Maximizing Children’s Health: Screening, Anticipatory Guidance, and Counseling

Periodicity Schedule and Guidelines

The frequency and content for well-child care activities are derived from evidence-based practice and research. In addition, federal agencies and professional organizations, such as the American Academy of Pediatrics (AAP), have developed evidence-informed, expert consensus guidelines for care. The Recommendations for Preventive Pediatric Health Care or Periodicity Schedule is a compilation of recommendations listed by age-based visits ( Fig. 12.1 ). It is intended to guide practitioners of pediatric primary care to perform certain services and intentionally make observations at age-specific visits; it designates the standard for preventive services for U.S. children and youth and is referred to as such in some legislation. It is updated regularly and is available online.

Comprehensive guides for care of well infants, children, and adolescents have been developed based on the Periodicity Schedule to expand and further recommend how practitioners might accomplish the tasks outlined. The current guideline standard is The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents , 4th edition ( https://brightfutures.aap.org/Pages/default.aspx ). These guidelines were developed by AAP under the leadership of the Maternal Child Health Bureau of the U.S. Department of Health and Human Services, in collaboration with the National Association of Pediatric Nurse Practitioners, American Academy of Family Physicians, American Medical Association, American Academy of Pediatric Dentistry, Family Voices, and others.

Tasks of Well-Child Care

The well-child encounter aims to promote the physical and emotional well-being of children and youth. Child health professionals, including pediatricians, family medicine physicians, nurse practitioners, and physician assistants, take advantage of the opportunity well-child visits provide to elicit parental questions and concerns, gather relevant family and individual health information, perform a physical examination, and initiate screening tests. The tasks of each well-child visit include the following:

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  Disease detection

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  Disease prevention

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  Health promotion

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  Anticipatory guidance

To achieve these outcomes, healthcare professionals employ techniques to screen for disease—or for the risk of disease—and provide advice about healthy behaviors. These activities lead to the formulation of appropriate anticipatory guidance and health advice.

Clinical detection of disease in the well-child encounter is accomplished by a careful physical examination and both surveillance and screening. In well-child care, surveillance occurs in every health encounter and is enhanced by repeated visits and observations with advancing developmental stages. It relies on the experience of a skilled clinician performing intentional observation over time. Screening is a more formal process using some form of validated assessment tool and has known sensitivity and specificity. For example, anemia surveillance is accomplished through taking a dietary history and seeking signs of anemia in the physical examination. Anemia screening is done by hematocrit or hemoglobin tests. Developmental surveillance relies on the observations of parents and the assessment of clinicians in pediatric healthcare who are experienced in child development. Developmental screening uses a structured developmental screening tool by personnel trained in its use or in the scoring and interpretation of parent report questionnaires.

The 2nd essential action of the well-child encounter, disease prevention , may include both primary prevention activities applied to a whole population and secondary prevention activities aimed at patients with specific factors of risk. For example, counseling about reducing fat intake is appropriate for all children and families. However, counseling is intensified for overweight and obese youth or in the presence of a family history of hyperlipidemia and its sequelae. The child and adolescent healthcare professional needs to individualize disease prevention strategies to the specific patient, family, and community.

Health promotion and anticipatory guidance activities distinguish the well-child health supervision visit from all other encounters with the healthcare system. Disease detection and disease prevention activities are germane to all interactions of children with physicians and other healthcare clinicians, but health promotion and anticipatory guidance shift the focus to wellness and to the strengths of the family (e.g., what is being done well and how this might be improved). This approach is an opportunity to help the family address relationship issues, broach important safety topics, access needed services, and engage with extended family, school, neighborhood, and community and spiritual organizations.

It is not possible to cover all the topics suggested by comprehensive guidelines such as Bright Futures in the average 18 min well-child visit. Child health professionals must prioritize the most important topics to cover. Consideration should be given to a discussion of the following:

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  First and foremost, the agenda the parent or child brings to the health supervision visit.

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  The topics where evidence suggests counseling is effective in behavioral change.

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  The topics where there is a clear rationale for the issue's critical importance to health, such as sleep environment to prevent sudden unexpected infant death (SUID) or attention to diet and physical activity.

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  A summary of the child's progress in emotional, cognitive, and social development, physical growth, and strengths.

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  Issues that address the questions, concerns, or specific health problems relevant to the individual family.

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  Community-specific problems that could significantly impact the child's health (e.g., neighborhood violence from which children need protection, absence of bike paths that would promote activity).

This approach must be directed at all children , including children and youth with special health care needs. CSHCN are no different from other children in their need for guidance about healthy nutrition, physical activity, progress in school, connection with friends, a healthy sense of self-efficacy, and avoidance of risk-taking behaviors. The existence of frequent visits to the medical home or specialists to address the special health needs sometimes masks the lack of general health supervision care. The coordination of specialty consultation, medication monitoring, and functional assessment, which should occur in their periodic visits, needs to be balanced with a discussion of the child's unique ways of accomplishing the emotional, social, and developmental tasks of childhood and adolescence. Comprehensive, integrated care planning for CSHCN should support partnerships between medical homes and families and youth through goal setting and negotiating next steps. In this process, chronic condition management and health surveillance (including adolescent engagement and planning for transition to adult care) occur within an effective patient care relationship, partnering to improve health outcomes and efficiencies of care provision.

Infancy and Early Childhood

Nutrition, physical activity, sleep, safety, and emotional, social, and physical growth, along with parental well-being, are critical for all children. For each well-child visit, there are topics specific to individual children based on their age, family situation, chronic health condition, or a parental concern, such as sleep environment to prevent SUID, activities to lose weight, and fences around swimming pools. Attention should also be focused on the family milieu and other social determinants of health, including screening for parental depression (especially maternal postpartum depression) and other mental illness, family violence, substance abuse, nutritional inadequacy, and lack of housing. It is equally important to identify, acknowledge, and empower family strengths. These issues are essential to the care of young children.

Answering parents’ questions while creating an environment where parents feel comfortable asking is the most important priority of the well-child visit. Promoting family-centered care and partnership with parents increases the ability to elicit parental concerns, especially about their child's development, learning, and behavior. Evidence-based approaches such as early literacy assessment and promotion (e.g., Reach Out and Read) provide a structure for enquiry, surveillance, and parent coaching efficiently within the health supervision visit.

It is important to identify children with developmental disorders as early as possible. Developmental surveillance at every visit combined with a structured developmental screening, neuromuscular screening, and autism screening at certain visits is a way to improve diagnosis, especially for some of the subtler delays or autism spectrum disorders for which early intervention is believed to be associated with reduced morbidity.