Guidelines

Comprehensive guides for care of well infants, children, and adolescents have been developed, based on the Periodicity Schedule, which expand and further recommend how practitioners might accomplish the tasks outlined in the Periodicity Schedule. In the USA, the current guideline standard is The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition. These guidelines were developed by the 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, the American Academy of Family Physicians, the American Medical Association, the American Academy of Pediatric Dentistry, Family Voices, and others. This subsumes previous guidelines and is consistent with the AAP and Bright Futures Periodicity Schedule (see Fig. 5-1).

Tasks of Well Child Care

The well child encounter has unique contributions for promoting 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 the 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:

To achieve these outcomes, health care professionals employ techniques to screen for disease, screen for 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 both surveillance and screening. In well child care, surveillance occurs in every health encounter and is enhanced by the opportunity for repeated visits and observations with advancing developmental stages. It relies on the experience of a skilled clinician over time. Screening is a more formal process utilizing some form of tool, which has been validated 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 watchful eyes of providers of pediatric health care who are experienced in child development. Developmental screening utilizes a structured developmental screening tool or approach 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. 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 health care professional needs to individualize disease prevention strategies to the community, as well as to the specific family and patient.

Health promotion and anticipatory guidance activities distinguish the well child health supervision visit from all other encounters with the health care system. Disease detection and disease prevention activities are germane to all interactions of children with physicians and other health care providers, but health promotion and anticipatory guidance shift the focus to wellness and to the strengths of the family, for example, 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 community services, and engage with extended family, school, neighborhood, and church.

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:

It is important to note that this approach is directed at all children, including those with special health needs. Children with special health needs 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 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.

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 that are specific to individual children based on their age, family situation, chronic health condition, or a parental concern, for example, sleep environment to prevent SIDS, activities to lose weight, and fences around swimming pools. Attention should also be focused on the family milieu, for example, screening for parental depression (especially maternal postpartum depression) and other mental illness, family violence, substance abuse, nutritional inadequacy, or lack of housing. These issues are essential to the care of young children.

Answering parents’ questions is 1 of the most important priorities of the well child visit. Promoting family-centered care and partnership with parents increases the ability to elicit parent concerns, especially about their child’s development, learning, and behavior. It is important to identify children with developmental disorders as early as possible. Developmental surveillance at every visit combined with a structured developmental screening and autism screening at some visits is a way to improve diagnosis, especially for some of the more subtle language delays or autism spectrum disorders where early intervention is believed to be associated with reduced morbidity.

Middle Childhood and Adolescence

As the child enters school-aged years, additional considerations emerge. Attention to developing autonomy requires fostering a clinician-patient relationship separate from the clinician-child-family relationship with increasing needs for privacy and confidentiality as the child ages.

The 6 health behaviors that are most important in adolescent and adult morbidity and mortality are: nutrition, physical activity; sexuality related behavior; tobacco, alcohol, and other drug use; behaviors that contribute to unintentional and intentional injuries; and violence. Emotional well-being with attention to the developmental tasks of adolescence (competence at school and other activities, connection to friends and family, autonomy, empathy, and a sense of self-worth), as well as early diagnosis and treatment of mental health problems, are of equal importance.

Office Intervention for Behavioral and Mental Health Issues

Twenty percent of primary care encounters with children are for a behavioral or mental health problem, or are sickness visits complicated by a mental health issue. Pediatricians need increased knowledge for diagnosis, treatment, and referral criteria for attention-deficit/hyperactivity disorder (ADHD) (Chapter 30), depression (Chapter 24), anxiety (Chapter 23), and conduct disorder (Chapter 27), as well as an understanding of the pharmacology of the frequently prescribed psychotropic medications. Encouragement of behavioral change is also an important responsibility of the clinician. Motivational interviewing provides a structured approach that has been designed to help patients and parents identify the discrepancy between their desire for health and their behavioral choices. It also allows the clinician to use proven strategies that lead to a patient-initiated plan for change.

Strength-Based Approaches and Framework

Questions about school or extracurricular accomplishments or competent personal characteristics should be integrated into the content of the well child visit. This often sets a positive context for the visit, deepens the partnership with the family, and acknowledges the child’s healthy development. This facilitates discussing social-emotional development with children and their parents. There is a strong relationship between appropriate social-emotional development (e.g., children’s strong connection to their family, social friends, and mentors; competence; empathy; and appropriate autonomy) and decreased participation in all the risk behaviors of adolescence (related to drugs, sex, and violence). An organized approach to the identification and encouragement of a child’s strengths during health supervision visits provides both the child and parent with an understanding of how to promote healthy achievement of the developmental tasks of childhood and adolescence. Children with special health needs often have a different timetable, but they have an equal need to be encouraged to develop strong family and peer connections, competence in a variety of arenas, ways to do things for others, and appropriate independent decision-making.

Office System Change for Quality Improvement

Some of the office strategies to improve the preventive services delivered to children and youth include screening schedules and parent handouts, flow sheets, registries, and the use of parent and youth previsit questionnaires. Such tools are available in The Bright Futures Guidelines, 3rd Edition, Toolkit. These efforts are part of a larger national effort that is built on a coordinated team approach in the office setting and the use of continuous measurement for improvement.

Evidence

The clinical encounter with the well child is guideline- and recommendation-driven and requires the integration of clinician goals, family needs, and community realities in seeking better health for the child. Few well child care activities have been evaluated for efficacy, yet these activities are highly valued; lack of evidence is not the same as lack of benefit. The rationale for well child care activities is a balance of evidence from research, clinical practice guidelines, professional recommendations, expert opinion, experience, habit, intuition, and preferences or values. Clinical or counseling decisions and recommendations may also be based on legislation (seat belts), on common sense measures not likely to be studied experimentally (lowering water heater temperatures), or on the basis of relational evidence (television watching associated with violent behavior in young children). Most important, sound clinical and counseling decisions are responsive to family needs and desires, and support “patient-centered decision-making.”

Caring for the Child and Youth in the Context of the Family and Community

A successful primary care practice for children incorporates families, is family centered, and embraces the concept of the medical home. A medical home is defined by the AAP as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. In a medical home, a pediatrician works in partnership with the family and patient to assure that all medical and nonmedical needs of the child are met. Through this partnership, the child health care professional helps the family/patient access and coordinate specialty care, educational services, out-of-home care, family support, and other public and private community services that are important to the overall health of the child and family.

Ideally, health promotion activities occur not only in the medical home, but also in partnership with community members and other health and education professionals. This rests on a clear understanding of the important role that the community plays in supporting healthy behaviors among families. Communities where children and families feel safe and valued, and have access to positive activities and relationships, provide the important base that the health care professional can build on and refer to for needed services that support health but are outside the realm of the health care system or primary care medical home. It is important for the medical home and community agencies to identify mutual resources, communicate well with families and each other, and partner in designing service delivery systems. This interaction is the practice of community pediatrics, whose unique feature is its concern for all of the population: those who remain well but need preventive services, those who have symptoms but do not receive effective care, and those who do seek medical care either in a physician’s office or in a hospital.

Injury Control

The term accident prevention has been replaced by injury control. The word accident implies an event occurring by chance, without pattern or predictability. In fact, most injuries occur under fairly predictable circumstances to high-risk children and families. Accident connotes a random event that cannot be prevented. The use of the term injury promotes an awareness of a medical condition with defined risk and protective factors that can be used to define prevention strategies.

The reduction of morbidity and mortality from injuries can be accomplished not only through primary prevention (averting the event or injury in the first place), but also through secondary and tertiary prevention. The latter 2 approaches include appropriate emergency medical services for injured children; regionalized trauma care for the child with multiple injuries, severe burns, or head injury; and specialized pediatric rehabilitation services that attempt to return children to their previous level of functioning. This broadened scope of prevention is more properly described by the term injury control.

This expanded definition also encompasses intentional injuries (assaults, self-inflicted injuries). These injuries are important in adolescents and young adults, and in some populations, they rank 1st or 2nd as causes of death in these age groups. Many of the same principles of injury control can be applied to these problems; limiting access to firearms may reduce both unintentional shootings and suicides.

Scope of the Problem

Nonfatal Injuries

Mortality statistics reflect only a small portion of the effects of childhood injuries. Approximately 11% of children and adolescents receive medical care for an injury each year in hospital emergency departments, and at least an equal number are treated in physicians’ offices. Of these, 2% require inpatient care and 55% have at least short-term temporary disability as a result of their injuries.

The distribution of these nonfatal injuries is very different from that of fatal trauma (Fig. 5-4). Falls are the leading cause of both emergency department visits and hospitalizations. Bicycle-related trauma is the most common type of sports and recreational injury, accounting for approximately 300,000 emergency department visits annually. Nonfatal injuries, such as anoxic encephalopathy from near-drowning, scarring and disfigurement from burns, and persistent neurologic deficits from head injury, may be associated with severe morbidity, leading to substantial changes in the quality of life for victims and their families.

Figure 5-4 Emergency department visit rates for leading 1st-listed causes of injury by age, USA, 1993-1994.

(Data from Centers for Disease Control and Prevention, National Center for Health Statistics, and National Hospital Ambulatory Medical Case Survey.)

Principles of Injury Control

At one time injury prevention centered on attempts to pinpoint the innate characteristics of a child that result in greater frequency of injury. Most discount the theory of the accident-prone child. Although longitudinal studies have demonstrated an association between hyperactivity and impulsivity and increased rates of injury, the sensitivity and specificity of these traits for injury are extremely low. The concept of accident proneness is, in fact, counterproductive in that it shifts attention away from potentially more modifiable factors, such as product design or the environment. It is more appropriate to examine the physical and social environment of children with frequent rates of injury than to try to identify particular personality traits or temperaments, which are difficult to modify. Children at high risk for injury are likely to be relatively poorly supervised, to have disorganized or stressed families, and to live in hazardous environments.

Efforts to control injuries include education or persuasion, changes in product design, and modification of the social and physical environment. Efforts to persuade individuals, particularly parents, to change their behaviors have constituted the greater part of injury control efforts. Speaking with parents specifically about using child car seat restraints and bicycle helmets, installing smoke detectors, and checking the tap water temperature is likely to be more successful than offering well-meaning but too-general advice about supervising the child closely, being careful, and “childproofing” the home. This information should be geared to the developmental stage of the child and presented in moderate doses in the form of anticipatory guidance at well-child visits. Important topics to discuss at each developmental stage are shown in Table 5-2.

The most successful injury prevention strategies generally are those involving changes in product design, as shown in Table 5-3. These passive interventions protect all individuals in the population, regardless of cooperation or level of skill, and are likely to be more successful than active measures that require repeated behavior change by the parent or child. However, for some types of injuries, effective passive interventions are not available or feasible; we must rely heavily on attempts to change the behavior of individuals. Turning down the water heater temperature, installing smoke detectors, and using child-resistant caps on medicines and household products are examples of effective product modifications. Many interventions require both active and passive measures. Smoke detectors provide passive protection when fully functional, but behavior change is required to ensure annual battery changes and proper testing.

Table 5-3 INJURY CONTROL INTERVENTIONS

Modification of the environment often requires greater changes than individual product modification, but may be very effective in reducing injuries. Safe roadway design, decreased traffic volume and speed limits in neighborhoods, and elimination of guns from households are examples of such interventions. Included in this concept are changes in the social environment through legislation, such as laws mandating child seat restraint and seatbelt use, bicycle helmet use, and graduated driver licensing laws.

Prevention campaigns combining 2 or more of these approaches have been particularly effective in reducing injuries. The classic example is the combination of legislation and education to increase child seat restraint and seatbelt use; other examples are programs to promote bike helmet use among school-aged children and improvements in occupant protection in motor vehicles.

Risk Factors for Childhood Injuries

Major factors associated with an increased risk of injuries to children include age, sex, race and ethnicity, socioeconomic status, rural-urban location, and the environment.

Mechanisms of Injury

Motor Vehicle Injuries

Motor vehicle injuries are the leading cause of serious and fatal injuries for individuals of all ages. Among adolescents ages 14-19 yr, motor vehicle crashes alone account for 37% of all deaths in 2006, including deaths from natural causes. Large and sustained reductions in motor vehicle crash injuries can be accomplished by identifiable interventions.

Occupants

Injuries to passenger vehicle occupants are the predominant cause of motor vehicle deaths among children and adolescents, with the exception of the 5-9 yr old group, in whom pedestrian injuries make up the largest proportion. The peak injury and death rate for both males and females in the pediatric age group occurs between 15 and 19 yr of age (see Table 5-1). Proper restraint use in vehicles is the single most effective method for preventing serious or fatal injury. The recommended restraints at different ages are shown in Table 5-4. Examples of car safety seats are noted in Figure 5-5.

Table 5-4 RECOMMENDED CHILD RESTRAINT METHODS

Figure 5-5 Car safety seats. A, Rear-facing infant seat. B, Forward-facing child harness seat. C, Forward-facing convertible harness seat. D, Low-back booster seat. E, High-back booster seat.

(From Ebel BE, Grossman DC: Crash proof kids? An overview of current motor vehicle child occupant safety strategies, Curr Probl Pediatr Adolesc Health Care 33:33–64, 2003. Source: NHTSA; graphics courtesy of Transportation Safety Training Center, Virginia Commonwealth University: Types of child safety seats [website]. www.nhtsa.dot.gov/people/injury/childps/safetycheck/typeseats/index.htm. Accessed November 1, 2010.)

Much attention has been given to child occupants younger than 8 yr of age. Use of child restraint devices, infant car seats, and booster seats can be expected to reduce fatalities by 71% and the risk of serious injuries by 67% in this age group. All 50 states and the District of Columbia have laws mandating their use, though the upper age limit for booster seat requirements varies by state. Physician reinforcement of the positive benefits of child seat restraints has been successful in improving parent acceptance. Pediatricians should point out to parents that toddlers who normally ride restrained behave better during car trips than children who ride unrestrained.

A detailed guide and list of acceptable devices is available from the American Academy of Pediatrics (www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Families-2010.aspx). Children weighing <20 lb may use an infant seat or be placed in a convertible infant-toddler child restraint device. Infants younger than 2 yr or if less than manufacturer’s weight limit should be placed in the rear seat facing backward; older toddlers and young children can be placed in the rear seat in a forward-facing child harness seat, until it is outgrown. Emphasis must be placed on the correct use of these seats, including placing the seat in the right direction, routing the belt properly, and ensuring that the child is buckled into the seat correctly. Government regulations have made the fit between car seats and the car easier, quicker, and less prone to error. Children younger than age 13 yr should never sit in the front seat, especially if an airbag is present. Inflating airbags can be lethal to infants in rear-facing seats and to small children in the front passenger seat.

Older children are often not adequately restrained. Many children ride in the rear seat restrained with lap belts only. Booster seats have been shown to decrease the risk of injury by 59%, and should be used by children who are between 40 lb (≈4 yr of age) and 80 lb, are <8 yr of age, and are <4 ft, 9 in (145 cm) tall. Many states have extended their car seat laws to include children of booster seat age as well. Shoulder straps placed behind the child or under the arm do not provide adequate crash protection and may increase the risk of serious injury. The use of lap belts alone has been associated with a marked rise in seatbelt-related injuries, especially fractures of the lumbar spine and hollow-viscus injuries of the abdomen. These flexion-distraction injuries of the spine are usually accompanied by injuries to the abdominal organs.

The rear seat is clearly much safer than the front seat for both children and adults. One study of children younger than the age of 15 yr found that the risk of injury in a crash was 70% lower for children in the rear seat compared with those sitting in the front seat. Frontal airbags appear to offer little protection to children in crashes and also present a risk of serious or fatal injury from the airbag itself. Side airbags also pose a risk for children who are in the front seat and are leaning against the door at the time of a crash. The safest place for children is in the rear middle seat, properly restrained for their age and size. Educational and legislative interventions to increase the number of children traveling in the rear seat have been successful.

Transportation of premature infants presents special problems. The possibility of oxygen desaturation, sometimes associated with bradycardia, among premature infants while in child seat restraints has led the AAP to recommend monitoring of infants born at <37 wk of gestational age in the seat before discharge and the use of oxygen or alternative restraints for infants who experience desaturation or bradycardia, such as seats that can be reclined and used as a car bed. Monitoring in the neonatal intensive care unit should be done for 60-90 min. Car seats should only be used for travel and not as a general use infant seat around the home.

Children riding in the back of pickup trucks are at special risk for injury because of the possibility of ejection from the truck and resultant serious head injury. They are also at increased risk for carbon monoxide poisoning from faulty exhaust systems.

Teenage Drivers

Drivers aged 15-17 yr of age have more than twice the rate of collisions compared with motorists 18 yr of age and older. Formal driver education courses for young drivers appear to be ineffective as a primary means of decreasing the number of collisions, and in fact may increase risk by allowing younger teens to drive. The risk of serious injury and mortality is directly related to the speed at the time of the crash and inversely related to the size of the vehicle. Small, fast cars greatly increase the risk of a fatal outcome in the event of a crash.

The number of passengers traveling with teen drivers influences the risk of a crash. The risk of death for 17 yr old drivers is 50% greater when driving with 1 passenger compared with driving alone; this risk is 2.6-fold higher with 2 passengers and 3-fold higher with 3 or more passengers. The risk is also increased if the driver is male and the passengers are younger than age 30 yr.

Teens driving at night are overrepresented in crashes and fatal crashes, with nighttime crashes accounting for >33% of teen motor vehicle fatalities. Almost 50% of fatal crashes involving drivers younger than age 18 yr occur in the 4 hr before or after midnight. Teens are 5-10 times more likely to be in a fatal crash while driving at night compared with driving during the day. The difficulty of driving at night combined with the inexperience of teen drivers appears to be a deadly combination.

Graduated licensing laws (GLL) consist of a series of steps over a designated period before a teen can get full, unrestricted driving privileges. In a 3-stage graduated license, the student driver must first pass vision and knowledge-based tests. This is followed by obtaining a learner’s permit and once a specific age has been achieved and driving skills advanced, the student driver is eligible to take the driving test. Once given the provisional license, the new driver will have a specified time to do low-risk driving. GLLs usually place initial restrictions on the number of passengers (especially teenaged) allowed in the vehicle and restrict driving during nighttime. There is a decrease in the number of crashes of 20-40% among the youngest drivers in states with a graduated licensing system. Elements of graduated licensing programs have been adopted by many states. Driver’s education classes do not consistently reduce motor vehicle crashes.

Alcohol use is a major cause of motor vehicle trauma among adolescents. The combination of inexperience in driving and inexperience with alcohol is particularly dangerous. Approximately 20% of all deaths from motor vehicle crashes in this age group are the result of alcohol intoxication, with impairment of driving seen at blood alcohol concentrations as low as 0.05 g/dL. Approximately 30% of adolescents report riding with a driver who had been drinking and about 10% report driving after drinking. All states have adopted a zero tolerance policy, which defines any measurable alcohol content as legal intoxication, to adolescent drinking while driving. All adolescent motor vehicle injury victims should have their blood alcohol concentration measured in the emergency department and be screened for high-risk alcohol use with a validated screening test (such as the CRAFFT or AUDIT screening tools) to identify those with alcohol abuse problems (Chapter 108.1). Individuals who have evidence of alcohol abuse should not leave the emergency department or hospital without plans for appropriate alcohol abuse treatment. Interventions for problem drinking can be effective in decreasing the risk of subsequent motor vehicle crashes. Even brief interventions in the emergency department using motivational interviewing can be successful in decreasing adolescent problem drinking.

All-Terrain Vehicles

All-terrain vehicles (ATVs) in many parts of the country are an important cause of injuries to children and adolescents. These vehicles can attain high speeds and are prone to rollover because of the high center of gravity. Orthopedic and head injuries are the most common serious injuries seen among children involved in ATV crashes. Helmets can significantly decrease the risk and severity of head injuries among ATV riders, but current use is very low. Unfortunately, voluntary industry efforts to decrease the risk of injuries appear to have had little effect in making ATVs safer. The AAP recommends that children younger than 16 yr should not ride on ATVs.

Psychosocial Consequences of Injuries

Many children and their parents have substantial psychosocial sequelae from trauma. Studies in adults indicate that 10-40% of hospitalized injured patients will have post-traumatic stress disorder (PTSD; Chapter 23). Among injured children involved in motor vehicle crashes, 90% of families will have symptoms of acute stress disorder after the crash, although the diagnosis of acute stress disorder is not predictive of later PTSD. Standardized questionnaires that collect data from the child, the parents, and the medical record at the time of initial injury can serve as useful screening tests for later development of PTSD. Early mental health intervention, with close follow-up, is important for the treatment of PTSD and for minimizing its effect on the child and family.