A 4-year-old boy is brought to the office by his mother for a routine health maintenance visit. The patient has been toilet trained for 2 years. He sees a pediatric dentist every 6 months and has no dental caries. The boy's mother describes him as a picky eater. She states that he prefers to eat bananas, apples, and bread but dislikes vegetables, meat, and milk products. He participates in a weekly community soccer league. He had acute gastroenteritis twice during infancy, but has no chronic medical conditions and takes no medications. The boy lives with his mother, who is a single parent, and 2 older brothers. He attends preschool 5 days per week and is learning to write his name. His mother says that he is not a social child and prefers to play with his best friend or his brothers. Which of the following preventive health measures is most appropriate at this visit?
Vision is evaluated at every well-child visit, as untreated eye abnormalities during the first few years of life can lead to permanent vision loss. Infants and young children are assessed by observation of visual behavior. For example, infants can fixate on objects shortly after birth, and by age 3 months they demonstrate horizontal and vertical tracking. Red reflex testing is also performed to detect a congenital cataract or retinoblastoma, and corneal light reflex testing assesses ocular alignment. In older infants and children, strabismus can also be detected by the cover test, in which a child focuses on an object and each eye is covered independently to assess for abnormal movement in the contralateral, fixated eye.
Visual acuity testing is performed routinely at age 4 but can be performed as early as age 3 in cooperative children. The Snellen chart is the gold standard, although the HOTV (4-letter) or LEA (picture) chart may be used for young children with limited or no ability to identify letters. Visual acuity worse than 20/40 at age 4 or worse than 20/30 at age ≥5 should prompt ophthalmologic evaluation for refractive errors. Additional indications for referral include pupillary asymmetry of ≥1 mm, nystagmus, and ptosis or other conditions obstructing the visual field.
(Choices A and B) Autism screening is routinely performed at ages 18 months and 2 years, and depression screening starts at age 12. As this child has appropriate relationships, is doing well in preschool, and is participating in activities, he does not require testing for autism or depression.
(Choice C) The quadrivalent meningococcal vaccination is routinely administered at age 11 or 12, followed by a booster dose at age 16 due to the risk of college outbreaks. Children with asplenia, HIV, or complement deficiency may be vaccinated as early as age 2. This patient is at low risk for meningococcal disease and does not require early vaccination.
(Choice D) The rotavirus vaccine is recommended at age 2-8 months as the greatest risk for dehydration from severe gastroenteritis is during early infancy. The vaccine is not administered past this age range.
(Choice E) Urinalysis is indicated for a patient with concerning urinary symptoms (eg, dysuria, frequency). It is not a preventative health test.
Educational objective:
Vision is evaluated at every well-child visit, as early detection of eye abnormalities can prevent long-term vision loss. Formal visual acuity testing is recommended starting at age 4 as well as in cooperative 3-year-olds.