Chapter 11 Health Supervision
What Is Health Supervision?
Health supervision (“well-child check”) emphasizes the health and well-being of the patient in the context of the family and the community. The health visit includes an interview, a review of developmental progress, an age-appropriate physical examination, and selected screening assessments. Personalized guidance, education of patients and families, promotion of health, and prevention of illness and injury are the goals of the visit. The Bright Futures Pocket Guide contains much useful information about health supervision and is available as a free download from www.brightfutures.org/pocket/index.html.
Why Emphasize Health Supervision?
Complex interactions between biologic and psychosocial factors affect the health of children and their families throughout life. A family may not be traditional, nuclear, or biologic, but it is crucial to growth and development from infancy through adolescence. Attention to families is especially important because an increasing number of children are homeless or in foster care, lack stable and effective parenting, or may be exposed to domestic violence. Chronic health conditions and special healthcare needs affect more than 25% of the patients followed in pediatric practices.
How Do I Organize the Health Supervision Visit?
The “chief complaint of health” will help you focus on the systems that contribute to the health of a child and family, just as the chief complaint of a problem helps direct your evaluation of the ill patient. The background information for the visit comes from the medical record and from the physicians, nurses, and other health professionals who have been involved in the care of the child and family. The age-appropriate assessment should be comprehensive:
Listen to the concerns expressed by parents, children, and adolescents
Review and update family and social history
Review and summarize the information in the chart about illnesses and injuries
Review previous physical findings and results of screening tests
Review developmental progress and consider using a screening tool such as the Denver II
Look at vital signs, growth charts, and the body mass index (BMI) nomogram
Identify risks to the child’s well-being, whether medical, social, or environmental, including the home and the community
Determine the strengths of the child and ask about family strengths and problems
Ask about safety, nutrition, growth, behavior, discipline, illness, and injury
Assess immunization status at each health supervision visit; ideally, you should inquire about immunizations for all children in the family
Observe the interactions between parent and child
Observe the patient to assess development before you start the examination
Base the examination on the patient’s development, as discussed in Chapters 5, 8, and 9
Select screening tests based on information from the history and examination
What Is Anticipatory Guidance?
Anticipatory guidance provides age and developmentally focused counseling about health that is based on the concerns expressed by parents and patients. You will need the ability to answer questions and explain findings, and the knowledge to provide counseling about what can be expected during the time interval until the next visit. If at first you do not feel comfortable providing anticipatory guidance, observe an experienced pediatrician. You will be able to assume more responsibility with each subsequent patient. The focus for anticipatory guidance will be based on your interview, the physical examination, your assessment of the patient’s health, and any concerns that you might have identified. Guidance must be individualized for each patient and family, although most discussions include development, behavior, education, nutrition, safety, immunizations, discipline, language, sleep, dental health, family, medical, and psychosocial topics. Anticipatory guidance can assist the family to make best use of community resources. See the Bright Futures Pocket Guide for age-specific suggestions.
INFANTS
What Should I Evaluate about Infant Health?
Health supervision visits are scheduled at short intervals during infancy to monitor growth and developmental progress and to initiate the primary immunization series: Hepatitis B vaccine at birth or shortly after; all other vaccines starting at age 2 months (or as soon as the infant is brought to the office to establish ongoing care—see Chapter 12). Ask about prenatal and perinatal events, the family history, and the home environment. Review developmental progress and immunization status at every visit. During the interview, observe the interaction between infant and parent and note whether the infant appears well nourished and cared for. A careful physical examination (Chapter 5) allows detection of congenital diseases and of disorders that have their roots in prenatal, intrapartum, and immediate postnatal problems but do not become apparent until after the infant is sent home from the newborn nursery. Routine hearing screen and the neonatal metabolic screen detect many congenital problems, but not all; thus, you must be attentive to the uncommon but serious disorders that occasionally appear. A screening tool such as the Denver II (see Chapter 9) can assist you to monitor development. Infant behaviors often cause concerns, sometimes because they reflect problems and other times because inexperienced parents need guidance about age-appropriate activities. Nutrition questions almost always come up, especially regarding breast-feeding (see Chapter 10). Nutritional surveillance is key early in life because rapid growth demands a high calorie intake. Screening for lead exposure should be initiated at 12 months, or even earlier in high-risk environments. When the lead level is obtained, a screen for nutritional anemia can also be done (see Chapters 13 and 50).
How Do I Assess the Family?
The adaptation of the family to the new infant gives you important insight into parenting skills and family stress. As you monitor the family, you can provide guidance for new parents and reinforcement for experienced parents. Listen actively when parents ask questions or tell about their experiences. Young parents may be unprepared for parenthood, may lack physical and financial resources, and may not have a support network of family, grandparents, neighbors, friends, and colleagues at work. Experienced parents may be concerned with older children in the family who demonstrate jealousy or show behavioral regression when a new sibling arrives. Family dysfunction may manifest during the stressful early months of new parenthood, especially with regard to crying, sleep, and financial pressures. You need to be alert to the possibility of domestic violence in any stressed family. Parental habits, such as smoking, may pose a risk for the infant. Ensure that parents pay attention to safety in the home and automobile. Inquire about family risk factors that would have an impact on immunizations or on the infant’s health, such as immunocompromised relatives, or family members with active tuberculosis.
How Do I Assess the Community?
Child care is an essential community resource for mothers who must work or attend school. In some communities, child care may be lacking, which restricts parental work and education. The community itself may be unsafe, may lack public transportation, may have old housing (a risk for lead exposure), and may not have many child and family services. The “simple” becomes difficult if transportation is lacking or if medical services are located at a distance.
What Anticipatory Guidance Is Needed?
The first year of life is filled with change. Parents appreciate guidance about what to expect in the weeks or months from one health visit to the next. They benefit from practical information about feeding, sleep, behavior, developmental milestones, and common illnesses. As the infant matures, safety becomes more and more important. Information about reliable child care services can provide a valuable service to families. See the Bright Futures Pocket Guide for age-specific suggestions.
TODDLERS AND PRESCHOOL CHILDREN
What Problems Arise for Toddlers and Preschoolers?
Parents of toddlers and preschoolers commonly raise concerns about behavior, nutrition, language development, and intercurrent illnesses. You will need to distinguish problems that indicate health or developmental concerns from those that reflect the expected development of the child. Emerging independence makes the toddler particularly prone to confrontations with parents. Temper tantrums usually reflect the toddler’s desire for attention and can trigger parental reactions that have bad consequences for the child or that reinforce the undesirable behavior. Behavior problems can also manifest at the birth of a sibling—a common occurrence in families with toddlers—with regressive behaviors, jealousy, and even aggressive outbursts occurring when the newborn is brought home. Often, behavior problems occur at bedtime or mealtime and may result in ongoing confrontation between parents and toddlers. Behavioral feeding disorders seem to peak at about age 3 years, cause much mealtime distress, and may result in either poor weight gain or excessive weight gain. Daycare or preschool exposes the child to new experiences and demands for socialization. Behavior assessment is discussed in Chapter 22. You do not need to do screening tests such as hematocrit, urinalysis, and tuberculin test unless the history provides a reason to do so.
What Should I Emphasize During the Evaluation?
Careful monitoring of growth measurements on growth charts and the BMI nomogram helps identify the young child at risk for failure to thrive or obesity. Developmental progress should be reviewed with parents at each visit. Observe the child’s responses to environmental stimuli, both auditory and visual, and listen to the child’s language. You should be able to understand approximately half of the words spoken by a 2-year-old, two-thirds to three-fourths of the words spoken by a 3-year-old, and all of the language of a 4-year-old. Delayed language may result from conductive hearing loss caused by chronic middle ear effusions or recurrent ear infections; referral to a speech and language specialist may be needed. Behaviors often trigger concerns and also prompt ineffective responses by parents. Important parenting skills should progress as the child develops. You gain important insight from observing how the parent interacts with the child for comforting, discipline, and positive reinforcement and listening to the tone of voice a parent uses to communicate with the child. Be aware of the potential for child abuse or domestic violence. Review immunization status, make certain that vaccinations are up to date, and encourage yearly influenza vaccine. The physical examination may detect a congenital problem such as coarctation of the aorta or a subtle neurologic deficit that was not identified earlier. Look for physical findings that might explain any problem identified in the history. Identify early cavities and evidence of poor dental hygiene such as plaque and gingival inflammation.
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