Health supervision

Overview of pediatric health supervision.

1. Health Supervision

2. Learning Objectives 1. Design a plan for routine screening during a health supervision visit. 2. Describe the organizations that decide the periodicity schedule and recommended interventions. 3. Evaluate the evidence supporting the topics discussed during a well-child visit. 4. Critique current well-child visit models and offer alternative approaches to typical well-child care. 5. Discuss the relevance of well-child care on adult health outcomes .

3. The Pevensies, a family with four children, arrive in clinic together for health supervision visits. Susan, the oldest, is age 10, Lucy is 5 years old, Edmund is age 2, and Peter is 9 months old. Their mother says that the older two “just need their school physical forms” and “just the shots” for the younger two. She is 8 months pregnant with her fifth child, and is in a hurry to get to her obstetric appointment.

4. Recommendations for Preventive Pediatric Health Care - Bright Futures/American Academy of Pediatrics https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf 1. What screening tests and interventions are recommended for the Pevensie kids? What resources are available to guide you to design their visit today? Periodicity table! All children should have: Routine interval history Developmental surveillance Body measurements Psychosocial/behavioral assessment Physical exam Vaccines per age Anticipatory guidance Use Periodicity table to determine what is unique to each age

5. Recommendations for Preventive Pediatric Health Care - Bright Futures/American Academy of Pediatrics S E L P

6. 2. How is the schedule for “well-child visits” determined? What organizations offer input into the content and timing of these visits? Committee on Practice and Ambulatory Medicine (within AAP) Bright Futures (an initiative launched by the Maternal and Child Health Bureau in 1990 United States Preventive Services Task Force (USPSTF, within US Dept of HHS) The timing of health surveillance visits has been heavily influenced by the vaccine schedule

7. You ask Mrs. Pevensie if she has any specific concerns about her children’s health or development today, and she denies any recent illnesses. Their physical exams are normal, and Peter’s developmental screen reveals no delay. You open your health record for the visit, and find a barrage of pre-selected topics for you to click off as “discussed.”

8. As you start to remind Mrs. Pevensie that the AAP recommends less than two hours of screen time daily, and that her children should always wear sunscreen, and that backyard pools should have 4-foot tall secure fencing, and that children should now be in rear-facing car seats until age 2, and that well water needs fluoride supplementation… you notice that her eyes are glazing over, and she is simply nodding a lot! You wonder… does any of this talk actually help anything? Why did we choose to spend our time here discussing all this?

9. 3. What evidence is there for the current preventive guidelines for health supervision? Are there interventions or strategies that have been shown to be more effective than others? Remember that u sing the limited resource of face to face time to cover a laundry list of topics may steal time from the few interventions that have stronger evidence of success. There is supportive evidence to promote: Reading aloud Since the advent of the “Reach Out and Read” program, numerous studies have shown that giving out books, talking to parents about reading aloud, and modeling reading behavior increases the rate of parents who do read aloud to their children. Even more promising, several studies have shown improved language function in these children. Breastfeeding “Back to sleep” Avoidance of physical discipline Use your time wisely! If you tell them everything, they may remember nothing. So tell them what is most important and the more interactive, the better.

10. U.S. Preventive Services Task Force Ratings

11. 4. How are we supposed to fit it all in? Are there alternative strategies for well-child care? Most well child visits are scheduled and reimbursed estimating a maximum 30-minute visit, and some insurance companies expect ancillary staff to perform much of the screening and guidance, leaving only fifteen minutes with the clinician. Given the potentially overwhelming list of possible topics and interventions, what actually ends up in the discussion has tremendous inter-provider variability, and is frequently not family-centered. This phenomenon is noted frequently in surveys. In a survey of young parents conducted by the AAP, nearly all reported at least one unmet need in more than one of the following areas: anticipatory guidance, psychosocial risk, and substance abuse. Another study noted that for 40% of children, developmental and behavioral concerns were never solicited from the parents by the pediatrician. There are alternative models available intended to alleviate some of these challenges. In most developed nations, nurses and advanced practice providers conduct the majority of routine pediatric surveillance. Physicians are used only for abnormal screenings and the more specialized portions of the examination . Many practices rely on handouts to cover much of the routine anticipatory guidance, and use “face to face” time to prioritize specific topics that are both important and responsive to direct provider intervention such as those mentioned above. Finally, the group well-child care model is one option intended to increase the time available for discussion of important topics by combining families and therefore avoiding repetitive conversations. There is data that this model is non-inferior to the traditional individual well-child care model in terms of healthcare outcomes and Emergency Department utilization, and that parents who participate appreciate the shared support and information gathering. There is also data that physicians in training reported more authentic inter-professional relationships when involved in group care for their continuity clinic , compared with the traditional model for health surveillance.

12. You enter the room for your next visit and greet Mr. and Mrs. Risk, with their now three-year old daughter Ahaya. They are new to your practice, and during family history you learn that both parents suffer from diabetes, and that Mr. Risk has already had his first heart attack. You notice that Ahaya is already at the 99th percentile for age on the BMI curve.

13. 5 . What is the effect of childhood health surveillance on adult health? How can we structure our well-child visits with adult health outcomes in mind? There are ample data in the literature regarding modifiable childhood drivers of adult health. These include childhood poverty, educational attainment, environmental exposures and adverse childhood experiences. Poverty: Clear association between childhood poverty and adverse adult health, that is the result of multiple factors: environment, food choices, and neighborhood/family structure and interactions. There is data that early childhood poverty (before age 9) is associated with an elevated “allostatic load” (a physiologic concept which includes blood pressure, BMI, and stress hormone levels). Almost a quarter of US children live in poverty , but the percentages in most resident clinics are much higher. Questioning about the psychosocial stressors involved in poverty (including homelessness and food insecurity) can lead to referrals to community agencies which may partially alleviate the effects of poverty on childhood and adult health. In one study of an urban clinic, 82% of families expressed one such concern at the time of their visit, and over half reported an unaddressed need that could have been met with a referral to a community agency. Educational attainment: Higher educational attainment is associated with improved healthcare behaviors and outcomes in adults, even when controlling for socioeconomic status. Well-child visits allow for screening and intervention for children at high risk for learning disabilities and specific developmental delay. Nationwide, half of parents report that their child’s pediatrician does not inquire about developmental concerns and less than 20% of children receive standardized screening as recommended by the periodicity schedule. The well-child visit will not allow for intensive intervention for children at risk, but can lead to more intensive interventions at school and follow-up visits. Environmental exposures: Lead/tobacco screening . Childhood tobacco exposure is associated with cardiovascular disease. Interventions surrounding tobacco cessation have led to at least a modest decrease in parents who smoke (4% in one study). Adverse childhood experiences (domestic violence, parental substance abuse, neglect, parents’ psychiatric disease) are strongly associated with adverse health outcomes as adults. Many large cohort studies demonstrate a clear dose-response effect of adverse childhood events on negative health outcomes. Spending a portion of our limited time in well child visits screening for these possible exposures and making referrals where available can decrease these exposures over time.