Melanie Cole, MS (Host): There's no handbook for your child's health. But we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And joining me today is Dr. Corey Wasserman. She's an Assistant Attending Pediatrician at New York Presbyterian Hospital, Weill Cornell Medical Center, and an Assistant Professor of Clinical Pediatrics at Weill Cornell Medical College, Cornell University. And she's here to tell us everything about pediatric well visits.

Melanie Cole, MS: Dr. Wasserman, thank you so much for joining us today. I remember how exciting and terrifying and all of those feelings when we have our new, little babies and we start those pediatric well visits. I'd like you to start by telling us what's included on those yearly well visits, the importance of having those visits. So go from babies up until, I don't know, toddlerhood, and tell us a little bit about what we can expect.

Dr Corey Wasserman: Sure. Well, thank you very much for having me. It's obviously an important topic that I'm happy to speak on, since it impacts all of our patients really at any age. Really, the point of well visits or what sometimes people will call their yearly physical or their checkup is it's a chance to really sit down with the pediatrician and the family, the patient and the caregivers, to go over some really important elements of preventative medicine. There tends to be a couple of elements that are seen through all of the pediatric age groups that we'll cover, things like developmental or behavioral screenings that may be more like mental health assessments in older kids. Everyone will include a physical exam, an assessment of growth and their measurements. And then, of course, the thing that everyone asks about as soon as the pediatrician walks in the room, screening tests, shots, procedures, what's going to be needed on the day of that visit as well as just general conversation and anticipatory guidance for the parents or caregivers about what to expect between that point in time and perhaps the next time that they'll be seeing the doctor for their next checkup.

So, the first time that we meet a patient is when they come home from the hospital as a newborn oftentimes. For most babies without any complications in their nursery stay, this will be about two to three days after hospital discharge. This may be sooner if there's any weight concerns or jaundice issues, but generally that's our first exposure to meeting the family in the office and their first exposure to us. And as you can imagine, there are a ton of questions and a slew of concerns that we have to get through.

At newborn well visits, a lot of what we do revolves around making sure that the infant is not losing too much weight at first, and then indeed is in fact gaining weight. Our goal for newborns is, although they may lose even up to 10-15% of their birth weight, we can make sure that they're staying hydrated. And our next goal for them will be to be back to their birth weight at the two-week visit. So, a lot of what we'll discuss at that first visit will be feeding, both what the goals are from the caregiver standpoint and what is healthy and safe for the infant in terms of hydration and nutrition and caloric intake.

As we see the infant back several times throughout the first couple months, that continues to be an important part of our well visit assessments. We continue to follow both their physical exam and their growth and their measurements at every visit to make sure that they are growing not only in a healthy way, but in a consistent way. Children that may be gaining too much weight or not enough weight may require some interventions and at those well visits would be the time to observe that trend and hopefully make some interventions to help the patient grow and thrive as much as they can.

Melanie Cole, MS: So, talking about those interventions and those milestones, can you just tell parents that not every kid hits every milestone exactly on the same day and exactly at the same time? Because we do freak out. And I remember that my daughter did start speech therapy and early intervention. Of course, at 20, now you can't shut her up. But really, parents worry about those milestones. Reassure us a little bit.

Dr Corey Wasserman: Well, everything you just said is absolutely true. And I will disclose this to my patients as well. I'm not only a doctor, I am also a parent. So, I see it from both sides, although I really try to encourage my patients to take the advice that I give them as the pediatrician. Because as a parent, admittedly, I'm just as clueless as the next person.

In terms of developmental milestones, obviously, this is a place where a lot of people have a lot of anxiety about it. But exactly what you said, it's one of those things that we monitor and check in at every single visit. And we do developmental screenings, we do surveillance of developmental milestones and keeping in mind that there's a range of normalcy. Not every patient will achieve a specific milestone at a specific time or a specific date. And oftentimes there's other factors that can come into play. If the patient was born prematurely, for example, we can adjust for their gestational age if there is a stressor at home or a chronic illness or even birth order can affect these things. So, that's why it's so important to have these longitudinal assessments starting at the newborn visit to see where the patient is growing both physically and developmentally and behaviorally. And from that point, we can take it and, assess where they are over time. Are they achieving things in a more delayed manner? Are they ahead of the curve on things? Parents love to hear that their kids are so advanced. There are some 18-month-olds that come in and are talking in sentences, which is not the expectation. And there's some kids that are coming in and they have somewhere between four and 10 words, and that's okay too. So, it's an important metric to measure in each patient, but keeping in mind that it's the whole child, not necessarily one box that you have to check off on the developmental screening that is more defining of the patient and their overall development.

Melanie Cole, MS: How do you monitor our children's growth as a toddler? Because of course, in this age of obesity, we're looking at these percentages, we're looking at BMI. My kids were tiny, so they were always in the fifth percentile. And she said, "Don't worry, as long as they stay in their percentile, as long as they grow like they should be growing." Instead of, you know, jumping around, tell us how that works.

Dr Corey Wasserman: Exactly. So, a lot of people will put a lot of emphasis on percentiles. And I'm not entirely sure if this is just more of a cultural thing or we're a competitive culture. But essentially, the percentiles on a growth chart are really unhelpful if you're looking at something on an individual level. So if you're looking at something from a population level, yes, it's very helpful. It's helpful to know where the average weight or height or body mass index is for a particular gender and age of a child. But when you get down to the individual, it doesn't necessarily matter what percentile they're growing upon.

As you can imagine, there are five-year-olds that are growing beautifully at the third percentile. And I just want to take a moment and remind people what percentiles mean. And I try to go through this if patients are at either extreme of the percentile curve. And with the older patients, I actually explain it to them this way. I'll say, "Okay. So, you are at the 20th percentile for height. So, that means if we took a hundred boys or girls in your age group and we lined them up, you would be taller than 20 out of 100. Eighty out of a hundred of those would be taller than you. And that's an okay place to be. Because when I measured you last year, do you know where you were? You were at the 18th percentile, you were at the 22nd percentile. And it's more important that you are growing well for you than compared to the population at large because there are many factors including genetic and environmental that can factor into where somebody falls upon the growth curve." So, I agree with your pediatrician assessment, Melanie, that it's more important that a patient be growing consistently along a particular percentile than worrying where they fall in the grand scheme of the population. By definition, the kids that are growing at the first percentile represent 1% of the population of happy, healthy kids.

Melanie Cole, MS: Wow. That's really encouraging for parents to hear. Now, as our kids get older, and we don't have enough time to do all the immunizations because vaccinations are so, so important, and you're going to reiterate that for sure for us. But there are a few that stand out among the others and through the years as we come in for our well visits, and one of them is Gardasil. Can you speak just a little bit about the immunizations that are starting to take place as our kids become tweens and why you want parents to understand the importance of these?

Dr Corey Wasserman: Sure. And I'm glad that you bring this up because there's a lot of immunizations that are more accepted by parents. And I think that has to do with the fact that if your child does not get X number of polio vaccines, they will not be going to school. So all of those aside, keeping our population as healthy and safe as possible, as we get into the the age of nine years old, we can offer males and females the Gardasil vaccine, which is a vaccine that protects against a certain virus, human papilloma virus. Currently, the Gardasil vaccine contains 13 strains. And this protects males and females against different types of cancers that should they be exposed to this virus later on in life, it can mutate and turn into different types of pathology. In females, most notably cervical cancer, although there's been a significant uptick in HPV-related head and neck cancers in both males and females.

An important thing to discuss both with the caregiver and the patient about this is it is sexually transmitted. So, a lot of people find it a little uncomfortable or they're not too sure how to broach this topic when their child is 9, 10, 11, and I say the term sexually transmitted, kids will sometimes giggle or turn red, but it is an important thing to think about. One of the most important things we can do, both with well visits and immunization, is preventive pediatric healthcare. And that's where an immunization like Gardasil falls in. So oftentimes, I will start the conversation with the parent and the child to see where in the mental process they are. Obviously, I am on the side of, I think, everyone should be immunized against everything that we possibly can keep them healthy and safe from. So, I fall under the realm of, obviously, pro-vaccine. But it's also helpful to get a conversation going to gauge where in the thought process the patient and parent is, and then kind of change the dialogue depending on their thoughts or concerns and go back and forth and sometimes follow up the following visit or the following year if need be.

What's nice about the Gardasil vaccine is we can start the process as early as age nine. Oftentimes at the beginning, the 9, 10, 11-year-olds will have other vaccines that are due. So, I'll start the conversation, but say, "Listen, this is not something that urgently needs to be done," but the timeline that I'll put on it, and in a way to incentivize them a little bit of thinking about it sooner rather than later would be if we begin the Gardasil series before the patient's 15th birthday, we can achieve lifelong immunity in two doses. If we wait until they are older, it is a three-dose series to complete the entire series. So obviously, there is the push to immunize all children long before they would ever be exposed to this sexually transmitted disease, so that's why we would want to do it sooner. But also in just the no one likes being stuck with a needle camp, if we start the series before their 15th birthday, we can save them a shot overall.

Melanie Cole, MS: Wow. You know, really what we're doing for our kids today just absolutely amazes me and you pediatricians are the gold standard. You are helping us to raise our kids healthy and happy. And before we get ready to wrap up, can our pediatricians help with advice and discipline and behavior? And though we talked about early intervention before for things red flags, milestones issues, but what about discipline? As our kids are toddlers and then they grow to be tweens and even, help us all, teens, then can our pediatricians be the one to help us? And I'd like you to offer your best advice, Dr. Wasserman, for parents listening. You and I, both parents, what do you want us to know about reaching out to our pediatrician, not being afraid to reach out, because that's why you're there?

Dr Corey Wasserman: My best advice for parents would be not to wait until their child's next checkup if there's concerns. The well visit is in place to check in periodically at key moments in children's growth and maturation. But by all means, It's not the only time that you should be engaging in a dialogue with your pediatrician.

In fact, I would argue a well visit is not the time to bring up any concerns that you've been having since there's so much to cover in such a short amount of time. If you really have a concern about your child's development, behavior, nutrition, anything like that, a dedicated visit may be helpful. And accessibility is easier than ever now with telemedicine and telehealth. So, I would certainly encourage not waiting until the next visit to discuss any concerns you have with your doctor.

That said, during the visit and as part of the anticipatory guidance that pediatricians can give to their patients and families, we discuss everything from nutrition and diet and sleeping patterns and safety and, most notably, development and behavior since in the regular schedule of well visits, we may not see a toddler for six months to a year; certain things to look out for, certain milestones that they should be achieving. And if those aren't met, those shouldn't wait until the next well visit to be addressed. That's where things like early intervention or referrals, or even just further discussion as the first step is a nice place to intervene because the relationship between a parent and a pediatrician does not only happen once or twice every year, any issues or concerns should be addressed promptly so that we can lead to the best outcome for our kids.

Melanie Cole, MS: I agree with you 100%. And I just think that what a field you're in because you are really there to help our children and people don't realize to help the parents, because this is not easy raising kids. It's scary and exciting, and all of those things put together, so many emotions. Dr. Wasserman, thank you so much for all of the great work that you're doing with our children and for joining us today.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate and review Kids Health Cast on Apple Podcast3, Spotify, and Google Podcast3. For more health tips, please go to we cornell.org search podcasts. And don't forget to check out our Back to Health. Great podcast there. I'm Melanie Cole. Thanks so much for listening.

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