Bright Future – 18 Month Visit
Health supervision
Surveillance of development
- Social language and self-help
- – Engages with others for play
- – Helps dress and undress self
- – Points to pictures in book, to object of interest to draw parent’s attention to it
- – Turns, looks at adult if something new happens
- – Begins to scoop with spoon
- – Uses words to ask for help
- Verbal language (Expressive and receptive)
- – Identifies at least 2 body parts
- – Names at least 5 familiar objects
- Gross Motor
- – Walks up steps with 2 feet per step with hand held
- – Sits in small chair
- – Carries toy while walking
- Fine Motor
- Scribbles spontaneously
- Throws small ball a few feet while standing
Observation of Parent-Child interaction
How do parent and child communicate? Does child show parent book? What is tone, feeling of parent-child interactions? Does parent notice and acknowledge child’s positive behaviors? How does parent set limits?
Complete Physical Examination, including
Measure and plot: Recumbent length, weight, head circumference, and weight-for-length
Assess/observe for: Gait, hand control, arm/spine movement; communication efforts; adult-child inter- action, eye contact, use of gestures; ocular motility, pupil opacification, red reflexes, visual acuity; number of teeth, condition of gums and teeth; abdominal masses; nevi, café-au-lait spots, birthmarks, bruising
Screening (www.aap.org/periodicityschedule) universal: Autism Spectrum Disorder; Development; Oral Health (in absence of dental home)
selective: Anemia; Blood Pressure; Hearing; Lead; Oral Health; Vision
Immunization
Anticipatory Guidance
The first priority is to attend to the concerns of the parents. In addition, the Bright Futures Early Childhood Expert Panel has given priority to the following topics for discussion in this visit:
Temperament, development, toilet training, behavior, and discipline: Anticipation of return to separation anxiety and managing behavior with consistent limits, recognizing signs of toilet training readiness and parental expectations, new sibling planned or on the way
- Anticipate anxiety/clinging in new situations.
- Spend time with child each day; plan ahead for difficult situations, and try new things to make them easier.
- Be consistent with discipline/enforcing limits.
- Wait until child is ready for toilet training (dry for periods of about 2 hours, knows wet and dry, can pull pants up/down, can indicate bowel movement).
- Read books about using the potty; praise attempts to sit on the potty.
- Prepare toddler for new sibling by reading books; avoid new developmental demands on toddler; take action to ensure own health.
Communication and social development: Encouragement of language, use of simple words and phrases, engagement in reading, playing, talking, and singing
- Encourage language development by reading and singing; talk about what you see.
- Use words that describe feelings and emotions to help child learn about feelings.
- Use simple language to give your child instructions.
TV viewing and digital media: Promotion of reading, physical activity, and safe play
- Make time for technology-free play every day; use consistent bedtime routine of reading/songs, not media.
- Use methods other than TV or other digital media for calming (distraction, removal from trigger, going outside, addressing hunger/tiredness).
- If you choose to introduce media now, choose high-quality programs/apps and use them together; limit viewing to less than 1 hour per day; be aware of own media use habits; discuss family media use plan (healthychildren.org/MediausePlan); avoid TV during meals.
Does your child watch TV or videos or use other Internet-connected devices? If no, have you started to discuss a plan for media use when your child is older?
Healthy nutrition: Nutritious foods; water, milk, and juice; expressing independence through food likes and dislikes
- Offer variety of healthy foods/snacks, especially vegetables/fruits/lean protein.
- Provide 1 bigger meal, multiple small meals/snacks; trust child to decide how much to eat.
- Provide 16 to 24 oz milk.
- Juice is not a necessary drink. If you choose to give juice, limit to 4 oz daily and always serve it with a meal.
- Continue to offer new foods; let toddler experiment by touching and mouthing.
Safety: Car safety seats and parental use of seat belts, poisoning, sun protection, firearm safety, safe home environment: burns, fires, and falls
- Use rear-facing car safety seat until child is highest weight or height allowed by manufac- turer; make necessary changes when switching seat to forward facing; never place car safety seat in front seat of vehicle with passenger air bag; backseat is safest.
- Make sure everyone uses a seat belt.
Does everyone use a seat belt, booster seat, or car safety seat? - Remove/lock up poisons/toxic household products; keep Poison Help number (800-222-1222) at each telephone, including cell.
- Use hat/sun protection clothing, sunscreen; avoid prolonged exposure when sun is strongest, between 11:00 am and 3:00 pm.
- Remove firearms from home; if firearm necessary, store unloaded and locked, with ammunition locked separately.
- Childproof home (medications, cleaning supplies, heaters, dangling cords, small/sharp objects, plastic bags); keep child away from heavy/hot objects.
- Install smoke detector on every level; test monthly; change batteries annually; fire escape plan; keep child out of driveway when cars moving.