The Well Child And Adolescent

Introduction

The periodic health examination of the well child is a cornerstone of pediatric primary care in Canada. For the MCCQE1, understanding the schedule, content, and objectives of these visits is crucial. This topic encompasses growth monitoring, developmental surveillance, nutrition, immunization, and anticipatory guidance.

The approach aligns with the CanMEDS roles, particularly Health Advocate (disease prevention) and Communicator (providing guidance to families).

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Canadian Context: In Canada, well-child care is often guided by evidence-based tools like the Rourke Baby Record (RBR) for children 0–5 years and the Greig Health Record for children and adolescents 6–17 years.

The Periodic Health Visit (PHV) Schedule

In Canada, the standard schedule for well-baby and well-child visits typically follows the immunization schedule of the specific province or territory. However, a general framework (aligned with the RBR) is:

Newborn: Within first week (often 24-72 hours after discharge)
Infancy: 2 weeks, 1 month, 2 months, 4 months, 6 months, 9 months (optional/developmental), 12 months
Toddler: 15 months (optional), 18 months
Preschool: 2-3 years, 4-5 years
School Age & Adolescence: Every 1-2 years

Key Tools for the MCCQE1

Familiarity with these tools is essential for the exam.

Rourke Baby Record (0-5y)

The Rourke Baby Record (RBR)

A system for well-baby and child care from 0 to 5 years. It guides the physician through:

Growth: WHO Growth Charts.
Nutrition: Breastfeeding, Vitamin D, solids.
Development: Surveillance of milestones.
Physical Exam: Maneuvers specific to age (e.g., red reflex, hips).
Immunization: As per NACI and provincial schedules.
Education/Advice: Safety, sleep, behaviour.

Growth Monitoring

Monitoring growth is a sensitive indicator of general health and nutritional status.

Corrected Age

For premature infants (<37 weeks gestation), use “corrected age” for growth and development assessments until 24 to 36 months of age.

Formula for Corrected Age

Corrected Age = Chronological Age - (40 weeks - Gestational Age at Birth)

Red Flags in Growth

Crossing two major percentile lines (e.g., dropping from 75th to 25th).
Weight-for-length or BMI <3rd percentile (Failure to Thrive / Faltering Growth).
Discrepancy between head circumference, height, and weight percentiles (e.g., microcephaly).

Developmental Surveillance

The MCCQE1 tests your ability to recognize normal milestones and identify red flags requiring referral.

Key Milestones Table

Age	Gross Motor	Fine Motor	Language	Social/Cognitive
2 Mo	Lifts head/chest in prone	Hands open 50% of time	Coos, reciprocates vocalization	Social smile
4 Mo	Rolls front to back, no head lag	Reaches, hands to midline	Laughs, orients to voice	Regards hand
6 Mo	Sits with support (tripod)	Transfers objects, raking grasp	Babbles (consonants)	Stranger anxiety begins
9 Mo	Pulls to stand, cruises	Pincer grasp (immature)	“Mama/Dada” (non-specific)	Peek-a-boo, wave bye-bye
12 Mo	Walks alone or with hand	Fine pincer grasp	1-2 specific words, follows 1-step command with gesture	Proto-imperative pointing (wants)
18 Mo	Runs, walks up stairs (rail)	Tower of 2-4 blocks, scribbles	10-25 words, points to body parts	Pretend play (feeding doll)
2 Yr	Kicks ball, jumps with 2 feet	Tower of 6 blocks, copies line	2-word phrases (“want juice”), 50+ words	Parallel play
3 Yr	Tricycle, balances on 1 foot	Copies circle, cuts with scissors	3-word sentences, 75% intelligible	Group play, toilet training
4 Yr	Hops on 1 foot	Copies cross/square, draws person (3 parts)	Tells stories, 100% intelligible	Cooperative play

Developmental Red Flags (Immediate Referral)

Any age: Loss of previously acquired skills (Regression).
18 months: No single words, not walking independently.
Language: No babbling by 12 months; no two-word phrases by 24 months.
Social: No social smile by 6 months; no eye contact; Autism concern (use M-CHAT-R/F at 18 and 24 months).

Nutrition Guidelines

Nutrition advice is a frequent topic on the MCCQE1.

0 to 6 Months

Exclusive Breastfeeding is the gold standard.

Vitamin D: All breastfed infants require 400 IU/day to prevent rickets.
Formula-fed infants usually get enough Vitamin D if consuming >1L/day (otherwise supplement).

6 Months

Introduction of Solids.

Start iron-rich foods first (iron-fortified cereals, meat, meat alternatives).
Continue breastfeeding on demand.
Introduce common allergens (peanuts, egg) early to prevent allergy (especially in high-risk infants).

9 to 12 Months

Transition to table foods.

Avoid cow’s milk before 12 months (risk of iron deficiency anemia and GI bleeding).
Avoid honey before 12 months (Botulism risk).

12 Months +

Introduction of Cow’s Milk.

Whole milk (3.25%) until age 2.
Limit milk to 500 mL/day to prevent iron deficiency (milk fills them up, displacing iron-rich foods).

Immunization

While schedules vary by province, the National Advisory Committee on Immunization (NACI) provides the Canadian Immunization Guide.

Routine Childhood Vaccines

2, 4, 6 months: DTaP-IPV-Hib-HB (6-in-1) + Pneumococcal (Pneu-C-15 or 20) + Rotavirus.
12 months: MMRV (Measles, Mumps, Rubella, Varicella) + Men-C-C (Meningococcal C) + Pneumococcal booster.
18 months: DTaP-IPV-Hib (5-in-1) + MMRV (2nd dose - timing varies by province).
4-6 years: DTaP-IPV (4-in-1) + MMRV (if not given earlier).
Grade 6-9: HPV, Hepatitis B (if not given in infancy), Meningococcal (ACWY).

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Live Vaccines: MMR, Varicella, Rotavirus, Intranasal Influenza. Contraindicated in immunocompromised patients and pregnancy.

Adolescent Health (HEEADSSS)

For adolescents, the psychosocial history is paramount. Use the HEEADSSS mnemonic to structure the interview. Ensure confidentiality is discussed at the start (limitations: harm to self, harm to others, abuse).


H - Home (relationships, living situation)
E - Education/Employment (school performance, bullying, work)
E - Eating (body image, dieting, eating disorders)
A - Activities (peers, screen time, sports)
D - Drugs (tobacco, alcohol, cannabis, street drugs - use CRAFFT screen)
S - Sexuality (orientation, partners, practices, protection, pregnancy)
S - Suicide/Depression (mood, sleep, self-harm)
S - Safety (seatbelts, driving, weapons, online safety)

Canadian Guidelines

When answering MCCQE1 questions, rely on these specific guidelines:

Canadian Paediatric Society (CPS): The primary source for clinical practice points (e.g., circumcision, screen time, cannabis).
Canadian Task Force on Preventive Health Care (CTFPHC): Provides screening guidelines (e.g., vision screening, obesity).
Iron Deficiency Screening: Targeted screening for high-risk infants (not universal).
Vision Screening: Visual inspection of eyes (red reflex) at all visits; subjective vision testing starting at age 3-5 years.
Dental: First dental visit recommended by 12 months or within 6 months of eruption of first tooth.

Key Points to Remember for MCCQE1

Vitamin D: 400 IU/day for all breastfed term infants. 800 IU/day for northern communities in winter may be recommended.
Car Seats: Rear-facing as long as possible (until height/weight limits of seat are reached), typically at least until age 2.
Screen Time (CPS): None for <2 years (except video chatting). <1 hour/day for 2-5 years.
Safe Sleep: Back to sleep, firm mattress, no loose bedding, room-sharing (not bed-sharing) for first 6 months.
Autism Screening: Specific screening (M-CHAT-R/F) is recommended at the 18-month visit.
Blood Pressure: Routine measurement starts at 3 years of age annually.

Sample Question

A 15-month-old girl is brought to the clinic by her father for a routine well-child visit. She was born at 39 weeks gestation without complications. The father reports that she is a “picky eater” and drinks about 900 mL (30 oz) of cow’s milk daily. She is walking independently and says “mama” and “dada” specifically. Physical examination reveals pale conjunctivae. Her weight is at the 75th percentile, and her height is at the 50th percentile.

Which one of the following is the most appropriate initial management step?

A. Reassure and continue current diet
B. Prescribe a multivitamin supplement
C. Order a Complete Blood Count (CBC) and Ferritin
D. Refer to a pediatric gastroenterologist
E. Switch to 1% cow’s milk

Click to see the answer and explanation

Explanation

The correct answer is:

C. Order a Complete Blood Count (CBC) and Ferritin

Explanation: This clinical scenario is classic for nutritional iron deficiency anemia caused by excessive cow’s milk intake (milk baby syndrome).

Data Interpretation: The child is consuming 900 mL of milk/day (Recommendation is max 500 mL/day). Cow’s milk is low in iron and can cause micro-intestinal bleeding. The large volume displaces iron-rich solid foods.
Physical Findings: Pallor (pale conjunctivae) suggests anemia.
Development: Walking and specific words are appropriate for 15 months.
Management: The most appropriate next step is to confirm the diagnosis with a CBC (to check hemoglobin and MCV) and Ferritin (iron stores).

Why other options are incorrect:

A: Reassurance is inappropriate given the pallor and excessive milk intake risk.
B: A standard multivitamin may not contain sufficient therapeutic iron, and diagnosis should precede treatment.
D: Referral is premature before basic investigations and a trial of iron therapy/dietary modification.
E: Switching to 1% milk is not recommended for children under 2 years (who need fats for brain development) and does not solve the iron issue.

References

Rourke Baby Record. (2020). Evidence-based infant/child health maintenance guide. https://www.rourkebabyrecord.ca/
Greig Health Record. (2016). Preventive health care visits for children and adolescents. https://www.cps.ca/en/tools-outils/greig-health-record
Canadian Paediatric Society. (2023). Nutrition for healthy term infants. https://www.cps.ca/
Public Health Agency of Canada. Canadian Immunization Guide. https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html
Dietitians of Canada. WHO Growth Charts for Canada. https://www.dietitians.ca/