Maximizing Children’s Health

Chapter 5 Maximizing Children’s Health


Screening, Anticipatory Guidance, and Counseling



Joseph F. Hagan, Jr., Paula M. Duncan



The care of well infants, children, and adolescents is an essential prevention effort for children and youth worldwide. The constantly changing tableau of a child’s development lends added value to regular and periodic encounters between children and their families and practitioners of pediatric health care. Health supervision visits from birth to age 21 yr are the platform for a young person’s health care: well care is provided in the medical home, fostering strong relationships between clinic or practice and child and family, and assisting in the provision of appropriate surveillance, screening, and sick care.


The evolution of this preventive health care approach is derived from the long-standing view that the science of pediatrics is a science of health and development. To assure the optimal health of the developing child, pediatric care in the USA and other countries evolved into regularly scheduled visits to assure adequate nutrition, detect and immunize against infectious diseases, and observe the child’s development. Immunization, nutrition assessment, and developmental assessment remain essential elements of the well child health supervision visit, but changes in the population’s health have led to the addition of other components to the content of today’s well child encounter. Preventive care for children and youth offers greater opportunity for health cost savings.


It is axiomatic that a healthy economy requires educated and healthy workers. For children to have a successful educational experience, they must have both physical and emotional health. Educational success is also tied to early childhood developmental competence. Thus health supervision well child care plays a vital role in promoting adult health, a concept endorsed by business leaders.


Adversity impairs development and adverse factors in life experience increase the risk of disease. Adults who experienced abuse, violence, or other stressors as children have an increased risk for depression, heart disease, and other morbidities. Biology informs us that stress leads to increased heart rate and blood pressure, and increased levels of inflammatory cytokines, cortisol, and other stress hormones, all of which impair brain activity, immune status, and cardiovascular function. There is a causal model for preventable childhood events adversely affecting health.



Periodicity


The frequency and content for well child care activities are derived from expert consensus, both from federal agencies and professional organizations such as the American Academy of Pediatrics (AAP), and from evidence-based practice, when available. The Recommendations for Preventive Pediatric Health Care or Periodicity Schedule (Fig. 5-1) is a compilation of recommendations listed by age-based visits. It is intended to guide practitioners of pediatric primary care to perform certain services and make observations at age-specific visits.


image

Figure 5-1 Recommendations for Preventive Pediatric Health Care.


(From Bright Futures/American Academy of Pediatrics.



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:


• Disease detection

• Disease prevention

• Health promotion

• Anticipatory guidance

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:


• The agenda the parent or child brings to the health supervision visit

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

• The topics where there is a clear rationale for the issue’s critical importance to health, for example, sleep environment to prevent sudden infant death syndrome (SIDS) or attention to diet and physical activity

• A summary of the child’s progress in emotional and social development, physical growth, and strengths

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

• Community-specific problems that could significantly impact the child’s health; for example, neighborhood violence from which children need protection or absence of bike paths that would promote activity

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.



Bibliography



American Academy of Pediatrics, Committee on Community Health Services. The pediatrician’s role in community pediatrics. Pediatrics. 1999;103:1304-1307.


American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Bright Futures Steering Committee. Recommendations for preventive pediatric health care. Pediatrics. 2007;120:1376.


American Academy of Pediatrics, Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, et al. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405-420.


American Academy of PediatricsCouncil on Children with DisabilitiesJohnson CP, et al. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120:1183-1215.


American Academy of Pediatrics, Division of Health Policy Research. Periodic survey of fellows #56: executive summary. Pediatricians’ provision of preventive care and use of health supervision guidelines. Elk Grove Village, IL: American Academy of Pediatrics; May 2004.


Bordley WC, Margolis PA, Stuart J, et al. Improving preventive service delivery through office systems. Pediatrics. 2001;108:E41.


Dube SR, Felitti VJ, Dong M, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111:564-572.


Frankowski BL, Leader IC, Duncan PM. Strength-based interviewing. Adolesc Med. 2009;20:22-40.


Hagan JF, Shaw JS, Duncan PM, editors. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, ed 3, Elk Grove Village, IL: American Academy of Pediatrics, 2008.


Medical Home Initiatives for Children with Special Needs Project Advisory Committee, American Academy of Pediatrics. The medical home. Pediatrics. 2002;110:184-186.


Murphey DM, Hale K, Carney J, et al. Relationships of a brief measure of youth assets to health promoting and risk behaviors. J Adolesc Health. 2004;34:184-191.


National Business Group on Health. Investing in maternal and child health: an employer’s toolkit. (website) www.businessgrouphealth.org/benefitstopics/et_maternal.cfm Accessed May 9, 2009


Resnick MD. Resilience and protective factors in the lives of adolescents. J Adolesc Health. 2000;27(1):1-2.


Resnicow KD, DiIorio C, Soet JE, et al. Motivational interviewing in health promotion: it sounds like something is changing. Health Psychol. 2002;21:444-451.



5.1 Injury Control



Frederick P. Rivara, David C. Grossman



Injuries are the most common cause of death during childhood and adolescence beyond the 1st few mo of life and represent 1 of the most important causes of preventable pediatric morbidity and mortality (Figs. 5-2 and 5-3). The identification of risk factors for injuries has led to the development of successful programs for prevention and control. Strategies for injury prevention and control should be pursued by the pediatrician in the office, emergency department, hospital, and community setting.


image

Figure 5-2 Ten leading causes of death by age group, USA, 2007.


(Modified from National Vital Statistics System, National Center for Health Statistics, CDC. Produced by Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC: 10 leading causes of death by age group, United States—2007 [PDF]. www.cdc.gov/injury/wisqars/pdf/Death_by_Age_2007-a.pdf. Accessed November 1, 2010.)


image

Figure 5-3 National estimates of the 10 leading causes of nonfatal injuries treated in hospital emergency departments, USA, 2008.


(Modified from NEISS All Injury Program operated by the Consumer Product Safety Commission [CPSC]. Produced by Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC: National estimates of the 10 leading causes of nonfatal injuries treated in hospital emergency departments, United States—2008 [PDF]. www.cdc.gov/injury/wisqars/pdf/Nonfatal_2008-a.pdf. Accessed November 1, 2010.)



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



Mortality


In the USA, injuries cause 42% of deaths among 1-4 yr old children and 3 times more deaths than the next leading cause, congenital anomalies. For the rest of childhood and adolescence up to the age of 19 yr, 65% of deaths are due to injuries, more than all other causes combined. In 2006, injuries caused 17,252 deaths (21 deaths per 100,000) among individuals 19 yr old and younger in the USA (Table 5-1), resulting in more years of potential life lost than any other cause.



Table 5-1 INJURY DEATHS IN THE USA, 2006*

image

Motor vehicle injuries lead the list of injury deaths at all ages during childhood and adolescence, even in children younger than 1 yr of age. In children and adults, motor vehicle occupant injuries account for the majority of these deaths. During adolescence, occupant injuries are the leading cause of injury death, accounting for >50% of unintentional trauma mortality in this age group.


Drowning ranks 2nd overall as a cause of unintentional trauma deaths, with peaks in the preschool and later teenage years (Chapter 67). In some areas of the USA, drowning is the leading cause of death from trauma for preschool-aged children. The causes of drowning deaths vary with age and geographic area. In young children, bathtub and swimming pool drowning predominate, whereas in older children and adolescents, drowning occurs predominantly in natural bodies of water while the victim is swimming or boating.


Fire and burn deaths account for 4% of all unintentional trauma deaths and 8% in those younger than 5 yr of age (Chapter 68). Most of these are due to house fires; deaths are caused by smoke inhalation and asphyxiation rather than severe burns. Children and the elderly are at greatest risk for these deaths because of difficulty in escaping from burning buildings.


Suffocation accounts for approximately 73% of all unintentional deaths in children younger than 1 yr of age. The majority of these deaths result from choking on food items, such as hot dogs, candy, grapes, and nuts. Nonfood items that can cause choking include undersized infant pacifiers, small balls, and latex balloons.


Homicide is the 3rd leading cause of injury death in children 1-4 yr of age and the 2nd leading cause of injury death in adolescents (15-19 yr old). Homicide in the pediatric age group falls into 2 patterns: infantile and adolescent. Infantile homicide involves children younger than the age of 5 yr and represents child abuse (Chapter 37). The perpetrator is usually a caretaker; death is generally the result of blunt trauma to the head and/or abdomen. The adolescent pattern of homicide involves peers and acquaintances and is due to firearms in >80% of cases. The majority of these deaths involve handguns. Children between these 2 age groups experience homicides of both types.


Suicide is rare in children younger than age 10 yr; only 1% of all suicides occur in children younger than age 15 yr. The suicide rate increases markedly after the age of 10 yr, with the result that suicide is now the 3rd leading cause of death for 15-19 yr olds. Native American teenagers are at the highest risk, followed by white males; black females have the lowest rate of suicide in this age group. Approximately one half of teenage suicides involve firearms (Chapter 25).



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.

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Jun 18, 2016 | Posted by in PEDIATRICS | Comments Off on Maximizing Children’s Health

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