When I arrive at my office in the morning, the first thing I do is see how many well-baby checks are listed on my schedule. The more there are, the happier I am. It means I get a chance to sit and talk with parents, look at all aspects of their child's life and health, and prevent future problems.
During the first two years of your baby's life, you will probably spend more time in the pediatrician's office than you ever will again. Regular checkups, called well-baby visits, help your doctor make sure that your child's weight gain and growth are on track, his development is progressing normally, and he's eating well and getting the nutrients he needs. The visits also prepare parents for what to expect in terms of baby care and developmental milestones before the next exam.
Your first well-baby visit will probably be a day or two after coming home from the hospital or birthing center. Your pediatrician will want to check your newborn for problems, such as jaundice, heart murmurs, and feeding difficulty, which sometimes aren't apparent until the third or fourth day of life. After that, the American Academy of Pediatrics recommends a checkup at 2 weeks, followed by visits at 2, 4, 6, and 9 months, 12, 15, and 18 months, and 2 years.
Why so many visits? Your baby's body and mind are changing at a phenomenal rate, and frequent checkups can reveal deviations from what's normal. Your doctor is on the lookout for any medical issues that may affect your baby, because detecting problems early makes them easier to correct. In addition, these visits coincide with the schedule of immunization shots your child will receive.
At each visit your pediatrician will measure your child's height and weight and mark them on a growth chart. Your doctor uses the chart to determine how your baby is growing compared with other children of the same age and gender. Percentiles are the lines on the growth chart; they tell you how many children are above or below your baby's measurement. For instance, if your 5-month-old boy is in the 70th percentile for height, it means that 70 percent of 5-month-old boys are shorter than he is, and 30 percent are taller.
Bigger is not necessarily better, however. How long or short or heavy an infant is at any point in time is less important than how that relates to where he was at a previous point. Small children are just as healthy as large ones as long as they are growing steadily — which means they are progressing along a single percentile over time.
So don't get caught up in worrying too much about what percentile your child is in — it's all relative. One of my patients, for example, has a mother who is barely 5 feet tall and a father who is well over 6 feet. The baby has been gaining and growing steadily along the fifth percentile. Her father's family is disappointed, while her mother's relatives are ecstatic that at least she is on the chart (many of them were not)!
When a child's weight gain or growth drops off its original curve, this could be a sign of a health problem, but there are many normal reasons that children "fall off the curve." Infants are born at a weight determined partly by their mother's nutrition and other influences in the womb. A newborn may be big because her mother is diabetic, for example, but the baby's weight percentile may drop off in the first few months of life as she veers toward her genetically determined size.
Perhaps because they are burning more calories, another time that weight may drop is at 9 to 12 months of age, when babies begin to pull up and start walking. The change, however, should not be dramatic, just a small dip in percentile. An illness can also cause a temporary drop from baby's usual percentile for weight.
Another important measurement taken at every visit is the head circumference, which is used to gauge baby's brain growth. Your child's brain grows the most during the first two years of life. Again, parents are often worried about whether their baby's head is too big or too small. Although either extreme can indicate a problem in rare instances — a head could be growing too fast because something is creating pressure, for example — usually it is simply due to genetics. By measuring the mom's and dad's head, I can figure out whether a big (or small) cranium is a family trait.
Poking and Probing
At each visit your pediatrician will give your child a thorough physical examination. Her skin will be checked for birthmarks. Your pediatrician will look at her eyes with a special light to make sure there is a "red reflex" — the red glow responsible for red eye in photographs. (This indicates that there isn't anything, including cataracts, obstructing her vision.) The shape of your child's head and the size and form of the soft spots will be examined. Your pediatrician will look in the baby's mouth to make sure the palate has formed properly. During a newborn visit, your doctor may also feel the neck and collarbone to see if there is a fracture from delivery, a common complication that heals quickly.
Your doctor will listen to your baby's heart for murmurs and irregular rhythms, check the lungs to make sure they are clear, and examine the nipples for any discharge or swelling (normal in the first weeks of life but not after that). The doctor will feel the abdomen carefully to see if there is any enlargement of organs such as the liver, spleen, or kidneys or any abnormal masses. Then she will stretch your baby's legs to check for a birth defect called hip dysplasia — a too-shallow hip socket that can cause hip dislocation and affect walking. This maneuver often makes infants cry, but it's an important one. If hip dysplasia is found, putting the baby in a special splint for several weeks to a few months can correct it. As with many problems, finding and treating this defect early prevents complications later on.
Your pediatrician will ask you questions about how your child is doing — whether she's hit typical milestones, is active, and is feeding and sleeping okay. Although everyone wants their child to be ahead of the pack, the truth is that "normal" covers a broad range when it comes to reaching developmental milestones. For example, some children start to walk at 10 months while others crawl until 15 months. Both scenarios are normal, and hitting milestones earlier doesn't mean a baby is innately more intelligent. Nonetheless, these discussions with your doctor are an opportunity for you to bring up any concerns you have about baby's development or health — say, if your 14-month-old hasn't said his first word, or your 8-month-old is having trouble sleeping through the night.
Your doctor should also give you relevant safety information for your baby's age. For example, I warn the parents of a 4-month-old who hasn't yet turned over that their child may do so for the first time when left unattended in the middle of an adult bed, and could roll off. And I tell the parents of a 9-month-old who is pulling up to be sure to babyproof her environment, so that it's free of dangling appliance cords and tablecloths that she can pull down.
Well-baby visits are a chance for you to address your concerns — parents are usually the first ones to notice a problem — and to get comfortable with your doctor before you have to bring your child in sick with a cold or an ear infection. Come prepared with questions and an open ear — you are an equal partner in your baby's health.
Loraine M. Stern, MD, is a clinical professor of pediatrics at the University of California, Los Angeles, and a practicing pediatrician.
Originally published in American Baby magazine, March 2004.