Anticipatory guidance
Infancy (< 12 months)
Nutrition : Exclusive breastfeeding to 6 mos; Vit D 400 IU/d from birth; Iron 1 mg/kg/d at 4 mos if exclusively breastfed. Early allergen intro at 4–6 mos.Avoid : Honey < 12 mos (botulism ); cow’s milk < 12 mos (IDA , GI bleed).SIDS Prevention : Supine (“Back to sleep”) , firm mattress, room-sharing without bed-sharing, no soft bedding/toys.Safety : Rear-facing car seat in back seat; water heater < 120°F (49°C) (scalding prevention).
Early Childhood (1–4 years)
Nutrition/Dental : Whole cow’s milk at 12 mos (limit < 24 oz/day to avoid IDA ). First dental visit by 12 mos .Development : Toilet training readiness at 2–3 yrs (stays dry > 2 hrs, communicates need). Screen time < 1 hr/day (ages 2–5).Safety : Locked chemicals/meds; 4-sided pool isolation fence; rear-facing car seat until weight/height limit.
Middle Childhood (5–10 years)
Safety : Belt-positioning booster seat until 4 ft 9 in (145 cm) (ages 8–12); back seat until age 13 .Lifestyle : Helmet use for bikes/scooters; guns stored unloaded and locked ; screen time < 2 hrs/day .
Adolescence (11–21 years)
HEADSSS Assessment : Home, Education, Activities, Drugs, Sexuality, Suicide/Depression, Safety.Confidentiality : Interview alone; maintain privacy EXCEPT active suicidal/homicidal ideation, abuse, or life-threatening emergencies.Counseling : Dual protection (condoms for STIs + LARC or OCPs for contraception). c
High-Yield Screening Milestones
Anemia (Hb/Hct) : Universal at 12 mos .Lead : Universal at 12 and 24 mos (if high-risk area/Medicaid).Autism (M-CHAT) : Universal at 18 and 24 mos .Lipids : Once at 9–11 yrs and once at 17–21 yrs .Depression (PHQ-2/9) : Annually starting at age 12 .Vision/Hearing : Vision starting at age 3 ; Hearing universal at birth and age 4 .
Growth
Macrocephaly
Etiology
Defined as Occipitofrontal Circumference (OFC) > 97th percentile (> +2 SD) for age and sex, or crossing percentiles rapidly.
Benign Familial Macrocephaly : Most common cause; AD inheritance pattern. c
In children with normal development, examination, and no evidence of rapidly increasing FOC, macrocephaly is most likely benign
Hydrocephalus :
Non-communicating (obstructive): Aqueductal stenosis, Chiari I/II malformations, Dandy-Walker malformation, posterior fossa tumors (e.g., medulloblastoma, pilocytic astrocytoma).
Communicating (non-obstructive): Post-intraventricular hemorrhage (IVH in preemies), post-meningitis, subarachnoid hemorrhage.
Genetic / Overgrowth Syndromes : Fragile X syndrome, PTEN hamartoma syndromes (Cowden, Bannayan-Riley-Ruvalcaba), Sotos syndrome, Neurofibromatosis type 1 (NF1), Tuberous Sclerosis Complex (TSC).Metabolic / Storage Disorders : Tay-Sachs, Canavan disease, Alexander disease, Mucopolysaccharidoses (MPS).Vascular / Trauma : Chronic subdural hematoma (evaluate for Non-Accidental Trauma [NAT] ), arteriovenous malformations (e.g., Vein of Galen malformation).
Microcephaly
Etiology
Definition : Occipitofrontal circumference (OFC ) > 2 to 3 standard deviations (SD ) below the mean for age and sex (< 3rd percentile).Primary / Congenital (in utero insult/genetic) :
Chromosomal / Genetic : Trisomy 13 (Patau), Trisomy 18 (Edwards), Trisomy 21 (Down), Cri-du-chat (5p- ), Rett syndrome (MECP2 mutation).Infectious (TORCH) : Zika virus , Cytomegalovirus (CMV) , Toxoplasma gondii , Rubella, HSV, Syphilis.Teratogenic / Toxic : Maternal alcohol abuse (FASD ), unmanaged maternal PKU , antiepileptic drugs (e.g., Valproate, Phenytoin), radiation exposure.
Secondary / Acquired (postnatal arrest) :
Hypoxic-ischemic encephalopathy (HIE ), perinatal stroke.
Postnatal CNS infection (bacterial/viral meningitis, encephalitis).
Craniosynostosis (premature suture fusion).Severe malnutrition, inborn errors of metabolism.
Diagnostics
Initial : Serial OFC measurements plotted on growth chart; compare to parental OFC.Imaging :
Brain MRI (Gold Standard) : Cortical malformations (lissencephaly, pachygyria). c Head CT : Craniosynostosis (fused sutures) or intracranial calcifications.
Key Labs :
Urine CMV PCR (if < 3 wks of life).Zika RT-PCR / IgM.
Chromosomal microarray (CMA) .
Adjuncts : Audiology screen (BAER) + ophthalmology exam.