Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter I.6. Anticipatory Guidance
Corinne C. Chan-Nishina, MD
February 2002

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A 2 year old male presents at a pediatrician's office for his annual physical. His mother has concerns about his appetite. He is described as a finicky eater and will not sit still at the dinner table for very long. He will occasionally eat meat. He eats vegetables, and loves rice. He also eats fruit and whole grain cereals. He drinks about two to three glasses of milk a day and maybe one glass of fruit juice per day. He has no problems with his bowel movements. She is also concerned about his temper tantrums, especially when he doesn't get his way. Spanking has not worked too well. He has difficulty sharing with his siblings. This often escalates from sibling conflicts to severe temper tantrums. She is also concerned that he is not making progress with his toilet training. He has used the toilet for both bowel movements and urination, but he will not consistently tell his mother when he has to go. His mother would also like to know when he should stop using his car seat. She has no concerns about his development. He actually seems advanced compared to his older sibling who is doing well at school. His birth and past medical history is unremarkable. His parents are happily married and there have been no remarkable changes in the household.

Exam: VS are normal. Height 90cm (75%ile), Weight 13.5kg (75%ile), Head circumference 50cm (50-75%ile). He is awake, alert and active. His head is normal. Red reflexes are present in both eyes. His pupils are equal, round and reactive to light. Extraocular movements are intact. The cover test is negative. The tympanic membranes are without erythema. There is a good light reflex bilaterally. The nares are clear and without discharge. Oropharynx is moist and pink without erythema, exudates or other lesions. There are multiple dental caries present. There are about twenty teeth. They are cream colored and have plaque present. His neck is supple without lymphadenopathy. His heart and lungs are normal. His abdomen is soft and nondistended without organomegaly or masses. There are normal Tanner I male genitalia with testes descended bilaterally. Extremities are normal. There are no signs of scoliosis. There is no rash. However, there is a Mongolian spot to the buttocks. His neurological exam demonstrates good strength and muscle tone. DTR's are 2+ in the lower extremities. He has good coordination and a normal gait. There is also normal sensation to light touch.


There are many challenges that parents and children face today. One of four children in the U.S. currently lives in poverty. These children and families face poor nutrition, poor access to health care, violence and neglect. Many of the nation's children grow up in single parent households (1). There are many children who live with foster families because of neglect, abuse, parental substance abuse or domestic violence. These families are at particularly high risk for their children having poor physical and emotional health.

However ALL parents and caregivers with support from medical professionals have the potential for greater impact on the health and well being of their children. Pediatricians and other child health providers emphasize prevention, early detection, and management of various behavioral, developmental, and social functioning problems (2). A major aspect of preventing and managing such problems includes concise and effective discussions with parents and other caregivers; what is commonly called anticipatory guidance.

The United States Preventive Services Task Force has compiled a list of evidence based preventive health recommendations. These include risk reduction with vehicle safety seats, smoke detector use, hot water heater temperature reduction, smoking cessation, use of bicycle helmets, and child proofing the home for medications and poisons. For a number of important health related behaviors (e.g. smoking) there is good evidence from high quality studies that physicians can change patient behavior through simple counseling in the primary care setting. For many other behaviors, the effectiveness of counseling has been demonstrated only over the short term or has not been examined in appropriately designed studies (3).

The child in the case above does not have any serious physical exam findings except for dental caries. He is growing well. A pediatrician or trained medical professional can address all his mother's other concerns.

Each age group has anticipatory, behavioral and developmental issues that relate particularly to children of that age. The following are some of the important topics used in anticipatory guidance for caregivers of two year old children. The gender throughout this discussion is for a boy (as in our case above) but this discussion is completely relevant for girls also.

Nutrition: The two year old toddler is in the process of becoming more independent and separating from his primary caregiver who has nurtured and protected him. He begins to make his own choices and has the desire to do things by himself. He is more interested in play and exploring the world, and discovering how it all works. Children at this age have a difficult time sitting down for extended periods of time, and want to choose their own foods, and feed themselves.

There are ways to continue to make mealtimes pleasant and enjoyable for everyone. It is important for the toddler (and children of all ages) to have meals with his family to support the promotion of constructive family relationships and to provide role models at mealtime. Parents should encourage conversation at mealtimes, and make meals pleasant and comfortable. The TV should be turned off and reading materials should be put somewhere else. Children at this age may receive two to three nutritious snacks per day. Nutritious snacks should be rich in complex carbohydrates. Sweets and high fat snacks should be limited or avoided, since this may cause children to lose their appetite for a nutritious lunch or dinner. Juice should be limited to 4-6 ounces per day. Children can be offered a variety of nutritious foods and be allowed to choose what to eat and how much. It is perfectly normal for children at this age to eat a lot for one meal, and not much the next. Reasonable mealtime behavior should be enforced, but eating should never be forced. Eating should not become a power struggle. Children at this age like to experiment with their food (1). Good nutrition can make a big difference in how children grow, develop and learn.

Pediatric Oral Health: Dental decay (caries) is the most common chronic infectious disease of childhood. If severe enough, they may lead to malnourishment, absence from school, and low self-esteem. Pediatricians need to take a more active role in promoting good oral health and counseling parents on the importance of preventing dental disease in children. High risk children need to be identified. A brief dental screening includes oral inspection, noting the number of erupted teeth, and their color, spacing and enamel status, as well as inspection for dental caries. Those with dental caries should be referred to the dentist immediately.

Caregivers should be taught the role of diet in promoting good oral health, and those factors that can lead to dental caries. Bottles and "Sippy" cups should not be used as pacifiers. Bottles or breastfeeding at bedtime should be discouraged after the eruption of teeth. Infants should be weaned from the bottle before 15 months (10). Parents should be informed of the effects of prolonged use of high sugar liquids and foods (such as juices, sodas, and candy). High sugar medicines may also lead to dental caries. For infants, parents should be instructed to clean their mouth and teeth regularly after feedings. The pediatrician should demonstrate this whenever possible. Toddlers and preschoolers will need the help of a parent, but they can be encouraged to brush their own teeth first, before receiving help as necessary from the parent.

Physicians should prescribe and counsel parents on the use of fluoride supplements in communities without fluoridated water supplies, and on the use of fluoride toothpaste (use only a pea-sized amount or less to prevent excessive fluoride ingestion). Both of these should be kept out of the reach of children to prevent ingestion of excessive amounts of fluoride. Most importantly, pediatricians can ensure that every child has an established "dental home". It is recommended that the first visit with a dentist occur six months after the eruption of the first tooth (which is at approximately twelve months of age) (4).

Discipline: This is a topic that often comes up at the well child visit. Parents often ask pediatricians for their advice regarding appropriate and effective discipline. The word discipline comes from the root word disciplinare, which means "to teach or instruct". This refers to the system of teaching and nurturing that prepares children to achieve competence, self-control, self-direction, and caring for others (5). There are three key elements to effective discipline: 1) a learning environment characterized by positive, supportive parent-child relationships; 2) a strategy for systematic teaching and strengthening of desired behaviors; and 3) a strategy for decreasing or eliminating undesired behaviors. All of these must be present to achieve improved child behavior (3).

The developmental age of the child must be considered when choosing a form of discipline. One would not expect an infant or toddler to respond to reasoning. A two year old might respond well to the caregiver providing attention to him to increase positive behaviors. A caregiver withholding attention can decrease undesirable behaviors. Being consistent is very important. Removing or eliminating undesirable behaviors requires that the parent and child are both clear on what the problem behavior is. Once this is established, then there should be an immediate consequence when the targeted behavior occurs. An appropriate consequence should consistently be provided each time the targeted behavior occurs at this age. At older ages more sophisticated techniques may be used that delay the positive or negative reinforcers. Time-out is a form of extinction that may be used at this age. For a two year old this would consist of removing parental attention or being placed in a chair for a specified time (one minute per year of age of the child is suggested) without any adult interaction. Initially this may result in an increase in negative behavior. If the parent accepts this as a normal reaction and chooses to ignore the behavior, this will eventually result in a decrease in outbursts, as well as a decrease in the targeted behavior (6).

Caregivers should try to remain calm. Parents are more likely to use aversive techniques and punishment when they are angry, irritable, fatigued and stressed. It can be difficult to discuss discipline with parents since many will use methods with their children that were once used on them. They may be hesitant to discuss methods of corporal punishment. One good way to start the discussion is to talk about a behavior that was observed during the visit, and discuss its occurrence at home. It is important to remain non-judgmental or the conversation may become emotionally charged.

Toilet training: This topic concerns many caregivers during the toddler stage. Parents should be counseled to start toilet training when the toddler shows interest and is willing to participate. It should not become a control issue. Signs that signify readiness are: staying dry for periods of about two hours; knowing the difference between wet and dry; being able to pull their pants up and down; wanting to learn; and being able to signal when they are about to have a bowel movement. Once these signs are present, parents may want to seat their child on their potty. Caregivers should give lots of positive reinforcement for sitting and also praise when the child is successful using the potty. Making the experience a pleasant and positive one will ensure success in toileting.

Injury prevention: There is a fair amount of evidence to suggest that injury prevention counseling to parents of young children is effective (3). Every child deserves to grow up in a safe environment, and most authorities believe that counseling families in injury prevention is both effective and cost efficient. This aspect of anticipatory guidance is an essential part of the comprehensive care of infants, children and adolescents. Severe injuries are most commonly caused by motor vehicle crashes, followed by drowning, burns, choking, and falls (7). Initially the focus should be on the parents, but as the child matures, the focus should switch more to the child as they become more responsible for their own actions. Counseling on the prevention of automobile injuries should be a priority, since there is good evidence to suggest that the use of car safety seats is effective. Motor vehicle injuries are a leading cause of death and morbidity. Child safety seats can reduce serious injury by as much as 67%, and mortality by as much as 71% (8). The focus of this counseling should be on the use of approved child safety seats, and following the instruction manual on the proper installation and use.

There is also good evidence to suggest that poisoning in young children is associated with parents' lack of awareness of the treatment of poisonings (7). Parents should be given the number for the poison control center. They should be advised to not administer anything for the poisoning before calling the poison control center. Most importantly, they should be counseled on the proper storage of medications, cleaning agents, household chemicals and toxins. Bottles for chemicals and household cleaners, or other potential toxins should not be reused for other things.

An association exists between drowning and leaving a child less than 3 years old unattended in the bathtub. Evidence that a health provider can influence parental supervision of young children during bath time is limited (9). Still, parents should be cautioned of the dangers of leaving young children unattended around water, such as the bathtub, a bucket full of water or the swimming pool. Specifically, counseling should include example points such as attending to their infant in a bathtub is more important than answering the phone or the doorbell. Parents of older children may develop a false sense of security if their children have had swimming lessons and should be cautioned that their children still need to be supervised around water, since they are still at risk for drowning.

In conclusion, there are multiple potential opportunities in the office and clinic setting for preventing injury and disease with caregiver guidance and teaching. This is true for children with and without serious medical or social issues. A complete discussion of all the elements of anticipatory guidance at each age group is beyond the scope of this chapter. The American Academy of Pediatrics provides pediatricians with recommendations on anticipatory guidance counseling at each age group (1,10).


Questions

1. True or False: For most problems caused by parental child rearing knowledge deficits, there is good evidence from high quality studies that physicians can change parental behavior through simple counseling in the primary care setting

2. True or False: The anticipatory guidance issues for two year olds are very different for boys as compared to girls.

3. In "disciplining" a two year old child, one should
. . . . a. Punish
. . . . b. Explain verbally at length the reason for the "disciplining".
. . . . c. Teach or instruct.
. . . . d. Always use positive reinforcement.
. . . . e. Do to the child what the child does to others so they learn why not to do certain things.

4. True or False: Children can develop fluorosis by using fluoride toothpaste and fluoride supplements.

5. What is the most common cause of serious injury and death for children and teens?
. . . . a. Falls
. . . . b. Water-related injuries (submersions, drownings)
. . . . c. Burns
. . . . d. Choking
. . . . e. Motor vehicle crashes

6. True or False: Parents do not need to supervise their two year olds who have already completed swimming lessons.

7. Which is INCORRECT about a toddler around feeding issues?
. . . . a. Parents should encourage conversation at mealtimes.
. . . . b. Children at this age may receive two to three nutritious snacks per day.
. . . . c. Juice should be limited to 4-6 ounces per day.
. . . . d. Children can be offered a variety of nutritious foods and be allowed to choose what to eat and how much.
. . . . e. It is abnormal for children at this age to eat a lot for one meal, and not much the next.


References

1. Green M (ed). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 1994, Arlington, VA: National Center for Education in Maternal and Child Health.

2. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The pediatrician and the "new morbidity." Pediatrics 1993;92:731-732.

3. Guide to Clinical Preventive Services, second edition. 1996, Report of the U.S. Preventive Services Task Force.

4. Schafer TE, Adair SM. Pediatric oral health, prevention of dental disease, the role of the pediatrician. Pediatr Clin North Am 2000;47(5):1021-1042

5. Howard BJ. Advising parents on discipline: what works. Pediatrics 1996;98:809-815.

6. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Guidance for effective discipline. Pediatrics 1998;101(4):723-728.

7. Panagiotou L, Rourke LL, Rourke JTB, et al. Evidence-based well-baby care Part 2: Education and advice section of the next generation of the Rourke Baby Record. Canadian Fam Phys 1998;14:568-572.

8. Brewer D, Parham J, Johnson M. Preventive services: Preventive care for newborns and infants. Clin Fam Prac 2000;2(2):233-250.

9. The Canadian Task Force on the Periodic Health Examination. The Canadian Guide to Clinical Preventive Health Care. 1994, Ottawa: Supply and Services Canada.

10. Guidelines for Health Supervision III. The American Academy of Pediatrics. 1997, Elk Grove Village, Illinois.


Answers to questions
1.False, 2.False, 3.c, 4.True, 5.e, 6.False, 7.e


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