Evidence Based Well Child Visits

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Evidence BasedWell Child Visits

• Robert L. Ringler, Jr., MD, FAAFP
• Portsmouth Family Medicine Residency
• Eastern Virginia Medical School
• 15 March 2008, 1500 USAFP, Portland, OR

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Objectives

• Review standard sources for standardized
  well-child examinations
• Evaluate commonly used history questions,
  physical exam points, and counseling/anticipatory
  guidance and identify which have good evidence
  that they affect health outcomes for children
• Present an efficient approach to conducting
  well-child examinations

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Bright Futures

• American Academy of Pediatrics
• www.brightfutures.aap.org
• Guidelines for Health Supervision of Infants,
  Children, Adolescents 3rd edition
• Bright Futures Pocket Guide
• Bright Futures Toolkit

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Promoting Healthy Outcomes

• Disease Prevention
• Health Promotion and Anticipatory Guidance
• Early Detection of Disease

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Well Child Visits

• Parent and youth concerns
• Preventive services
• Structured developmental screening
• Establish community linkages
• Recall and reminder system
• Practice detects special health care needs
  ensures they receive preventive services

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Health Outcomes

• Healthy weight and BMI
• Normal BP, vision, hearing
• Pursuing healthy behaviors
• Nutrition
• Physical activity
• Safety
• Sexuality
• Substance use

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Health Outcomes

• Accomplishing developmental tasks
• Social connections
• Competence
• Autonomy
• Empathy
• Coping skills
• Loving responsible family, supported by a safe
  community
• Children with special needs should be able to
  achieve self-management skills

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Health Promotion Themes

• Promoting Family Support
• Promoting Child Development
• Promoting Mental Health
• Promoting Healthy Weight
• Promoting Healthy Nutrition

• Promoting Physical Activity
• Promoting Oral Health
• Promoting Healthy Sexual Development Sexuality
• Promoting Safety Injury Prevention
• Promoting Community Relationships and Resources

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Promoting Healthy Weight

• Normal or healthy weight BMI lt85th
• Overweight BMI 85th but lt95th
• Obese 95th
• rising rapidly between
• 1988-2004

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Screening for Overweight and Obesity

• One or more parents are obese
• One or more siblings are obese
• Family with low income
• Chronic disease or disability that limits
  mobility
• BMI for age
• Comprehensive physical assessment

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Second level assessment screening

• Family Hx early CVD, lipids, obesity, DM2
• BP for age, gender, height
• gt90th prehypertensive
• gt95th HTN
• FLP Total gt200, low HDL, high trig
• Large ? in BMI 2-3 points in 1 yr
• Concern about weight

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Actions for providers

• Plot BMI routinely
• Address BMIs before they reach 95
• Identify at risk children

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The Well Child (Health Supervision) Visit

• Disease detection
• Disease prevention
• Health promotion
• Anticipatory guidance

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The Well Child (Health Supervision) Visit

• Subjective
• Parent and child concerns
• Surveillance of development
• Nutrition, activity, sleep
• Home, school, mental health, strengths
• Safety, substances, puberty
• Objective
• BMI, vision, hearing, other screening
• Physical Examination

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The Well Child (Health Supervision) Visit

• Assessment
• Well child
• Normal physical and emotional development
• Plan
• Anticipatory Guidance
• Immunizations

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Bright Futures Visit

• Context review of development and milestones for
  age
• Priorities for visit
• Attend to concerns of parents
• 5 additional priorities for each visit
• Health Supervision
• History
• Observation of child-parent interaction
• Surveillance of development
• Physical examination
• Assessment of growth
• Exam for age

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Bright Futures Visit

• Health Supervision
• Screening
• Universal screening
• Selective screening
• Risk assessment
• Action if risk assessment positive
• Immunizations
• Other practice-based interventions
• Anticipatory Guidance
• For provider
• Visit related health promotion questions
• For parent and child

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Rationale for clinical decisions

• Clinical evidence
• Practice guidelines
• Colleagues
• Decision support systems
• Experience
• Habit
• Judgment
• Preferences

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Evidence basis for preventive health issues

• Evidence-informed rather than evidence-driven
• Satisfactory studies uncommon
• Few studies evaluate effectiveness of components
  of PE (considered screening interventions) and
  counseling interventions

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Evidence Based Recommendations

• USPSTF strongly recommends for
• Screening for cervical cancer in women who are
  sexually active and have a cervix
• Good evidence that screening reduces incidence of
  and mortality from cervical cancer
• Begin within 3 yrs of onset of sexual activity or
  age 21, whichever comes first and screening
  every 3 years

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Evidence Based Recommendations

• USPSTF recommends
• Structured breastfeeding education and behavioral
  counseling programs to promote breastfeeding (B
  recommendation)

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Evidence Based Recommendations

• USPSTF Evidence is insufficient to recommend for
  or against
• Routine clinical breast exam (CBE) alone to
  screen for breast CA
• ACS recommends CBE as part of periodic health
  exam every 3 yrs in 20s and 30s
• Teaching or performing regular self-breast-exam
  (BSE)

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Evidence Based Recommendations

• USPSTF recommends against
• Routine screening for testicular cancer
• Routine screening of asymptomatic adolescents for
  idiopathic scoliosis

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Universal Screening Bright Futures

• Newborn Metabolic and Hemoglobinopathy
• Essential public health responsibility
• State laws
• Development 9/18/30m
• Standardized tests

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Universal Screening Bright Futures

• Autism (18/24m) AAP
• Specific autism screening in addition to general
  developmental screening
• Oral Health (As early as 6m, 6 mos after 1st
  tooth erupts, NLT 12m) American Academy of
  Pediatric Dentistry
• Risk assessment
• Vision
• USPSTF Screening for amblyopia, strabismus, and
  visual acuity defects in children lt5
• AAP 3/4/5/6/8/10y, early/mid/late adolescence

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Universal Screening Bright Futures

• Hearing (NB, 1w, 1/2m, 4/5/6/8/10y) AAP
• Universal screening of all infants
• Periodic screening throughout adolescence
• Anemia (9-12m) AAP
• Measurement of HCT or HGB for all full-term
  infants
• Lead (12m, 2y hi prevalence or Medicaid) AAP
• Universal screening beginning at 9-12 mos and
  repeated at 2 yrs (blood levels peak)
• Dyslipidemia (Older adolescents) NCEP
• Over age 20 should have FLP every 5 yrs

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Selective Screening

• Oral Health Dental Home (12/18m, 2/2.5/3/6y)
  Bright Futures
• Referral based on risk assessment
• Oral Health Fluoride (12/18m, 2/2.5/3/6y)
• USPSTF Supplement if 1o water supply deficient
  in fluoride, starting _at_ 6m
• AAP Supplement until 16y or 2nd molars,
  whichever is first

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Selective Screening

• BP (children under 3 with risks) - NHBPEP
• Prematurity, VLBW, other NICU
• Congenital HD, repaired or not
• Recurrent UTI, hematuria, proteinuria
• Known renal dz or urologic malform
• FHx of cong renal dz
• Solid organ transpl
• Malignancy or bone marrow transpl
• Rx with drugs that raise BP
• Other systemic dz assoc with HTN
  (neurofibromatosis, tuberous sclerosis, etc.)
• Evidence of ? ICP
• BP children over 3 is part of routine PE

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Selective Screening

• Vision (NB, 1w, 1/2/4/6/9/12/15/18m, 2/2.5/7/9y,
  adolescents 11-21y)
• Very prem
• FHx cong cataract, retinoblastoma, and
  metabolic/genetic dz
• Signif develop delay or neuro prob
• Systemic dz assoc with eye abnorm

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Selective Screening

• Hearing (4/6/12/15/18m, 2/2.5y) Joint
  Committee on Infant Hearing
• Caregiver concern
• FHx of perm childhood hearing loss
• NICU gt5d
• In utero infections (CMV, herpes, rubella,
  syphilis, toxo)
• Craniofacial abnl
• Physical findings like white forelock
• Syndromes assoc with hearing loss or
  progressive/late onset hearing loss
• Neurodegenerative disorders
• Culture-positive postnatal infx assoc with
  sensorineural hearing loss - meningitis
  (bacterial, herpes, varicella)
• Head trauma req hosp, esp basal skull/temporal
  bone fx
• Chemotherapy
• Delayed onset hearing loss

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Selective Screening

• Anemia (4m) AAP
• Prematurity
• LBW
• Use of low-iron form, infants not getting
  iron-fortified form
• Early introduction of cows milk
• Anemia (18m, annual 2y) AAP
• Special health needs
• Low-iron diet (eg, non-meat diet)
• Environment (eg, poverty, limited food)

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Selective Screening

• Anemia (6-10y visits) AAP
• Strict vegetarian diet, not on iron supplement
• Anemia (11-21y visits) CDC
• All non-pregnant women every 5-10y throughout
  childbearing
• Annually for women with risk factors (extensive
  blood loss, low iron intake, previous dx of
  Fe-defic anemia)

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Selective Screening

• Lead (6/9m, 12m low prev, not on Medicaid,
  18m, 2y low prev, not on Medicaid, 3/4/5/6y)
  CDC
• Does your child live in or regularly visit a
  house or facility built before 1950?
• Does your child live in or regularly visit a
  house or facility built before 1978 that is being
  or has recently been renovated or remodeled
  (within last 6m)?
• Does your child have a sibling or playmate who
  has or did have lead poisoning?

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Selective Screening

• TB (1/6/12/18m, annually _at_2y) AAP
• Annual skin test
• HIV-infected children
• Incarcerated adolescents
• Risk factor questions
• Has a family member or contact had TB?
• Has a family member had a positive TB skin test?
• Was your child born in a high-risk country (other
  than US, Canada, Australia, New Zealand, Western
  Europe)
• Has your child traveled (had contact with
  resident populations) to a high-risk country for
  gt1 wk?

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Selective Screening

• Dyslipidemia (2/4/6/8/10y, adolescents 11-21)
  AAP
• Parents/grandparents 55y had cath or had CAD
  (includes angioplasty/CABG)
• Parents/grandparents 55y had documented MI,
  angina, PVD, cerebrovascular dz, sudden cardiac
  death
• Parent had ? Chol (240)
• Parental hx unobtainable (provider choice)
• High risk children
• Smoking
• HTN
• DM
• Physical inactivity
• ? Sat fat diet, Overweight

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Selective Screening

• Dyslipidemia (2/4/6/8/10y, adolescents 11-21)
  Expert Committee Recommendations on assessment,
  prevention, and treatment of child and adolescent
  overweight and obesity.
• BMI for age and sex 85th-94th (overweight) with
  no risk factors FLP
• BMI for age and sex 85th-94th with risk factors
  on HX or PE FLP, AST, ALT, FBS
• BMI for age and sex 95th (obese), even w/o risk
  factors FLP, AST, ALT, FBS, BUN, creat

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Selective Screening

• Chlamydia (11-21y visits, if sexually active)
  USPSTF
• Routinely screen all sexually active women under
  25, and others at ? risk for STDs
• Chlamydia (11-21y visits, if sexually active)
  AAP
• Screen at least annually, even if asymptomatic
  and even if barrier contraception reported

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Selective Screening

• Gonorrhea (11-21y visits, if sexually active)
  USPSTF
• Routinely screen all sexually active women under
  25, and others at ? risk for STDs

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Selective Screening

• HIV Testing (11-21y visits, if sexually active)
  USPSTF
• Past or present injection drug use
• M who have had sex with M
• M and F having unprotected sex with multiple
  partners
• M and F who exchange sex for money or drugs, or
  have sex partners who do
• Past or present sex partners were HIV-infected,
  bisexual, or injection drug users
• Persons being Rx for STDs
• Persons who request HIV test despite reporting no
  risk factors
• Persons who report no risk factors but are seen
  in high-risk or high-prevalence clinical settings
• STD clinics, correctional facilities, homeless
  shelters, TB clinics, clinics serving M who have
  sex with M, adolescent health clinics with
  ?prevalence of STDs
• High prevalence (CDC) - 1 prevalence of
  infection among population being served

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Selective Screening

• HIV Testing (13-21y visits) CDC
• Routine screening unless prevalence documented
  lt0.1 (1 per 1000)
• Discussed with all adolescents encouraged for
  all who are sexually active

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Selective Screening

• Syphilis (11-21y visits, if sexually active)
  USPSTF
• M who have sex with M and engage in high-risk
  sexual behavior
• Commercial sex workers
• Persons who exchange sex for drugs
• Those in adult correctional facilities

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Selective Screening

• Alcohol or drug use (11-21y visits) Bright
  Futures
• Have you ever had an alcoholic drink?
• Have you ever used marijuana or any other drug to
  get high?

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Efficient Well Child Visits

• Staff training
• Weights and measures
• Standard weights (kg or lbs)
• Measuring length/height accurately
• Measuring HC accurately
• BP measurement on at-risk infants and all
  children 3y
• Vision/hearing screens
• Documentation
• Plotting growth curves
• Ht for age, wt for age, wt for ht
• BMI calculation
• BMI for age

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Efficient Well Child Visits

• Patient preparation
• Denver Developmental screening
• Lead screening (high risk areas)
• Screening questionnaires
• CHAT questionnaire
• Pediatric Symptom Checklist cognitive,
  emotional, and behavioral problems
• CRAFFT screen for drug and alcohol use

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Efficient Well Child Visits

• Well child forms
• EMR or Paper forms
• Reminders for appropriate history
• Reminders for physical examination
• Reminders for anticipatory guidance
• Reminders for immunization, screening tests

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Efficient Well Child Visits

• Patient education handouts
• Appropriate reading levels
• Age appropriate
• Things to watch for before next visit

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Questions?