Editorials

What to Do at Well-Child Visits: The AAFP's Perspective

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2015 Mar 15;91(6):362-364.

This editorial was published online ahead of print December 15, 2014.

More than two-thirds of practicing family physicians report that they provide care for children,1 and well-child visits provide the best opportunities to deliver evidence-based preventive services. These services include administering immunizations, assessing growth and development, and counseling children and parents about behavioral issues, nutrition, exercise, and prevention of unintentional injury.2

The American Academy of Pediatrics (AAP) recently updated its recommendations on preventive health care for children,3 which define a set of services that, under the Affordable Care Act, must be covered by Medicaid and private insurers at no out-of-pocket cost.4 The current AAP Bright Futures guideline (available at http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf) includes three screening tests that were not recommended for all children in previous versions: autism screening at 18 and 24 months of age, cholesterol screening between nine and 11 years of age, and annual screening for high blood pressure beginning at three years of age.

It should be noted that none of these screening tests are included in the American Academy of Family Physicians' (AAFP's) list of recommended preventive services for children (Table 1).5 The AAFP's clinical preventive services recommendations are generally consistent with those of the U.S. Preventive Services Task Force (USPSTF). The USPSTF methods for developing recommendations include performing a systematic evidence review of the benefits and harms of a preventive service, and recommending that the service be provided to the general population only after consistent data from high-quality randomized controlled trials or other prospective studies establish that the benefits exceed the harms.6 This rigorous approach to the development of clinical practice guidelines has been endorsed by the Institute of Medicine.7 In contrast, few AAP policy statements on well-child care are supported by direct evidence of net health benefit.8,9

View/Print Table

Table 1.

Recommended Preventive Services for Children from the American Academy of Family Physicians

PopulationService

Newborns

Congenital hypothyroidism, screening

Hearing loss, screening

Ocular gonorrhea infection, preventive medication

Phenylketonuria, screening

Sickle cell disease, screening

Children six months and older

Fluoride supplementation in areas where the primary water source is deficient in fluoride

Children three to five years of age

Visual impairment, screening

School-aged children

Tobacco use, counseling to prevent initiation

Children six years and older

Obesity, screening

Children 10 years and older

Skin cancer, counseling to reduce risk

Children 12 years and older

Depression, screening

Sexually active adolescents

Sexually transmitted infections, counseling to reduce risk

Sexually active adolescent females

Gonorrhea and chlamydia infections, screening

Children at high risk of infection

Hepatitis B virus, screening


Information from reference 5.

Table 1.

Recommended Preventive Services for Children from the American Academy of Family Physicians

PopulationService

Newborns

Congenital hypothyroidism, screening

Hearing loss, screening

Ocular gonorrhea infection, preventive medication

Phenylketonuria, screening

Sickle cell disease, screening

Children six months and older

Fluoride supplementation in areas where the primary water source is deficient in fluoride

Children three to five years of age

Visual impairment, screening

School-aged children

Tobacco use, counseling to prevent initiation

Children six years and older

Obesity, screening

Children 10 years and older

Skin cancer, counseling to reduce risk

Children 12 years and older

Depression, screening

Sexually active adolescents

Sexually transmitted infections, counseling to reduce risk

Sexually active adolescent females

Gonorrhea and chlamydia infections, screening

Children at high risk of infection

Hepatitis B virus, screening


Information from reference 5.

The rationale for the AAP's recommendation to routinely screen toddlers for autism spectrum disorders (ASDs) with ASD-specific screening tools is to advance the time of diagnosis and deliver early interventions.10 Although a systematic review of 40 studies found that a policy of universal screening for ASD increased rates of diagnosis and referral, the effects of such policies on time of diagnosis or enrollment in services are unclear.11 The entire body of evidence that intensive behavioral interventions improve language skills and cognitive or functional outcomes in children with ASD consists of a single randomized controlled trial and several prospective cohort studies of varying quality.12,13

The AAP recommends measurement of blood pressure and cholesterol levels in children to identify modifiable risk factors for cardiovascular disease and to provide early interventions to reduce future risk. However, no studies have evaluated whether treating primary hypertension in persons younger than 18 years reduces adverse cardiovascular outcomes in adulthood.14,15 Similarly, evidence is lacking that lowering cholesterol levels with lifestyle changes or medications improves cardiovascular outcomes, and long-term statin use is associated with rare but serious harms.16,17

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening (a service that the AAFP and the USPSTF recommend against because the harms outweigh the benefits18), but one minute or less each on nutrition and smoking cessation counseling.19 Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.

editor's note: Dr. Lin is associate deputy editor of AFP Online and chair of the Subcommittee on Clinical Practice Guidelines of the AAFP's Commission on the Health of the Public and Science. Because of Dr. Lin's dual roles, two other medical editors independently reviewed this editorial for publication.

REFERENCES

show all references

1. Bazemore AW, Makaroff LA, Puffer JC, et al. Declining numbers of family physicians are caring for children. J Am Board Fam Med. 2012;25(2):139–140....

2. Riley M, Locke AB, Skye EP. Health maintenance in school-aged children: part II. Counseling recommendations. Am Fam Physician. 2011;83(6):689–694.

3. Simon GR, Baker C, Barden GA III, et al. 2014 recommendations for pediatric preventive health care. Pediatrics. 2014;133(3):568–570.

4. American Academy of Pediatrics. Bright Futures. http://brightfutures.aap.org. Accessed August 20, 2014.

5. American Academy of Family Physicians. Summary of recommendations for clinical preventive services. July 2014. http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf. Accessed August 20, 2014.

6. Melnyk BM, Grossman DC, Chou R, et al. USPSTF perspective on evidence-based preventive recommendations for children. Pediatrics. 2012;130(2):e399–e407.

7. Graham R, Mancher M, Wolman DM, et al., eds. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011.

8. Moyer VA, Butler M. Gaps in the evidence for well-child care: a challenge to our profession. Pediatrics. 2004;114(6):1511–1521.

9. Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements. Pediatrics. 2006;118(4):e964–e978.

10. Johnson CP, Myers SM; American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183–1215.

11. Daniels AM, Halladay AK, Shih A, et al. Approaches to enhancing the early detection of autism spectrum disorders. J Am Acad Child Adolesc Psychiatry. 2014;53(2):141–152.

12. Warren Z, McPheeters ML, Sathe N, et al. A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics. 2011;127(5):e1303–e1311.

13. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;(10):CD009260.

14. Chiolero A, Bovet P, Paradis G. Screening for elevated blood pressure in children and adolescents: a critical appraisal. JAMA Pediatr. 2013;167(3):266–273.

15. Thompson M, Dana T, Bougatsos C, Blazina I, Norris SL. Screening for hypertension in children and adolescents to prevent cardiovascular disease. Pediatrics. 2013;131(3):490–525.

16. Grossman DC, Moyer VA, Melnyk BM, Chou R, DeWitt TG; U.S. Preventive Services Task Force. The anatomy of a U.S. Preventive Services Task Force recommendation: lipid screening for children and adolescents. Arch Pediatr Adolesc Med. 2011;165(3):205–210.

17. Psaty BM, Rivara FP. Universal screening and drug treatment of dyslipidemia in children and adolescents. JAMA. 2012;307(3):257–258.

18. Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Service Task Force recommendation statement. Ann Intern Med. 2012;157(2):120–134.

19. Pollack KI, Krause KM, Yarnall KS, Gradison M, Michener JL, Østbye T. Estimated time spent on preventive services by primary care physicians. BMC Health Serv Res. 2008;8:245.



 

Copyright © 2015 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article