive, physical or social-emotional) that children present with in school are preventable ( 6 ). The rates of vulnerability vary widely across Canadian neighbourhoods—from less than 5%, to nearly 70% of children—depending on socioeconomic, cultural, family and local governance factors.

When children fall behind, they tend to stay behind ( 7 , 8 ). Being a vulnerable child on the EDI negatively affects children’s school performance, reduces their well-being and decreases their chances of getting a decent job later in life. Each 1% of excess vulnerability will reduce Canada’s gross domestic product by 1% over the working lifetime of these children ( 9 ). Thus, if Canada fails to address developmental vulnerability in the early years, economic growth will likely be reduced by 15% to 20% over the next 60 years ( 10 ).

WELL-BABY VISITS IN OTHER COUNTRIES

Across the developed world, there are a wide variety of approaches to well-baby visits, and to the tools used to monitor and promote early child development. The Offord Centre for Child Studies (Hamilton, Ontario) recently completed a scan of developed countries to determine how well-baby/child visits are organized and which tools are used ( 11 ). The focus was on health and developmental surveillance and screening in children younger than six years of age in Canada, the United States, England, Ireland, Northern Ireland, Scotland, Australia, New Zealand, the Netherlands and Sweden. The number of surveillance visits for children younger than six years of age ranged from four in Scotland to 15 in Sweden, the Netherlands and the United States. The content of these visits ranged from immunization, growth monitoring and developmental screening to anticipatory guidance.

While developmental surveillance occurs in most countries, many do not recommend the use of standardized and validated development screening tools at well-baby/child visits, unless there is cause for concern. Scotland’s Hall 4 guidelines ( 12 ), along with the European Union’s Child Health Indicators of Life and Development (CHILD) project, have recommended that countries focus on child development surveillance and discourage general developmental screening. Most of these countries keep track of child development with the use of simple milestone checklists instead of a validated tool. In many countries (the United Kingdom, Ireland, Scotland, Australia, the Netherlands), using parent-held child health records has allowed families to play a larger role in child development monitoring. Parents can keep track of and record their child’s development in a universally available book, which is then reviewed by a health professional. Tools such as the ASQ (Ages & Stages Questionnaire) ( 13 ) and PEDS (Parents’ Evaluation of Developmental Status) ( 14 ) may also be used for parental input.

THE 18-MONTH VISIT IN CANADA

A scan of common practice in Canadian provinces at the 18-month visit ( 15 ) shows that while this is a consistent point in time for immunization, there is great variety in how, where and in what context vaccines are given. Well-child visits, including immunizations, are performed by family physicians or paediatricians in New Brunswick, Nova Scotia and Ontario, though in areas with few physicians (eg, Northern Ontario), public health nurses administer vaccines. The physician visits typically include a physical health assessment, anticipatory guidance and immunizations.

Public health nurses administer vaccines in Prince Edward Island, Alberta and Newfoundland-Labrador, in addition to activities such as physical assessment and connecting families to community resources. Manitoba has a mixed model of public health nurses and physician strategies. Alberta has recently completed a pilot project in five communities using the ASQ at screening clinics. Saskatchewan, Nova Scotia and Manitoba have initiated pilot projects. Information for Quebec and the Yukon Territory was not available at time of writing, and the Northwest Territories and Nunavut were not surveyed.

THE ONTARIO SYSTEM

In October 2009, Ontario introduced an enhanced 18-month well-baby visit with a new physician fee code. This followed extensive work by an expert panel, including the Ontario College of Family Physicians and the Ministry of Children and Youth Services, which reviewed the evidence for such a visit and proposed a series of recommendations to government and the Ontario Medical Association ( 16 ).

Recognizing that the 18-month visit is the last regularly scheduled primary care encounter (involving immunizations) before school entry, the panel recommended that the focus shift from a well-baby check-up to a pivotal assessment of developmental health. The panel also recommended introducing a process using standardized tools—the Rourke Baby Record and the Nipissing District Developmental Screen—to facilitate a broader discussion between primary care providers and parents about:

• child development;
• access to local community programs and services that promote healthy child development and early learning; and
• promoting early literacy through book reading.

In a survey, Ontario physicians said that the time needed to complete an enhanced visit was the most significant barrier to implementing it. They also expressed concern that identifying children with developmental needs without having adequate community supports for referral and treatment created a moral dilemma for physicians ( 16 ).

To support planned system enhancement and change, a web portal ( www.18monthvisit.ca ) was created by the Offord Centre for Child Studies and MacHealth (Hamilton, Ontario) for educational purposes. Also, in collaboration with the Foundation for Medical Practice Education, a Practice-Based Small Group (PBSG) module was developed. The work has proceeded in partnership with Ontario’s Best Start strategy, which supports communities in developing early child development parenting and resource pathways and in actively addressing wait list issues.

DEVELOPING A POPULATION HEALTH MEASUREMENT TOOL FOR 18 MONTHS

How are 18-month-olds in Canada doing? Unfortunately, we don’t know, since there is no common tool used to measure their developmental progress. However, in collaboration with the Offord Centre for Child Studies, a pan-Canadian group is exploring the development of a population health measurement tool for use at 18 months. Given that children in different parts of Canada are assessed using different tools (for example: in some provinces nurses administer the ASQ, while in Ontario, physicians use the Rourke Baby Record and Nipissing District Developmental Screen), creating a common platform for 18-month monitoring is a challenge. Efforts are currently underway to determine whether the ASQ could be shortened without loss of validity, such that it could be used by physicians in a fee-scheduled visit ( 17 ).

RECOMMENDATIONS

The Canadian Paediatric Society recommends strengthening the early childhood development system across Canada through a series of activities.

For primary care providers, in the clinical setting:

• A physician-prompt health supervision guide with evidence-informed suggestions (such as the Rourke Baby Record).
• A developmental screening tool (the most widely used are the Nipissing District Developmental Screen, ASQ, and PEDS/PEDS:DM) to stimulate discussion with parents about their child’s development, both how they can support it as well as any concerns they may have.
• Screening for parental morbidities (mental health problems, abuse, substance misuse, physical illness).
• Promotion of early literacy activities (reading, speaking and singing to babies) for every family ( 18 ).
• Information about community-based early child development resources for every family (parenting programs, parent and early learning resource centres, libraries, recreational and community centres, etc. See www.cps.ca and www.18monthvisit.ca for links).
• Paediatricians and family physicians must keep their professional skills current to ensure they can identify children who require further investigation, diagnosis and treatment. All children who are not meeting developmental milestones and expectations, including socio-emotional development, self-regulation and attachment, should be referred to both community-based early years resources as well as to more specialized, developmental assessments and interventions, as appropriate.

For primary care providers, in their communities:

Paediatricians and family physicians should:

• Advocate locally for the development and enhancement of early years resources, including programs and policies that benefit young children.
• Advocate for the implementation of an enhanced 18-month well-baby visit in all provinces and territories, supported by standard guidelines (see 1, above) and a special fee code.
• Promote the implementation of an enhanced 18-month well-baby visit to their colleagues, including other health care professionals, through informal and formal channels (continuing medical education opportunities, resident training and curriculum enhancement).
• Support and participate in pilot programs and research initiatives to identify cost-effective and outcome-based interventions that contribute to closing the gap between children who do well and those who do poorly.

For governments and child-focused organizations:

Achieving system-wide change will require governments and organizations to:

• Work toward the creation of and sustained funding for an early child development system, including an enhanced 18-month well-baby strategy for all Canadian children.
• Ensure that provinces and territories support the enhanced 18-month well-baby strategy with standard guidelines and a special fee code.
• Develop a comprehensive system of measurement and monitoring that collects appropriate data on the progress of Canada’s young children and their families. Such a system would include regular cycles of the EDI in kindergarten and developing other measures (for use at 18 months, in the middle years and beyond) that can be linked, compared and regularly analyzed and reported on. These data would inform actions at the clinical practice, community and government levels.
• Promote and support research initiatives to determine whether there is a need for a regularly scheduled well-child visit between the ages of 18 months and 4 years.

Acknowledgments

This statement has been reviewed by the Canadian Paediatric Society’s Community Paediatrics Committee and the Developmenal Paediatrics Section (Executive Committee), and by Dr Emmett Francoeur of Montreal, Quebec.

EARLY YEARS TASK FORCE

Members: Robin Williams MD (Chair until June 30, 2011); Sue Bennett MD; Jean Clinton MD; Clyde Hertzman MD; Denis Leduc MD; Andrew Lynk MD

Principal authors: Robin Williams MD; Jean Clinton MD

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Please consult the Position Statements section of the CPS website ( www.cps.ca ) for the full-text, current version.

Your Guide to Well-Baby Visits

Medical review policy, latest update:, what are well-baby visits and why are they so important, when will my child's well-baby visits happen, read this next, what you can expect at well-baby visits, tips on making the most of well-baby visits, time it right, make a checklist, write down your questions, have some answers, too, dress baby for success.

What to Expect the First Year , 3rd edition, Heidi Murkoff. WhatToExpect.com,  Your Baby's Vaccine Schedule: What Shots Should Your Child Get When? , January 2021. American Academy of Pediatrics, AAP Schedule of Well-Child Care Visits , September 2021. American Academy of Pediatrics, Checkup Checklist: 1 Month Old , September 2021. KidsHealth From Nemours,  Your Child's Checkup: 1 Month , April 2021.

Go to Your Baby's Age

Trending on what to expect, the covid-19 vaccine for infants, toddlers and young children, how to create a night shift system when you have a newborn, ⚠️ you can't see this cool content because you have ad block enabled., when do babies start laughing, baby-led weaning, what happens in the ‘4th trimester’ (and is it a real thing).

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.

Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract. 2013;1(1):29-36.

Grossman DC, Bibbins-Domingo K, Curry SJ, et al. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.

Daniels SR, Hassink SG Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275-e292.

American Academy of Family Physicians. Physical activity in children. https://www.aafp.org/about/policies/all/physical-activity.html . Accessed January 1, 2018.

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Ontario and the enhanced 18-month well-baby visit: Trying new approaches

Affiliation.

• 1 Niagara Region Public Health, Thorold, Ontario.
• PMID: 19436551
• PMCID: PMC2603505
• DOI: 10.1093/pch/13.10.850

Abstract in English, French

In Ontario, the 18-month well-baby visit is the last scheduled primary care visit before school entry. Recognizing the importance of this visit and the role that primary care plays in developmental surveillance, an Ontario expert panel recommended enhancing the 18-month visit. Their recommendations are based on evidence from multiple disciplines, which underscore the reality that the quality of the early years experience establishes trajectories of health and well-being for children. An underlying premise of the recommendations is that when there are collaborations among parents, primary care, community health and child development services, the outcomes for children will be improved. The present article focuses on two Ontario pilot projects that were funded to discover how, in real life primary care settings, the recommendations could be implemented and outcomes measured. Findings and insights were significant, and future directions are clear, as the strategy for an enhanced 18-month well-baby visit is implemented in the future for Ontario.

En Ontario, la visite de 18 mois de l’enfant bien portant est la dernière visite de première ligne prévue avant la rentrée scolaire. Conscient de l’importance de cette visite et du rôle des soins de première ligne sur la surveillance du développement, un groupe d’experts de l’Ontario a recommandé de l’améliorer. Leurs recommandations se fondent sur des données multidisciplinaires probantes selon lesquelles la qualité de l’expérience des premières années établit des trajectoires de santé et de bien-être pour les enfants. Selon une prémisse sous-jacente des recommandations, grâce à une collaboration entre les parents ainsi que les services de soins de première ligne, de santé communautaire et de développement des enfants, le devenir des enfants s’améliore. Le présent article porte sur deux projets pilotes ontariens mis sur pied pour découvrir comment, en soins de première ligne réels, il serait possible d’implanter les recommandations et de mesurer les issues. Ces projets ont suscité des observations et des constatations importantes et de futures orientations tellement claires que la stratégie en vue d’offrir une visite de 18 mois améliorée pour le bébé bien portant sera mise en oeuvre en Ontario.

18-Month Pathway

The 18-month enhanced well-baby visit (OHIP: A002, A268) provides healthcare providers an opportunity to identify growth and development concerns by using the Looksee Checklist ® (formerly Nipissing District Developmental Screen ® ) and Rourke Baby Record. Based on your findings, refer your patients to specialized services for early intervention.

To speak to a Public Health Nurse, or to refer to the Healthy Growth and Development home visiting program, call 613-PARENTS (613-727-3687) or visit OttawaPublicHealth.ca/PHNReferral .

Parenting in Ottawa Drop-ins Prenatal to 6 Years available daily! Parents can speak, in person, with a Public Health Nurse about all areas of parenting, including but not limited to infant feeding support, safe sleep, growth and development and perinatal mental health. For more information call 613-PARENTS (613-727-3687) or visit ParentinginOttawa.ca/dropins .

Do you have more questions?

• Speak with a Public Health Nurse. Call the Ottawa Public Health Info Centre at 613-PARENTS [613-727-3687]  (TTY: 613-580-9656) or email Ottawa Public Health at [email protected]
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• There are a variety of services to make it easier for your child to grow up healthy in Ottawa 

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Well-Child Visit: 1 Year (12 Months)

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What to Expect During This Visit

Your doctor and/or nurse will probably:

1. Check your toddler's weight, length, and head circumference and plot the measurements on a growth chart .

2. Ask questions, address concerns, and offer advice about how your child is:

Eating . By 12 months, toddlers are ready to switch from formula to cow's milk . Children may be breastfed beyond 1 year of age, if desired. Your child might move away from baby foods and be more interested in table foods. Offer a variety of soft table foods and avoid choking hazards.

Pooping. As you introduce more foods and whole milk, the look of your child's poop (and how often they go) may change. Let your doctor know if your child has diarrhea, is constipated , or has poop that's hard to pass.

Sleeping. One-year-olds need about 11–14 hours of sleep a day, including 1–2  naps .

Developing. By 12 months, most toddlers:

• call parents  "mama" and "dada"  or another special name
• understand “no” (pause briefly or stop when you say it)
• wave bye-bye
• enjoy pat-a-cake and other social games
• can put something in a container, like a block in a cup
• look for things that someone hides
• pull to stand
• walk while holding onto furniture ("cruising")
• pick things up with their thumb and pointer finger

Talk to your doctor if your toddler is not meeting one or more milestones, or you notice that your toddler had skills but has lost them.

3. Do an  exam with your child undressed while you are present.

4. Update immunizations. Immunizations can protect kids from serious childhood illnesses, so it's important that your child receive them on time. Immunization schedules can vary from office to office, so talk to your doctor about what to expect.

5. Order tests. Your doctor may check for lead , anemia , or tuberculosis , if needed.

Looking Ahead

Here are some things to keep in mind until your child's next checkup at 15 months :

• Give  whole milk (not low-fat or skim milk, unless the doctor says to) until your child is 2 years old.
• Limit the amount of cow's milk to about 16–24 ounces (480–720 ml) a day. Move from a bottle to a cup . If you're breastfeeding, you can offer pumped breast milk in a cup.
• Serve 100%  juice in a cup and limit it to no more than 4 ounces (120 ml) a day. Avoid sugary drinks like soda.
• Include iron-fortified cereal and iron-rich foods (such as meat, tofu, sweet potatoes, and beans) in your child's diet.
• Encourage self-feeding . Let your child practice with a spoon and a cup.
• Have your child seated in a high chair or booster seat at the table when drinking and eating.
• Serve 3 meals and 2–3 scheduled  healthy snacks a day. Don't be alarmed if your child seems to eat less than before. Growth slows during the second year and appetites tend to decrease. Let your child decide how much to eat. Talk to your doctor if you're worried.
• Avoid foods that can cause choking , such as whole grapes, raisins, popcorn, pretzels, nuts, hot dogs, sausages, chunks of meat, hard cheese, raw veggies, or hard fruits.
• Avoid foods that are high in sugar, salt, and fat and low in nutrition.
• Babies learn best by interacting with people . Make time to talk, sing, read , and play with your child every day.
• TV viewing (or other screen time, including computers) is not recommended for kids under 18 months old. Video chatting is OK.
• Have a safe play area and allow plenty of time for exploring .

Routine Care & Safety

• Brush your child's teeth with a soft toothbrush and a tiny bit of toothpaste (about the size of a grain of rice) twice a day. Schedule a dentist visit soon after the first tooth appears or by 1 year of age. To help prevent cavities, the doctor or dentist may brush fluoride varnish on your child’s teeth 2–4 times a year.
• Never spank or hit your child. When unwanted behaviors happen, say “no” and help your child move on to another activity. You can use a brief time-out instead.
• Continue to keep your baby in a rear-facing car seat in the back seat until your child reaches the weight or height limit set by the car-seat manufacturer.
• Avoid sun exposure by keeping your baby covered and in the shade when possible. You may use sunscreen (SPF 30) if shade and clothing are not protecting your baby from direct sun exposure.
• Install safety gates and tie up drapes, blinds, and cords.
• Keep locked up/out of reach: choking hazards; medicines; toxic substances; items that are hot, sharp, or breakable.
• Keep emergency numbers, including the Poison Control Help Line number at 1-800-222-1222 , near the phone.
• To prevent drowning , close bathroom doors, keep toilet seats down, and always supervise your child around water (including baths).
• Protect your child from secondhand smoke , which increases the risk of heart and lung disease. Secondhand vapor from e-cigarettes is also harmful.
• Protect your child from gun injuries by not keeping a gun in the home. If you do have a gun, keep it unloaded and locked away. Ammunition should be locked up separately. Make sure kids can't get to the keys.
• Talk to your doctor if you're concerned about your living situation . Do you have the things that you need to take care of your child? Do you have enough food , a safe place to live, and health insurance ? Your doctor can tell you about community resources or refer you to a social worker.

These checkup sheets are consistent with the American Academy of Pediatrics (AAP)/Bright Futures guidelines.

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Well Baby Visit, 12 Months

Topics to discuss with patients during their well baby visit at 12 months.

• anthropometric measurements (link to Optimizing Nutrition for Newborns and Infants/Nutrition Assessment Tools/Term Infant Growth Tools/WHO Growth Charts for Infants 0 to 24 Months)
• physical examination
• screen for iron deficiency and iron deficiency anemia
• babies who are breastfeeding beyond one year may need addition iron screening if iron intake is inadequate
• overweight babies >12 months may be given 2% milk but not skim milk
• continue vitamin D at 400 IU/day

Consider Referral

• Growth faltering (failure to thrive)

Additional Information

• Gastroesophageal reflux and gastroesophageal reflux disease: Parent FAQs , American Academy of Pediatrics.
• Parent’s Guide to GER (Gastroesophageal Reflux Disease) and GERD (Gastroesophageal Reflux Disease) (handout), American Academy of Pediatrics
• Solid Food (Baby Foods) (handout), American Academy of Pediatrics
• Tips for Introducing Solid Foods (handout), American Academy of Pediatrics
• Food Allergy (handout), American Academy of Pediatrics
• Food Allergy and Your Child (handout), American Academy of Pediatrics
• Anaphylaxis (handout), American Academy of Pediatrics
• Common Food Allergies , American Academy of Pediatrics.
• Lactose Intolerance and Your Child (handout), American Academy of Pediatrics.

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