Provide anticipatory guidance at well-child visits
Provide anticipatory guidance at well-child visits: Excerpt from Avoiding Common Pediatric Errors
Author:
Elizabeth Wells, MD
What to Do - Take Action
The term anticipatory guidance refers to the practice in which pediatricians
provide information and counsel parents about child development and behavior. It helps families understand what to expect during their child's, or
adolescent's, current and approaching stage of development. Studies show
parents value these interactions and, in general, view them favorably. Pediatricians should take steps to learn what families are doing and target the
discussion to the particular needs of each family.
GuidelinespublishedbytheAmericanAcademyofPediatrics(AAP)and
by others through the Bright Futures collaborative focus on health behaviors that have profound effects on childhood health and well-being. Topics
to be discussed with patients of all ages include healthy habits, prevention
of illness, nutrition, oral health, sexuality, social development, family relationships, parental health, community interactions, self-responsibility, and
school/vocational achievement. Certain safetytopics are appropriate to raise
at any age such as motor vehicle safety, sun protection, a tobaccofree home,
and smoke detectors. The AAP urges pediatricians to provide counseling for
violence prevention, including discussing firearms in the home, physical and
sexual abuse, and media exposure. Below is a summary of particular topics
that may be raised, according to patient age.
Infants (Birth to 1 Year)
Nutrition discussions with parents of infants should cover breast milk and
formula, food preparation, transitioning to solid food, preventing choking
and avoiding honey, which, if it contains the spores of Clostridium botulinum,
could cause botulism. Elimination is an important issue, particularly as an
increase in the diversity of the diet can lead to changes in stooling patterns.
Additionally, supplementation with iron and vitamin D should be discussed.
Oral health topics include preventing bottle caries and fluoride supplements.
Safety discussions should cover safe sleep environment, car seats, burn
prevention, fall prevention, choking prevention, drowning prevention, and
cardiopulmonary resuscitation. Discussions about development and behavior should involve milestones in motor abilities and language. Reading aloud
should be introduced early on. Guidance about family relationships may
include childcare and postpartum depression.
Toddlers and Preschool Age (1–5 Years)
In the toddler/preschool age group, providers should check that patients
are visiting the dentist and brushing habits should be discussed. Elimination
(bowel and bladder) training is an important topic at this age. Injury prevention should cover traffic safety, burn prevention, fall prevention, drowning
prevention, and dealing with strangers. Poison prevention includes keeping
medicines and household products locked up and the poison control telephone number (1-800-222-1222) readily available. Behavior guidance may
focus on discipline and temper tantrums.
School Age (6–11 Years)
Discussions with parents of school-age children about eating may focus on
healthy food choices; nutritious breakfasts, lunches, and dinners; and pleasant family meal times. Injury prevention should include talks about sports
and protective gear, the neighborhood and neighbors, and emergency plans.
Water safety guidance includes talking about and teaching children to swim.
Limiting television time and video games should be recommended, as these
activities are associated with an increased risk of obesity and problematic
behaviors. Pubertal development may be discussed during this time.
Younger Adolescents (11–15 Years)
Body image and weight management should be incorporated in discussions
about balanced diet and physical activity with adolescents. Avoidance of
alcohol, cigarettes, and illicit drugs should be emphasized. Pediatricians
should recommend sexual abstinence at this age and encourage teenagers
to make healthy lifestyle choices for themselves. Parents should be asked
about house rules and be reminded to provide for adequate supervision
while away. Adolescents should be reminded not to ride in cars with drunk
and/or distracted drivers. Resolving conflicts without violence should be
discussed.Safedatingandpartiesmaybediscussed.Adolescentsoftenforget
or ignore safety practices and should be reminded about seat belts, bike
helmets, and other measures for injury prevention. In-home firearms are
particularly dangerous during adolescence, because of the potential for their
impulsive use by teenagers.
Older Adolescents (16–21 Years)
In older adolescents, doctors should recommend managing weight through
healthy eating and regular exercise of at least three times per week. The
adolescent should also be encouraged to get adequate sleep. It is important to discuss avoiding anabolic steroids, cigarettes, and illicit drugs and
to provide resources for those who do report substance abuse. Responsible
drivingshouldbeaddressed.Inadditiontosexualactivity,adolescentsshould
be educated on creating healthy relationships and on avoiding or removing themselves from relationships involving physical violence or emotional
abuse. Additional guidance about social relationships may cover changing
communication patterns within the family and handling separation from
home. Future plans for education, work, sports, and general health should
be discussed.
Outcomes research is still emerging about the best way for clinicians to
provide anticipatory guidance. New research is focusing on challenges such
asovercomingcultural barriers,reimbursement issues, and time-limitations.
Anticipatory guidance is most effective when it is responsive to the individual needs of the children and the parents. Additionally, limiting the number
of topics discussed at each visit might lead to increased retention, and five
to eight topics may be the most appropriate number to address in one visit.
The use of supplementary handouts is also encouraged. Current research
suggests that effective anticipatory guidance consists of authoritative, useful
information offered in a supportive manner, respectful of parental decision
making. Intervening early and promoting positive approaches in a developmental context may provide a more comfortable forum for discussing these
issues.
Suggested Readings
American Academy of Pediatrics. Guidelines for Health Supervision III. Elk Grove Village, IL:
American Academy of Pediatrics; 2002.
Barkin AL, Scheindlin B, Brown C, et al. Anticipatory guidance topics: are more better?
Ambulatory Pediatrics. 2005;5(6):372–376.
Bethell C, Reuland CH, Halfon N, et al. Measuring the quality of preventive and developmental
services for young children: national estimates and patterns of clinicians' performance.
Pediatrics. 2004;113(6 Suppl):1973–1983.
Committee on Psychosocial Aspects of Child and Family Health. American Academy of Pediatrics. The new morbidity revisited: a renewed commitment to the psychosocial aspects of
pediatric care. Committee on Psychosocial Aspects of Child and Family Health. Pediatrics.
2001;108:1227–1230.
Gardner HG; American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics.
2007;119(1):202–206.
Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children,
and Adolescents. 2nd ed. Arlington, VA: National Center for Education in Maternal and
Child Health; 2002.
Schmidt ME, Rich M. Media and child health: pediatric care and anticipatory guidance for the
information age. Pediatr Rev. 2006;27(8):289–298.
Schuster MA, Duan N, Regalado M, et al. Anticipatory guidance: what information do parents
receive? What information do they want?Arch Pediatr Adolesc Med. 2000;154:1191–1198.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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» Next page: Sexual abuse is an important diagnosis to confirm for both the child and family so that appropriate treatment can begin. Remember though that some physical findings that may be suggestive of abuse, may not be definitive (Avoiding Common Pediatric Errors)
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