Why are low-income kids missing well-child visits?


Optimistically, 1 in 5 well-care visits among low-income children are missed, but that number may also be as high as half if children who miss visits with their regular provider aren’t getting care elsewhere.

headshot of Elizabeth R. Wolf, MD, MPH

Elizabeth R. Wolf, MD, MPH

Well-child visits are important at every age to screen for proper development and provide preventive care. Yet for some children, these appointments are missed, and with them valuable opportunities for care.

A new study in Pediatrics found that, in particular, children from low-income families frequently missed 15-month, 18-month, and 4-year well-care visits.1 The study assessed more than 150,000 children seen at 2 health networks spanning 20 states to determine which well-care visits were most often missed and what factors played in the absences.

“Well-child visits have been shown to reduce hospitalizations and emergency department (ED) visits. Yet despite these well-established benefits, our study showed that children miss 23% to 48% of these visits,” says Elizabeth R. Wolf, MD, MPH, assistant professor of Pediatrics at the Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, and lead author of the study. “We found that children are much more likely to miss well-child visits in the toddler (15 and 18 months) or preschool (4 years) periods compared with early infancy (0 to 6 months). This pattern of attendance was similar across various racial groups and insurance types. Providers may not be able to detect developmental delays and address behavioral problems before school if children are not attending these important visits.”

Researchers found that 77% of the children who most often missed well-care visits were publicly insured, and 14% were totally uninsured. Children in the study rarely missed the 2-month, 4-month, and 6-month well-care visits, according to the study, whereas the 15-month and 18-month visits had just 41% attendance among publicly insured children, and 4-year well-visits had just 19% attendance. The study also revealed that Hispanic and Asian-American patients had higher odds of attending well-care visits compared with non-Hispanic white patients.

What’s recommended vs what’s being missed

The American Academy of Pediatrics (AAP) recommends at least 13 well-care visits from birth to age 6 years, and these visits cover everything from immunizations to developmental screening and preventive care. In addition to missing out on well-care and preventive opportunities, the study notes that missed well-care visits also are associated with higher rates of ED use and hospitalizations.

Assuming that children who miss well-care visits are receiving care from other sources, this would translate to about 1 in 5 well-care visits being missed, but without that assumption, researchers caution that this data could mean that up to half of all well-care visits are missed in low-income populations, according to the report. The data is also consistent with national trends showing a dip in compliance with the fourth diphtheria-tetanus-acellular pertussis, pneumococcal conjugate, and Haemophilus influenzae type B vaccines that are recommended between ages 12 months and 18 months, the report notes.

It can be difficult to define the reasons for these missed visits, but the study offers several possible explanations, including that the missed visits are those in which fewer vaccinations are given compared with early infancy visits. Additionally, the researchers note that sick visits are more frequent in early childhood, and vaccines may be paired with those visits, resulting in skipped well-care visits down the road.

“We do not know with certainty why children are missing the 15-month, 18-month, and 4-year visits, but we have some good hypotheses based on the pattern of attendance that we observed,” Wolf says. “We think one reason children may be missing these visits is that parents are prioritizing attendance of the visits that contain more vaccines. In addition, children are frequently seen for sick visits between ages 1 and 2 years. If vaccines are given at these sick visits, children may be less likely to attend subsequent well-child visits. Pediatricians and healthcare systems can do a better job of emphasizing the importance of well-child visits that do not involve vaccination.”

Insurance access, access to transportation, and other socioeconomic factors also play a role, the researchers note, adding that more research is needed to better understand how well-care visits can be promoted to families of children who are publicly insured or uninsured-a cohort that makes up a respective 42% and 5% of children nationally.

Still, pediatricians need to educate parents on the importance of these visits, as they offer a unique opportunity to assess for key developmental milestones, behavioral problems, and school readiness-especially at the 4-year visit.

Wolf says she hopes the data in the study will be used to develop future interventions that could help increase compliance with well-care visits.


“It is our hope that we will be able to target the most vulnerable children who are most likely to miss well-child visits and prevent some of the negative health outcomes from occurring,” Wolf says.



1. Wolf ER, Hochheimer CJ, Sabo RT, et al. Gaps in well-child care attendance among primary care clinics serving low-income families. Pediatrics. 2018;142(5):e20174019.

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