Anticipatory guidance and screening in childhood

• Well-child care follows a predictable calendar: visits in the newborn period and at roughly 1, 2, 4, 6, 9 and 12 months, then at 15, 18, 24 and 30 months, and annually thereafter.
• Anticipatory guidance changes by age: safe sleep and breastfeeding in infancy; car seats, injury prevention and toilet training in early childhood; screen time at every age; confidentiality and self-care in adolescence.
• Hearing is screened in every newborn, usually with otoacoustic emissions (OAE) or automated auditory brainstem response (AABR), with ongoing surveillance for children with risk factors.
• Vision is screened from birth with red reflex testing, later with instrument-based screening and finally with age-appropriate optotypes; early detection reduces persistent amblyopia by more than half.
• Development is screened formally at 9, 18 and 30 months, autism at 18 and 24 months, iron status at 9 to 18 months depending on diet, and blood lead testing follows local epidemiology.
• An abnormal screen is not a diagnosis: it is a trigger for closer assessment, counselling, referral and follow-up, as shown in the flowchart below.

By the end of this page you should be able to:

1. Plan the content of an age-appropriate well-child visit from the newborn period to late adolescence.
2. Give current, practical advice on safe sleep, car seats, feeding, injury prevention, screen time and toilet training.
3. Describe newborn hearing and vision screening, the risk factors that modify them, and the ages at which each test is used.
4. State when developmental, autism, iron and lead screening should be done and which tool or test is used.
5. Explain how adolescent health supervision differs from child health supervision.
6. Outline the steps after an abnormal or failed screening result.

This page is about routine health supervision rather than the treatment of an illness. Health supervision means scheduled visits for a child who is growing and developing satisfactorily, at which the clinician monitors growth and development, provides anticipatory guidance (advice tailored to the next stage of life), delivers immunisations, and screens for conditions that are common, serious and treatable if found early. The recommendations below reflect the major North American and international guidelines available in 2026; local schedules, screening programmes and reporting requirements differ, so check the guideline or public health rules where you practise. The rhythm of visits is front-loaded: in the first year a child is seen at birth, at 3 to 5 days, and at 1, 2, 4, 6, 9 and 12 months. After that, visits at 15, 18, 24 and 30 months, then yearly, cover the rest of childhood and adolescence. ^[1]

Every child, from birth to 21 years of age, is the indication. The goals are prevention of injury and sudden infant death, optimal nutrition and growth, detection of vision or hearing impairment before it distorts language or learning, early identification of developmental delay, and support of the family through the transitions of each age. Anticipatory guidance is the single intervention that touches every visit. ^[1]

There is no contraindication to a well-child visit. Cautions are practical rather than medical: a child who is acutely unwell may need the preventive visit deferred; screening questionnaires and tests must be validated for the language and culture in which they are used; and a positive screen is not a diagnosis, so it should prompt further assessment rather than a label. Screening should be organised so that a positive result can be acted on: a test sent with no follow-up plan harms more than it helps.

Preparation is mostly informational. Before each visit in early childhood it helps to ask the parent what has changed since the last visit and whether they have concerns. Recommended screening tools and validated questionnaires (for example, developmental and behavioural checklists) can be completed in the waiting room. Explicit consent for examination is routine; in adolescence, the visit increasingly involves time alone with the young person, and confidentiality should be explained at the outset. ^[6]

A preventive visit can be thought of in five steps.

1. Review and surveillance: elicit parental concerns, review history (including risk factors such as prematurity, lead exposure and family history), and observe the child. ^[6]
2. Developmental surveillance: ask age-appropriate questions and use validated tools at the scheduled ages (see below). ^[6]
3. Examination: growth (weight, length or height, head circumference in infants, body-mass index in older children), vital signs including blood pressure from age 3 years, and a complete physical examination with special attention to eyes, ears, heart, hips in infants, and spine and gait in older children. ^[1]
4. Immunisation and screening: give due vaccines and perform the screening tests scheduled for that age (blood tests, vision and hearing checks). ^[1]
5. Anticipatory guidance: targeted advice for the next 6 to 12 months, plus referral or monitoring plans. ^[1]

The content of counselling is age-determined. The subsections below group the topics that come up repeatedly: safe sleep, car safety, nutrition and breastfeeding, injury prevention, screen time, and toilet training. These topics are distributed across visits rather than covered once: car safety is discussed at every visit because restraint needs change with size, and screen-time advice changes dramatically with age.

Sleep-related infant deaths include sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. About 3500 infants die this way each year in the United States. The main advice is consistent across age 0 to 12 months: place the infant on the back for every sleep, on a firm, flat, non-inclined surface, in the parents' room but on a separate sleep surface, with no soft objects or loose bedding. Room sharing without bed sharing is protective for at least the first 6 months. Breastfeeding is associated with reduced risk; avoiding nicotine, alcohol, marijuana, opioids and illicit drugs in pregnancy and afterwards, avoiding overheating and head covering, and keeping the immunisation schedule up to date are also recommended. Supervised, awake tummy time should begin soon after discharge and increase to 15 to 30 minutes daily by 7 weeks of age. Swaddling has no evidence for SIDS prevention and is unsafe once an infant shows signs of rolling (usually 3 to 4 months); weighted swaddles are not recommended. Couches and armchairs are extremely dangerous places for infant sleep (a 22- to 67-fold increased risk). ^[1]

Motor-vehicle crashes are the leading cause of death for children 4 years and older. Children should ride rear-facing in an approved seat as long as possible, then forward-facing with a harness at least through 4 years of age, then in a belt-positioning booster at least through 8 years, and finally in a lap and shoulder belt. Boosters are used until the adult belt fits properly, typically at 4 ft 9 in and between 8 and 12 years. All children younger than 13 years should be restrained in the rear seats. Transitions should be delayed as long as the seat's limits allow, because every step down reduces protection. Paediatricians should cover this at every health-supervision visit. ^[2]

The standard is exclusive breastfeeding for about 6 months, with complementary foods starting at about 6 months and continued breastfeeding for 2 years or beyond if mother and child wish. Complementary foods should include iron- and zinc-rich choices such as finely ground meat, chicken or fish, with texture adjusted for age and avoidance of added sugar and salt. Human milk has antimicrobial and immunoregulatory factors and is associated with lower rates of lower respiratory tract infection, severe diarrhoea, otitis media and obesity at 6 months of exclusive feeding. Medical contraindications are rare (classic galactosemia and certain maternal infections in some regions). Frequent on-demand feeding, at least 8 to 10 times in 24 hours, helps newborn weight gain and lowers the risk of significant jaundice. After the first year, cow or plant-based milk should not replace iron-rich foods, and intake should stay under 24 ounces (about 700 mL) per day to protect iron status. ^[3][14]

Beyond safe sleep and car seats, counselling is layered by age and by local epidemiology. In infancy the emphasis is on falls, burns, drowning and poisoning: install barriers on stairs, never leave an infant unattended on a changing surface, set the water-heater temperature to safe levels, store medicines and cleaning agents out of reach or locked away, and supervise around water even in small containers. Smoke alarms and seat-belt use for the whole family are standard advice. In early childhood, outdoor safety, helmet use on bicycles and scooters, water safety and gun storage (locked, unloaded, ammunition stored separately where firearms are present) are added. Injury prevention is the one health-supervision topic recommended at every visit. ^[2]

Digital-media advice is age-stratified. For children younger than 18 months, discourage screen media other than video-chatting. For 18 to 24 months, if parents wish to introduce media, choose high-quality content and co-view. For 2 to 5 years, limit screen use to 1 hour or less per day of high-quality programming, co-viewed, with no screens during meals and none for 1 hour before bedtime. Recommendations for children 6 years and older move from time limits to a personalised Family Media Plan that protects sleep, physical activity, school and relationships. Media should not be used as the only way to calm a child. ^[4]

There is no single right age. Readiness skills and the physical maturity needed usually develop between 18 months and 2.5 years, and starting intensive training before age 2 is not generally recommended. Readiness signs include staying dry for a couple of hours, being able to sit, squat and stand, following simple instructions, showing interest and communicating the need to go, and the ability to pull clothing down. Training should be started when the child is well, not during illness or major family change; parents should use consistent, calm steps, avoid punishment or pressure, and coordinate the plan with all caregivers. Night-time dryness can come up to a year later than daytime dryness. ^[5]

Screening is organised around the senses, development and common, treatable conditions. A screen is not a diagnosis: a positive result means "look closer".

All newborns should have physiologic hearing screening, usually by automated otoacoustic emissions (OAE, which tests outer-hair-cell function in the cochlea) or automated auditory brainstem response (AABR, which also tests the neural pathway). Sensorineural hearing loss occurs in 1 to 3 per 1000 live births in term healthy neonates and in 2 to 4 per 100 infants in high-risk groups, so targeted screening alone would miss too many children. OAE can miss auditory neuropathy; OAE pass rates are lower in the first days because of debris and fluid in the ear canal. The Joint Committee on Infant Hearing target is the 1-3-6 pathway: screen by 1 month, diagnosis by 3 months, intervention by 6 months, with a preferred 1-2-3 month timeline in mature programmes. EHDI goals are optimal language and social outcomes, and even mild hearing loss affects speech and language. ^[8][9]

Risk factors that call for continued surveillance or repeat testing after a pass include: family history of early, progressive or delayed-onset permanent childhood hearing loss; neonatal intensive care of more than 5 days; hyperbilirubinemia needing exchange transfusion; aminoglycoside use for more than 5 days; asphyxia or hypoxic-ischaemic encephalopathy; ECMO; in utero infections such as CMV, herpes, rubella, syphilis and toxoplasmosis; craniofacial malformations and many syndromes; culture-positive bacterial or viral meningitis or encephalitis; and caregiver concern. Congenital CMV, in particular, has a larger impact than previously recognised. Children who pass should still have hearing and speech milestones monitored at well visits; most late-onset losses are not detected by newborn screening. ^[8]

Vision screening begins in the newborn period and continues through childhood. In every infant the clinician should perform external inspection of the lids and eyes, red reflex testing and a check that fixation and following are present (fixation should develop by 6 months). Red reflex testing is done in a darkened room with a direct ophthalmoscope, looking at both pupils from arm's length; the two reflexes should match in colour, brightness and size. A white (leukocoria), dark or asymmetric reflex, or absent reflex, needs urgent referral: causes include cataract, corneal opacity, retinoblastoma and retinal detachment. The red reflex is repeated at the 12-month, 1 to 3-year, 4 to 5-year and 6-year-plus visits. ^[10][11]

Instrument-based screening (photoscreening or autorefraction) should be attempted between 12 months and 3 years of age and annually until acuity can be tested directly; it detects amblyopia, refractive error and strabismus. Direct (optotype) acuity testing can often start by 3 to 4 years. Vision screening in early childhood reduces persistent amblyopia at 7 years by more than 50%, though it cannot detect every cause. Referral triggers include failed screening, asymmetric or poor acuity, strabismus, anisocoria, ptosis, refractive-error or family history of amblyopia or strabismus, and preterm birth (screened for retinopathy of prematurity under neonatal guidance). ^[10]

Strabismus and amblyopia deserve emphasis. Amblyopia is reduced vision in an eye because of abnormal visual experience in childhood (most often from strabismus, refractive error or deprivation). The visual system is plastic only in early childhood, so treatment before 7 to 8 years is far more effective than later. A squint in a young child is never "just cosmetic": anywhere from a transient misalignment in the first months to a constant deviation needs ophthalmic assessment, because untreated strabismus commonly causes amblyopia. ^[10]

Developmental surveillance should be part of every preventive visit, and standardised screening should be applied at 9, 18 and 30 months (the 30-month test can be done at 24 months if attendance is a problem). Validated tools include the Ages and Stages Questionnaires, Parents' Evaluation of Developmental Status and the Survey of Well-being of Young Children. Surveillance has five components: eliciting and attending to parental concerns; a developmental history; accurate observation of the child; identifying risk and protective factors; and documenting findings. Risk factors include prematurity, low birth weight, known genetic or neurological conditions, sensory impairment, social adversity and family history. School-readiness screening before preschool or kindergarten is a useful addition. ^[6]

Autism spectrum disorder (ASD) can be suspected before the first words fail to appear. The American Academy of Pediatrics recommends standardised autism screening at 18 months and again at 24 months, using a tool validated in primary care such as the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F), which is designed for children 16 to 30 months. In low-risk settings a positive screen led to an eventual ASD diagnosis in roughly half of cases in a 2023 meta-analysis (about 90% had at least some developmental disorder), so counselling after a positive screen should be cautious but prompt: the screen is not a diagnosis but it does require timely developmental and medical evaluation and early intervention. Repeated screening at 18 and 24 months improves detection. ASD prevalence is about 1% worldwide and 2.3% in the United States; early behavioural intervention before 24 months of age is associated with better cognitive and adaptive outcomes. ^[7]

Iron deficiency and iron-deficiency anaemia peak in late infancy and toddlerhood. Current guidance (2026) recommends universal laboratory screening for iron deficiency and iron-deficiency anaemia in all infants and young children between 9 and 18 months, with the exact timing based on the main source of nutrition during the first year: 9 to 12 months for an infant whose primary nutrition is human milk, and 15 to 18 months for one fed iron-fortified formula (the highest-risk window is the transition to cow's or plant-based milk, especially over 24 ounces per day). Screening consists of a complete blood count (haemoglobin and red-cell indices) plus serum ferritin, or at minimum haemoglobin if ferritin is unavailable. A ferritin of 20 ng/mL or less indicates iron deficiency in young and school-aged children, and 30 ng/mL or less in adolescents. Children with risk factors (excessive milk intake, inadequate iron-containing foods, obesity or social adversity) should be re-screened at each subsequent well-child visit until 4 years of age. Universal screening with a complete blood count and ferritin is also recommended for all adolescents who are at least 1 year post-menarche but no later than 14 years. ^{[14] [13]}

The earlier 2010 guidance recommended universal haemoglobin screening at about 12 months with an Hb cut-off of 11.0 g/dL for further evaluation, and infant iron supplementation of 1 mg/kg per day from 4 months of age for exclusively breastfed infants (2 mg/kg for preterm infants from 1 month), plus an iron intake of 11 mg per day at 6 to 12 months and 7 mg per day at 1 to 3 years. These figures remain useful background, but the 2026 protocol above is the current standard. ^[13][14]

There is no safe blood lead level: cognitive effects are seen even below 5 µg/dL. From 2007 to 2010, about 2.6% of US preschool children had a blood lead level of at least 5 µg/dL, representing roughly 535 000 children aged 1 to 5 years. Universal capillary or venous blood lead testing is required for children enrolled in Medicaid at 12 and 24 months, and targeted screening is recommended for children aged 12 to 24 months living in communities or census block groups with at least 25% of housing built before 1960, or where more than 5% of children have blood lead levels of 5 µg/dL or higher, or whose home was built before 1960 and is in poor repair or has been renovated in the past 6 months. Children in an identified high-risk environment should be tested when they arrive. Primary prevention (housing remediation before occupancy) is the only reliable control. ^[12]

Adolescent visits (11 to 21 years) retain everything above but add identity, confidentiality, risk assessment and self-management. Each visit should include time alone with the young person and an explanation of confidentiality, including its limits around safety. A structured psychosocial review such as HEADSS (Home, Education, Activities, Drugs, Sexuality, Suicide and depression) organises the conversation. Screening in this age group includes depression (with instruments such as the PHQ-2, PHQ-9 or PHQ-9 modified for teens), substance use (with tools such as the CRAFFT, S2BI or BSTAD), sexual health and sexually transmitted infection screening, and eating-disorder risk. Immunisation catch-up and anticipatory guidance on sleep, physical activity, media and safe relationships continue; oral health and scoliosis (during the growth spurt) are reviewed. Adolescents with chronic conditions, disabilities or social complexity need more frequent contact. ^[10][12]

The single most important rule is that a failed or positive screen must always be followed through. The diagram below is a teaching outline; follow local guidelines and public-health rules.

Universal schedules and rich screening panels assume a functioning primary-care system, steady vaccine supply and laboratory access. Where these are limited, prioritise the measures with the strongest and most durable benefits: exclusive breastfeeding and maternal nutrition; safe sleep and simple car-safety messages even without purchased seats (children in rear seats, no front-seat sharing); immunisation; basic growth monitoring and vitamin A supplementation where locally indicated; and the cheapest screens, which cost almost nothing: developmental surveillance by history and observation, hearing by parent report of startle and sound localisation, and unfunded red-reflex examination. High-dose iron supplementation for documented anaemia still beats extensive laboratory work-ups when ferritin is unavailable. Lead is best controlled by source removal and housing policy, but where that is impossible, screening those at highest risk on the basis of housing age remains worthwhile. Document what was done and when, because children in low-resource settings often move between providers. ^[12]

• Health supervision is scheduled preventive care for every child from birth to 21 years, with a front-loaded calendar in infancy.
• Anticipatory guidance is age-specific: safe sleep and breastfeeding in infancy; car seats, injury prevention and toilet training in early childhood; screen-time limits by age; confidentiality and risk review in adolescence.
• Safe sleep is back, in a firm flat cot, in the parents' room on a separate surface, with no soft bedding; breastfeeding and avoidance of smoke and alcohol add protection.
• Car restraints progress rear-facing, then forward-facing, booster, then seat belt, with every child under 13 in the back seat.
• Breastfeeding is recommended exclusively for about 6 months, with solids at about 6 months and continuation to 2 years or beyond if desired.
• Toddlers 1 to 3 years need about 7 mg of iron a day; cow or plant-based milk should stay under 24 oz per day after 12 months.
• Screen time: none before 18 months except video chat; no more than 1 hour per day of high-quality co-viewed content from 2 to 5 years.
• Toilet training readiness usually appears between 18 months and 2.5 years; intensive training before 2 years is not generally useful. ^[5]
• Newborn hearing loss occurs in 1 to 3 per 1000 term infants and 2 to 4 per 100 high-risk infants; the 1-3-6 (preferably 1-2-3) pathway drives early intervention.
• Red reflex and instrument-based screening, with optotype acuity from about 4 years, cut persistent amblyopia by more than half.
• Formal developmental screening occurs at 9, 18 and 30 months; autism screening at 18 and 24 months.
• Iron is screened at 9 to 18 months (9 to 12 months for breastfed, 15 to 18 months for formula-fed) plus for all adolescents 1 year after menarche but no later than 14 years.
• There is no safe blood lead level; test all Medicaid-enrolled children at 12 and 24 months and high-risk communities on schedule.
• An abnormal screen is an indication for prompt, documented follow-up, not for a label.

• Growth and nutrition in infancy
• Developmental delay and intellectual disability
• Autism spectrum disorder
• Amblyopia and strabismus
• Iron deficiency anaemia
• Lead exposure
• Adolescent health and mental health