Well-Child Care

Judith S. Shaw and Judith S. Palfrey

Health supervision visits, the cornerstone of primary care pediatrics, provide health care professionals the opportunity to promote the optimal health and well-being of children and their families in the communities in which they live. The value of contributing to and influencing the developmental trajectory of a child cannot be overstated. Through promoting children’s health, nurturing their growth, anticipating their needs, and guiding their families, the health care professional supports and contributes to the healthy and positive development of children.

Children have many “homes” where they receive care, but it is the medical home that looks after their health. Health supervision entails a variety of interrelated activities, including health promotion, prevention, surveillance and management, and the coordination of care for children and youth with special health care needs. Going beyond diagnosis, management, and treatment of health-related problems, the medical home is foremost a place for promoting health and building on the recognized strengths of the child and family. Although most children remain healthy, there is an increasing population of children living with chronic illness, disability, and other special needs. The health care professional is in a unique position to coordinate the often complex care, advocate for appropriate services, and facilitate optimum communication among the various individuals involved.

Caring for children’s health provides many rewards and challenges. The interplay between environmental influence and factors intrinsic to the child becomes evident in many aspects of pediatric health and development. Continuity care is based on a developmental framework that recognizes the constancy of growth and change throughout childhood. Appreciating the impact of physical and psychosocial health not only on the child but on the people in the child’s life, the health care professional has responsibilities beyond the traditional medical model that include health promotional activities such as consideration for emotional, spiritual, and environmental health and for community and societal health as well as their influences on the child’s future development.

During time spent with a child, the health care professional’s goal is to establish as much as possible the child’s healthy growth and development with no deviations from the optimal developmental trajectory. However, when a deviation occurs, it should be detected early, receive all available appropriate treatment, and include a plan for preventing future sequelae or problems. Through the regular health supervision visits that take place throughout the child’s life, a special bond between the health care professional and the child and family often develops. This partnership is no longer unidirectional in which a health care professional imparts guidance and wisdom to a receptive child and family. In the past, health supervision visits were dictated by a periodicity schedule, and although their frequency is virtually unchanged, the visits are now parent driven and as interactive as possible. Effective health promotion involves a bidirectional relationship of receptivity that values the agenda and needs of the family while recognizing the importance of providing services essential to the health and well-being of the child and family.

This chapter provides an overview of health supervision of infants, children, and adolescents; covers specific aspects of the visits and other important areas pertaining to health supervision; and discusses considerations in the office practice to support excellence in health supervision.

HEALTH SUPERVISION GUIDELINES

INTRODUCTION

The goal of primary care pediatrics is to facilitate optimal health and well-being of children and their families. This is accomplished through a variety of interrelated activities, including problem solving and management, problem prevention, health promotion, and the coordination of care for children with special needs. The traditional focus on problem diagnosis and management has been broadened to include screening for disease and its precursors in an asymptomatic population. Pediatric providers have long recognized the value of preventive programs such as mass immunization and continue to lead the way in this area through an emphasis on regular health surveillance, anticipatory guidance, and involvement in community-based prevention strategies. Emphasis is placed on the related concept of health promotion, whereby optimal health and well-being is positively encouraged. These areas form the foundation for current recommendations for health supervision guidelines.

At each visit, the developmental level of the child dictates both the approach to the patient and much of the visit’s content. In pediatrics, the therapeutic alliance includes both the child and the family; the importance of establishing a trusting longitudinal relationship cannot be overemphasized.

The American Academy of Pediatrics’ Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents¹ is a consolidation of the many health supervision guidelines into a single set of guidelines for health care professionals. These guidelines, based on the latest evidence and expert opinion on standards of care, offer a roadmap for the health professional to follow and provide a new structure for health supervision in primary care.

WHAT IS NEW IN BRIGHT FUTURES

Experienced health professionals see the well-child visit as an opportunity to improve the health and well-being of children and their families. However, most report feeling tension as they seek to provide care that includes a personal assessment of the child’s health and the family’s ability to promote continued health in the limited time available during office encounters.

Resolving this tension is important to the success of the visit and is key to family and health professional satisfaction. Bright Futures proposes solutions to improve the organization of clinical processes and well-child care. Using the Bright Futures materials, a health care professional working with office staff can create effective encounters that meet their goals of disease detection, disease prevention, and health promotion.

The third edition of Bright Futures was revised following a careful examination of the evidence supporting each recommendation, and with a goal of improving the structure and format for delivery of primary care (see Table 10-1).

Table 10-1. Summary of Changes to the 2007 American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care

Note: The most recent visit periodicity schedule is available at http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf.

Source: Reprinted with permission from Hagan J, Shaw J, Duncan P, eds. Bright Futures: Health Supervision Guidelines for Infants, Children and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007:210, table 1.

OVERVIEW OF THE BRIGHT FUTURES VISIT

Bright Futures outlines the health supervision visit using four areas of importance: context, priorities, health supervision, and anticipatory guidance (Table 10-2).

The “Context” section in the new Bright Futures recommendations provides a brief overview of the child at different age levels, including the developmental tasks and milestones to be achieved, thereby setting the context for the visit. It points out the unique attributes, strengths, and assets of the child and special considerations for ensuring healthy growth and development.

For the “Priorities for the Visit” section, the Bright Futures Expert Panel identified 5 priority topics to be discussed during visits once the concerns of the child and family have been elicited and addressed.

Table 10-2. Bright Futures Visit Outline, Using a Strength-based Approach

Source: Reprinted with permission from American Academy of Pediatrics, Summary of Changes Made to the 2007 AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule).

“Health Supervision” includes six subsections: “History” offers questions relevant to the child and family to assess interval and past medical history. “Observation” provides ideas for observing the child and family as a starting point for the visit. “Surveillance of Development” suggests questions for assessing developmental milestones and tasks at those visits when a structured developmental screening tool is not used. “Physical Examination” emphasizes that a complete physical examination “is included as part of every health supervision visit” and describes aspects of the examination that are important for a child of specific ages. “Screening” provides tables for universal (done for all children) and selective (based on risk assessment) screening. The tables list the method of screening and the action to take if the risk assessment is positive. “Immunizations” refers readers to the appropriate Web sites for the most current recommendations.

The “Anticipatory Guidance” section describes in more detail each of the 5 priorities identified by the Expert Panel, including sample questions and guidance in the exact words that the clinician could use.

CONDUCTING A HEALTH SUPERVISION VISIT

PRIORITIES

Primary care pediatrics is changing as health care professionals are challenged to provide more service in less time and with shrinking reimbursement. The luxury of extended face-to-face time between the patient and clinician is disappearing. Health care administrators approach health supervision visits as a business, limiting nonreimbursed activities, seeking greater efficiencies, measuring return on investment and relative-value units. Recognizing that the long list of anticipatory guidance topics that could and should be discussed at each visit was unrealistic, and in response to a plea from health care professionals to help focus the topics, the Bright Futures authors were challenged with how to design a comprehensive visit, yet acknowledging the limited time available during the visit, to hone in on those areas most important to a child at each age level. The first priority is to attend to the concerns of the child and parents. Beyond that, the Bright Futures Expert panel developed 5 priorities through an exhaustive process considering and reviewing the available evidence, expert opinion, and numerous discussions with experts in preventive services.

In addition to 5 priorities for each visit, Bright Futures provides detailed information about each priority along with sample questions, dialog, and anticipatory guidance. The numerous individuals who contributed to the writing of Bright Futures recognized that it was important to explain not only what should be done but also how to do it and how to say it. For example, rather than just recommending “screen for domestic violence,” Bright Futures offers the clinician sample questions such as “Because violence is so common in many people’s lives, I’ve begun to ask about it. I don’t know if this is a problem for you, but many children I see have parents who have been hurt by someone else. Some are too afraid or uncomfortable to bring it up, so I’ve started asking about it routinely. Do you always feel safe in your home? Are you scared that your partners or someone else may try to hurt you or your child?” It offers anticipatory guidance such as “One way that I and other health care professionals can help you if your partner is hitting or threatening you is to support you and provide information about local resources that can help you.”

HISTORY TAKING

For a more detailed discussion of interview techniques, see Chapter 4.

Taking a History Process

As with any health encounter, the history is the central element of the health supervision visit. The way in which the history taking is conducted sets the tone for the entire visit. The information that is gleaned sets the agenda for the visit and for subsequent visits. In most cases, the information obtained by history affirms that the child is doing well on all health and developmental parameters. The history also affords the family the chance to voice concerns about any aspect of the child’s health and development that they would like more information or guidance about. Through a careful history taking, the child health clinician and parent can identify those areas that require further discussion or action. Occasionally during the history taking, a serious unmet health, developmental, or social need is uncovered. When this occurs, the clinician and family can readjust the content of the visit and establish a plan of consultations and further visits to meet the child’s and family’s need.

Health supervision visits are best accomplished when parents and providers see the enterprise as a shared task or partnership. It is helpful for the child health provider to make this partnership explicit by using words like we and us when taking a history. The history helps align the expectations of the parent with those of the provider.

The parents and clinician should be seated during history taking to emphasize the importance of the activity and show that the clinician is eager to listen to the parents’ answers and concerns. The clinician should record the information at the time of history taking (ideally in an electronic form). The clinician should also review with the family the prescreening questionnaire that may have been completed. While the computer is a valuable tool for recording and monitoring information, the child health clinician should make it a point to face the parents during the history taking and establish eye contact whenever possible. The history should be taken in the family’s preferred language whenever feasible. Even the best interpreter often miscommunicates key questions and answers. While conducting a child supervision history through an interpreter, the clinician should not hesitate to ask the interpreter to rephrase a question or answer if the information seems unclear. (See Chapter 15 for further discussion of culturally competent care.)

Table 10-3. History Taking at First and Subsequent Visits to the Practice

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