Health Supervision Guidelines Research Articles

Survey of the pre-school child health surveillance programme in Sweden

A survey of the programme for developmental surveillance in the Child Health Centres (CHCs) in Sweden was performed using a questionnaire administered to the Chief Medical Officers (CMO) of the Child Health Services. The questionnaire asked about methods used for auditory examination, developmental surveillance and identification of disturbances in mother-child interaction. Activities for health promotion concerning breastfeeding, non-smoking and allergy prevention were also queried. Thirty-four CMOs representing 1731 CHCs and 645000 children answered the questionnaire. The reply rate was 81%. Various methods of auditory examination are offered all infants and children in Sweden. The national guidelines for health supervision are followed fairly closely by all. Screening for disturbances in attention, motor development and perception (DAMP) is performed by all but four districts, with various methods, resources and degrees of co-operation with school health services. Support in mother-child interaction is considered very important and new methods to identify and treat disturbances are gradually introduced. Breastfeeding is encouraged; breast milk is the main source of food for 67% of babies at 4 mo of age. Activities to stop or diminish use of tobacco are ongoing everywhere, as are programmes to identify children at risk of developing allergies and for allergy prevention. Thus, the Child Health Services maintain a high standard and are ambitious about introducing new methods and ideas.

Survey of the pre‐school child health surveillance programme in Sweden

A survey of the programme for developmental surveillance in the Child Health Centres (CHCs) in Sweden was performed using a questionnaire administered to the Chief Medical Officers (CMO) of the Child Health Services. The questionnaire asked about methods used for auditory examination, developmental surveillance and identification of disturbances in mother-child interaction. Activities for health promotion concerning breastfeeding, non-smoking and allergy prevention were also queried. Thirty-four CMOs representing 1731 CHCs and 645,000 children answered the questionnaire. The reply rate was 81%. Various methods of auditory examination are offered all infants and children in Sweden. The national guidelines for health supervision are followed fairly closely by all. Screening for disturbances in attention, motor development and perception (DAMP) is performed by all but four districts, with various methods, resources and degrees of co-operation with school health services. Support in mother-child interaction is considered very important and new methods to identify and treat disturbances are gradually introduced. Breastfeeding is encouraged; breast milk is the main source of food for 67% of babies at 4 mo of age. Activities to stop or diminish use of tobacco are ongoing everywhere, as are programmes to identify children at risk of developing allergies and for allergy prevention. Thus, the Child Health Services maintain a high standard and are ambitious about introducing new methods and ideas.

Health supervision and anticipatory guidance of individuals with Wolf-Hirschhorn syndrome.

Wolf-Hirschhorn syndrome (WHS) is a well-known malformation syndrome due to microdeletion of the short arm of chromosome 4 (4p-). Almost 120 cases have been reported so far, yet there is still limited information on its natural history. It is generally thought that these children have severe developmental disabilities and tend to be mere survivors devoid of personality. It is evident to us [Battaglia et al., 1999a, 1999b], however, that individuals with WHS are capable of greater psychomotor development than previously suggested [Guthrie et al., 1971]. Thus, it is even more important to establish guidelines for health supervision and anticipatory guidance of such patients. This would help professionals and families in developing the most appropriate individualized plan for each child, in order to allow the maximum achievement possible. In the present article we propose guidelines for health supervision and anticipatory guidance of individuals with WHS. These guidelines derive from our experience with the natural history of several children, adolescents, and adults with WHS, gained through the literature, personal observation, and contacts with the national support groups in North America and Italy.

Should pelvic examinations and Papanicolaou cervical screening be part of preventive health care for sexually active adolescent girls?

Over the past 10 years preventive health care of adolescents has received increased attention with the publication of the American Medical Association (AMA) Guidelines for Preventive Services (GAPS) Bright Futures Health Supervision Guidelines and American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) recommendations. Screening of sexually active girls for risk behaviors and for sexually transmitted diseases (STDs) and with Papanicoloau (Pap) smears as well as the provision of human immunodeficiency virus (HIV) counseling and testing have assumed increased importance. The 1995 Youth Risk Behavior Survey found that over 50% of ninth- to 12th-grade high school girls reported ever having had sexual intercourse. Higher percentages are reported by out-of-school youth. In addition girls who do not report consensual intercourse but have been victims of sexual abuse or assault may add to the number of adolescents who have been exposed to STDs including human papillomavirus (HPV) a risk factor for abnormal Pap smears. (excerpt)

Preschool development. Part 2: Psychosocial/behavioral development.

1. Raymond A. Sturner, MD* 2. Barbara J. Howard, MD† 1. 2. *Associate Professor of Pediatrics, Director of Behavioral Pediatrics Fellowship Training Program. Drs Sturner and Howard are Codirectors of The Center for Promotion of Child Development Through Primary Care, Millersville, MD, and serve on the pediatric staff of the Patuxent Medical Group in Annapolis, MD. Dr Sturner is the author of the START test and owns the patent on the Communication Screening System. 3. 4. †Assistant Professor of Pediatrics, The Johns Hopkins University School of Medicine, Division of General Pediatrics, Baltimore, MD. Dr Howard is a content consultant for edutainment videotapes for children and parents. 1. Assessment of psychosocial and behavioral milestones during health supervision visits requires consideration of both child temperament and parental style. 2. Problem behaviors often occur when the child’s need for independent functioning, mastery, or self-identity conflicts with parental attitudes and expectations. 3. The clinician should be able to categorize parental concerns about psychosocial issues into “developmental variation,”“ problem,” or “disorder,” using the definitions provided by the DSM-PC . 4. The high continuity of aggressive and oppositional behavior from preschool to later years mandates preventive interventions for preschoolers. 5. Child health supervision that features discussion of one or two key issues based on a clinical hypothesis of each individual child/family’s developmental trajectory may be of greater value to families than recitation of generic advice about multiple topics. During the preschool years, children are rapidly developing patterns of behavior and psychosocial skills that can be long-lasting. Clinicians have important opportunities to monitor and help shape optimal development when seeing preschool children for their health supervision visits. This is the second of a two-part article discussing the development of the preschool child from the point of view of the clinician who is conducting a visit using Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents . Both articles are organized by the“ trigger questions” suggested for visits at ages 2, 3, 4, and 5 years of age. The trigger questions regarding psychosocial and behavioral aspects of the child’s development are reviewed here; the first article ( Pediatrics in Review September 1997) focused on the “more traditional” developmental areas of communication and motor development. Any dichotomy between behavior and development is murky because behavioral issues often are uncovered when reviewing areas traditionally called development, and behavior can be interpreted only in light of the child’s level of developmental functioning. Research indicates that emotions and cognition are interconnected in …

Vaccine-associated Paralytic Poliomyelitis

To the Editor. The Committee on Genetics of the American Academy of Pediatrics has shown that Turner syndrome affects many organs, and the Committee has given the pediatrician many useful health supervision guidelines.1 However, we do not agree with their recommendations for cardiac evaluation and follow-up for patients with Turner syndrome. Because more than 20% of patients with Turner syndrome have a cardiac abnormality, the following recommendations were made: 1. In the newborn, “obtain an echocardiogram… . Obtain an initial consultation with a pediatric cardiologist for all persons with Turner syndrome who have abnormal echocardiograms.” 2. Repeat the echocardiogram in infancy “even if one was obtained in the newborn period.” 3. Do echocardiography annually when the patient is between 1 and 5 years old. 4. Do echocardiography “each year if a cardiac anomaly is present; otherwise obtain an echocardiogram at 2-year intervals” when the patient is from 5 to 13 years old. 5. Do echocardiography “for aortic dilatation every 2 years or annually if a bicuspid aortic valve is present.” We do not agree with this recommended use of echocardiography. The better and more cost-effective practice is to have a pediatric patient with suspected heart disease evaluated by a pediatric cardiologist first instead of referring the patient for an echocardiogram first.2-4 Congenital heart defects in patients with Turner syndrome are usually easily diagnosed clinically by a pediatric cardiologist, who can then order appropriate testing and arrange follow-up and treatment. The frequency of echocardiography would be much decreased. For instance, a yearly echocardiogram would not be needed in a patient with a bicuspid aortic valve because such studies do not improve care—the cardiologist can follow-up on the patient on a regular basis and determine clinically when aortic stenosis or incompetence is progressing and can order an echocardiogram only when clinically indicated. This would be cost-effective …

Bright Futures: guidelines for health supervision of children.

Bright Futures: guidelines for health supervision of children.

Effects of Structured Encounter Forms on Pediatric House Staff Knowledge, Parent Satisfaction, and Quality of Care

To evaluate the effects of health supervision structured encounter forms on pediatric house staff knowledge, parent satisfaction, and quality of care. Randomized, controlled trial. Pediatric house staff continuity clinic in a university-based children's hospital. 53 pediatric house officers and 153 parents. House staff were randomized to use structured encounter forms focused on developmental milestones (group 1) or anticipatory guidance/preventive care (group 2) during health supervision visits. Changes in house staff knowledge were assessed with pretests and posttests. Parent satisfaction was assessed with surveys. Quality of care, defined as compliance with recommended guidelines for age-specific health supervision, was assessed by audiotaping visits. Group 1 demonstrated greater but not significantly different improvement in knowledge of developmental milestones than group 2, while group 2 improved more than group 1 in knowledge of anticipatory guidance/ preventive care. Parent satisfaction with developmental screening was significantly greater for group 1 visits than for group 2 visits (P < .001). Group 1 demonstrated significantly greater compliance than group 2 with recommended standards of developmental screening (P = .001). The use of structured encounter forms for health supervision in pediatric house staff continuity clinics may increase house staff knowledge of developmental milestones and anticipatory guidance/preventive care, increases parent satisfaction with developmental assessment during health supervision, and improves compliance with recommended guidelines for developmental assessment.

SECTION ON COMPUTERS &amp; OTHER TECHNOLOGIES 1996 ANNUAL MEETING PROGRAM

The AAP Guidelines for Health Supervision recommend age-specific anticipatory guidance and identification of health needs. A multimedia computer program was designed to obtain an accurate, comprehensive behavioral and health history, identify problem areas and health needs, give selective anticipatory guidance, and then provide problem-specific health advice and local referrals. Adolescent patients enjoyed anonymously engaging the nonjudgmental computer, which facilitated acceptance of medical advice. Within minutes, the computer completed the interview, printed feedback, dispensed specific handouts and then administered relevant audiovisual selections from a library of succinct, high-impact health education multimedia presentations designed for computer use. Evaluation of educational media used at outpatient pediatric physical exams assessed improvements in users' knowledge regarding smoking and sex. Test instruments based on the content of each presentation script were developed to assess impact of two different automated interventions. One third of a random sample of 595 anonymous adolescent computer users (average age 15.4 years, 51% female) had audio-visual presentations administered; the second matched third had none but were dispensed handouts identical to the scripts, and one third as matched controls were computer users without handouts or presentations. Measures of six knowledge items about smoking and sex were separately made on control and two experimental groups. Media users increased their knowledge of oral contraceptives, HIV testing, Depo-Provera, cigarette costs, smoker health care costs, and non-smoker longevity. The 215 computer/presentation users had 57% more knowledge improvements than the 194 computer/handout users; both groups showed significantly greater knowledge gains (p&amp;gt;0.05) than the control group of 186. There were 81% of teenagers who preferred the computer system over a personal interview.

Preventive Pediatrics—New Models of Providing Needed Health Services

The risks to children's well-being are accelerating because, in part, of an increasingly porous social safety net. Pediatricians are being asked to bear an ever-increasing burden for helping children and families address a myriad of issues, and they have become the providers of last resort. As the distance between what we should do and what we can do as clinicians widens, so too does our frustration and willingness to consider addressing yet one more issue. We often retreat to the comfortable world of otitis media and immunizations and shut out the loud cacophony of the outside world and its effects on our families. We need a new model of care, based on an ecological approach to child health consistent with Bright Futures,40 which provides child health supervision guidelines. To meet these needs, some settings may develop models in which skilled professionals can provide advocacy services, parental health, parental mental health, and child development services in the context of pediatric practice. Although most practices or clinic programs will not have the space or resources to include all of these services, the development and implementation of any one of them will enrich the care of children and families. Other services such as legal aid, family literacy, and mental health may be available in the community and could be colocated in the pediatric setting as outreach efforts on the part of these programs or linked in a manner that ensures accessibility. Similar enhancements to primary-care programs for special groups of children at risk, including those who are homeless, drug exposed, in foster care, and born to teen-age mothers, are being developed in many communities. The cost of such services presents difficult obstacles. However, given the progressive growth of prepaid practices and competition among plans for patients, services such as those provided by a child development specialist might increase the attractiveness of the plan and allow recruitment of more families. Reducing cigarette smoking, preventing unwanted pregnancy, and reducing drug and alcohol use have potential cost-saving implications that will interest managed-care programs. On the other hand, health care plans may limit services if potential financial benefits are uncertain or acrue to another sector such as schools. For populations at risk, especially health-education collaboration of this type (whether funded and/or cofunded with funds from federal or state department of education budgets, Medicaid, managed-care contracts, tobacco tax revenues, and/or federal family planning funds) should be pursued. Most of the services we have described are, in fact, already available in most communities and/or health plans. Without new net costs, it may be possible to reallocate some or all of these services to the pediatric primary-care setting in a single-site, one-stop-shopping model. Redeploying services to the pediatric primary-care setting may increase accessibility to these important preventive services and improve the health and well-being of children and their parents.

Prevention of tobacco use during childhood and adolescence. Five steps to prevent the onset of smoking.

Most tobacco users become addicted during childhood and adolescence. To reduce the prevalence of tobacco-related illnesses, more emphasis must be placed on preventing the onset of tobacco use. Physicians can play a major role. Based on a series of clinical trials, the National Cancer Institute (NCI) developed recommendations to help patients stop smoking. Behavioral and developmental research have identified factors that contribute to the onset of smoking. The American Academy of Pediatrics (AAP) has developed guidelines for health supervision from birth to adulthood, including engaging parents and children as partners in health care. The NCI recommendations, behavioral research results, and AAP guidelines were integrated to develop a strategy to prevent the onset of tobacco use. The NCI proposes five steps to prevent tobacco use during childhood and adolescence. There are five physician activities, beginning with the letter A, including anticipatory guidance, ask, advise, assist, and arrange follow-up. Anticipatory guidance, the practice of counseling for potential problems, is a key part of health care for the young. The nature of these steps varies, depending on the child's age, developmental stage, and behavior, as well as smoking habits of family members. Despite the long-term consequences of smoking, onset and addiction to tobacco use usually begins in childhood. Therefore, physicians who care for children have a major role in eliminating tobacco use by preventing its onset.

Use of Videotaping to Evaluate Pediatric Resident Performance of Health Supervision Examinations of Infants

To demonstrate reliability of a method for evaluating pediatric resident performance of health supervision examinations of infants using real patients and to evaluate pediatric resident performance of health supervision examinations of infants before and after an educational intervention consisting of a 6-month ambulatory rotation combined with video-assisted review of resident performance of the examination. Longitudinal cohort study in which all second-year residents were enrolled. Residents' preintervention (baseline) videotapes were compared with postintervention videotapes. Each resident served as his or her own control. University hospital pediatric resident continuity clinic. Sixteen second-year pediatric residents who were participating in a required 6-month ambulatory rotation. METHOD AND MAIN RESULTS: Reliability study: Using a 51-item instrument derived from the American Academy of Pediatrics Guidelines for Health Supervision, trained raters blind to the sequence and dates of the videotaped health supervision examinations independently rated 44 resident encounters (a minimum of two raters per tape) and achieved good interrater reliability (kappa = 0.80). Intervention study: After a 6-month ambulatory rotation which included resident-faculty reviews of preintervention videotapes, residents showed a 14% mean improvement in performance scores for the examination (P < .05). The results indicate that videotaped health supervision examinations using real patients can be reliably evaluated by observational techniques in a continuity practice. A 6-month ambulatory block rotation coupled with video-assisted interactive review of examinations is associated with measurable improvement in resident performance on the postintervention test.

Health Supervision and Anticipatory Guidance for Children with Genetic Disorders (Including Specific Recommendations for Trisomy 21, Trisomy 18, and Neurofibromatosis I)

A new model for care of children with genetic disorders has emerged from the pediatric and genetic communities in the last decade. This strategy incorporates the basic principles of well-child care, including ongoing psychological support for families, health screening, and prevention, into health supervision visits for children with these conditions. The same types of guidelines that have been developed for well children can also be applied to the routine follow-up and screening of children with these special health care needs. A number of general issues are applicable in the discussion of health supervision guidelines: correct diagnosis, analysis of the natural history of the condition, critical review of screening modalities and interventions, ongoing psychological support, and genetic counseling. With these points in mind and after a thorough review of the natural history of a disorder, guidelines can be developed and often applied to the primary care setting. Down syndrome is an ideal condition to which one can apply such a model because most children are cared for by primary care pediatricians, and the natural history is relatively well studied. Discussion of health provision in Down syndrome brings out some of the controversies regarding routine screening and review of interventions. Discussion of the natural history and uncertainties evident in the care of infants with trisomy 18 exemplifies the important issue of ongoing psychological support. Review of the natural history of neurofibromatosis emphasizes all of the principles involved in providing this model as a framework for health supervision. One of the key identified but unresolved issues is the decision as to when a primary care pediatrician can orchestrate the care on his or her own versus referral to a multidisciplinary team of specialists. In some conditions such as Down syndrome, it seems obvious that the primary care pediatrician can manage most of the care with periodic and appropriate referral to the necessary specialists. On the other hand, children with cystic fibrosis, meningomyelocele, and craniofacial syndromes almost always need referral to the specialist team because of the rarity of the disorder and the complex number of specialists involved in management. A condition such as NF-1 falls somewhere in between. Most children can be cared for in their childhood years by the pediatrician with referral when a symptom or sign emerges, but others would argue that all children with NF-1 need to be seen by a multidisciplinary team.(ABSTRACT TRUNCATED AT 400 WORDS)

Guidelines for Health Supervision II, by the Committee on the Psychosocial Aspects of Child and Family Health, 1985-1988

<i>Guidelines for Health Supervision II</i>is a 160-page 6-inch × 11-inch spiralring manual with accompanying set of 22 cue cards published by the American Academy of Pediatrics. It was written in 1985 by the Committee on the Psychosocial Aspects of Child and Family Health of the Academy. The authors represent nationally outstanding and experienced persons devoted to child health. The guidelines are intended to be used by practicing pediatricians as well in the education of physicians and other health professionals. This second edition begins with an emphasis on establishing a therapeutic alliance—the doctor-parent and doctor-patient relationship. Specific suggestions in the communication process are given as well as suggested readings. Beginning with the prenatal visit and extending to the health assessment of 20-year-old patients, the manual gives succinct and specific guidelines on gathering information, examination, immunization, anticipatory guidance, and closing the visit. This format is similar to that of the first

Review of Guidelines for Health Supervision II.

Review of Guidelines for Health Supervision II.