The main goal of health maintenance is to insure that the parents have an opportunity to
meet with the pediatrician, have their child examined and discuss issues that arise at different stages of development. Primarily we are interested in 

1. Immunizations
2. Anticipatory guidance
3. Promotion of safety concerns
4. Feeding practices
5. Assessment of growth and development
6. Early detection of treatable disorders
7. Observation of parent-child interaction

2 Weeks

1. Assess the growth and development. It is very important to discuss feeding practices and encourage the mother who is nursing. No introduction of solids or juices. Discuss common issues like going out, wardrobe, traveling, sleep, colic, feeding, elimination, etc
2. Important to express how well the baby and the parents are doing. 
3. On physical exam carefully assess growth, presence of murmurs, pulses, hip exam, head size and shape, and general activity and alertness of the baby
4. Safety issues: sleep position and crib contents in preventing SIDS (sleep supine, "Back to Sleep", eliminate bed clothes and stuffed animals in the crib, hard mattress, and eliminate smoking from the environment), sun (no exposure until 6 months), hot and cold temperature avoidance, and car seat, smoke detectors, fire extinguishers, bathing water temperature, no strings or necklaces
5. Immunizations: if haven't had the first Hepatitis B, give at this time. Give out booklets for immunizations that will be begin at the 2 month visit.
6. Discussion of the need for Vitamins and Fluoride. Nursing babies should be supplemented with Vit. D. 
7. Office procedures, hours, and how to get in touch with the physicians when the office is closed. Always encourage the parents to call if they have questions but calling during office hours is appreciated.
8. Check state screening results
9. Return visit

1. Assess the growth and development including head circumference, achievement of milestones. Infant should be able to get chest up when prone..
2. Feeding practices are unchanged, no introduction of solids necessary. Emphasize that no cereal or other solids should be placed in the bottle. 
3. Physical examination
4. Answer questions
5. Immunizations: Discuss the importance and indications for immunizations and reassure and answer questions. Hepatitis B #2, IPV(Polio) #1, DPT/Hib #1,Prevnar #1
6. Don't leave child unattended
7. Smoke detectors
8. Vision and hearing assessment. 
9. Tylenol dosing 10-15 mg./kg/dose q4-6 hours. ( 0.8cc dropper= 80mg.)

1. Assess growth and development.  Should be ble to roll prone to supine and laughs.
2. Discussion of the introduction of solid (baby) foods. Generally start with cereals and introduce fruits and vegetable during the next 2 months. Important to discuss amount of foods to be fed and how often. Children will usually let the parents know when they are full and there is no set amount that they need to feed. "Babies have the right of refusal." It is a good idea to not place juice in bottles to prevent the development of caries and a desire for sweets.
3. Safety issues-electrical outlets, hiding cords from appliances and curtains and blinds, cabinets need to be locked, stairways protected, adjusted hot water temperature to below 120 F to prevent accidental scalding. 
4. Immunizations: IPV#2, DPT/Hib#2, Prevnar#2
5. Increased drooling and placing of things in mouth starts at this age although most infants do not have teeth until they are about 6 months old.
6. Rolling over, good head control, follows 180 degrees, laughs
7. Inquire about sleep, hearing, elimination issues.

1. Assess growth and development. Starting to sit, transfers objects, babbles, rolls over
2. May introduce chicken and beef. Infant should continue on breast milk or formula with iron but may need to supplement with solids at this age.  May introduce a cup with milk or juices. 
3. Discussion of teething, sleeping, elimination, weaning if nursing
4. Safety concerns: need Ipecac and instructions on how and when to use, parents should have the phone number of poison control at Rush Pres (942-5969), infant can be exposed to sun but should have a hat a at least 15 SPF sun protection, bike helmets if on back of bicycle, watch small objects that child will put in mouth and choke (toileet paper roll is a good comparison of diameters that are acceptable for toys.) , water safety.
5. Immunizations:, DPT/Hib#3, Hepatitis B#3, Prevnar#3

1. Assess growth and development.  Pull to stand, Gesture games.  
2. More finger foods will be introduced and emphasize that the pieces of food given be small to avoid choking. All foods are acceptable as long as they are in the proper consistency.
3. Begin dental care by gently wiping off teeth and may introduce toothbrush
4. Shoes: shoes are only decorations and protectors and children do not need shoes to learn to walk. Shoes should be soft, wide, cheap, and fit. 
5. Safety becomes very important as the child becomes more mobile. Putting things in the mouth very common at this age and know what to do if child chokes. Discuss use of toddler car seat for children greater than 20 pounds. 
6. Hematocrit to screen for anemia and a PPD if indicated
7. Development- mama/dada, sits well, pulls to standing, pincer grasp, understands few words
8. Sleep and bedtime issues, elimination, hearing?, crossed eyes?

1. Assess growth and development.  Walks with one hand held, can place cube in a cup, 2 word vocabulary, one step command with gesture, Assists in dressing.
2. Child may switch to whole milk and should be on whole milk until 2 years old
3. Begin to discuss bottle caries and the importance of not taking bottle with sugar containing liquids to bed.
4. Discussions about discipline and what the parents should expect from their child
5. Immunizations: MMR#1 and Varicella Vaccine, DaPT/HiB, Prevnar#4
6. Screening for lead if indicated
7. Diet, elimination, sleeping habits
8. Accident prevention, change car seat, handgun safety, outdoor supervision, swimming pools, poisonings, Ipecac, stairs, cords and anything hanging

1. Assess growth and development.  Comes to stand alone, imitates scribble, imitates tower of two, follows one-step commands and has 4-6 words.  Able to use spoon.
2. May receive IPV # 3 and catch up on any vaccinations that may have been missed
3. Reiterate previous safety issues focusing on the fact that as the child becomes more mobile there is potential for more accidents 
4. Diet, elimination, sleep habits

1. Growth and development. Able to run, scribbles spontaneously, tower of three cubes, mature jargoning and 7-10 words, points to one picture, takes of shoes and socks.
2. Safety
3. Immunization catch-up
4. Hematocrit and lead
5. Bottle caries, dental care
6. Discussion of healthy diet
7. Discipline

1. May begin discussion about toilet training
2. Guns
3. Street awareness
4. May switch to low fat milk
5. Speech may often consist of some stuttering and this is usually normal. Expressive language may lag behind receptive 
6. Walks up and down stairs, imitaties vertical line, places cube in box, points to 4 pictures, 50 word vocabulary. 

1. Discussion about stranger danger and awareness of no touching
2. Carseat/seatbelt issues
3. Amount of television viewing, stressing increased physical activity, discussions about weight and diet
4. Suggest visit to dentist
5. Preschool 
6. Assessment of vision and possibly hearing. Parents may be given home vision test to use.
7. Blood pressure
8. Stands on one foot, can copy a circle, draw a man, 250 word vocabulary, three word seentences, follow 2 prepositional commond

1. Immunizations- IPV#4, DaPT#5, MMR#2
2. PPD if indicated
3. Hematocrit and Urine
4. Hearing and vision
5. School anticipatory guidance
6. Bike helmets and rollerblade protective equipment
7. Healthy diet and stress importance of physical activity, lowfat diet, is weight gain excessive? 
8. How to deal with strangers and touching. Important to express this to children at the time that you are examining them. 
9. Discuss sleeping, elimination, snoring
10. How is the child getting along with other children?
11. Amount of television viewing? 
12. Proper seat belt use

1. Review how the child is doing in school and how they are getting along with peers
2. Emphasize safety issues- seat belts, helmets, sun protection, water safety, guns, separate ammunition from the gun, bike helmets, mouth guards 
3. Growth and weight gain. Is the child active
4. Television viewing and exposure to violence
5. Sleep, snoring, enuresis, elimination

1. Review school performance
2. Introduce topic of sexual development and body changes
3. Discuss the avoidance of nicotine, alcohol, and drugs
4. On physical exam check spine for scoliosis
5. Safety
6. Personal hygiene- deodorants and antiperspirants, bathing, skin, menarche and use of tampons
7. You should discuss the ability of the patient to see the pediatrician alone and stress that the doctor-patient relationship is strictly confidential. 

1. Physical exam- close attention to growth and sexual development. Answer questions concerning differences between teenagers of the same age. Scoliosis check 
2. Skin care and discussion of acne
3. Contraception and sexually transmitted diseases
4. Alcohol, smoking, drugs, and sex. Important to tell the adolescents that they have the ability to do what they want and if they are firm in their decision to not use drugs or alcohol, nobody will hold them down and force them. 
5. Discussions about teen- parent relationship and how important is for the parents to talk to their kids. Also, parents must carefully monitor the teens behavior especially looking at their school performance, friends and acquaintances, and general behavior.
6. At times it is important to "side" with the teenager
7. Immunizations- Td booster (q 10 years), if didn't get initial Hepatitis B vaccine this is the time to start, Varicella vaccine if the adolescent is unimmunized and hasn't had chickenpox.
8. Routine gynecologic examination is not performed by many pediatricians. If there is a problem a gyne exam may be done but if you are uncomfortable or inexperienced, a referral may be appropriate.

References

1. Colson ER and Dworkin PH. Toddler Development. Pediatrics in Review. 1997; 18:255-259.
2. Johnson CP and Blasco PA. Infant Growth and Development. Pediatrics in Review. 1997; 18:224-242.
3. Sturner RA and Howard BJ. Preschool Development 1: Communicative and Motor Aspects. Pediatrics in Review. 1997; 18:291-301.
4. Sturner RA and Howard BJ. Preschool Development 2: Psychosocial /Behavioral Development. Pediatrics in Review. 1997; 18:327-336.