The editors and current author would like to thank and acknowledge the significant contribution of the previous author of this chapter from the 2004 first edition, Dr. Corinne C. Chan-Nishina. This current second edition chapter is a revision and update of the original author’s work.
A 3-year-old female presents to your pediatric office for her annual physical. Her mother has concerns about her temper tantrums. She drops to the floor and screams loudly every time she does not get her way. Her parents have tried spanking her but this did not result in any behavioral change. Her potty training was successful with only occasional bedwetting. She wakes up at night and walks herself to the bathroom. Her mother wonders if she should transition her from the car seat to the booster seat. Although she was previously a very picky eater, her diet has expanded recently. The preschool has not expressed any concerns and mother agrees that she seems to be growing and developing on par with her peers. She enjoys listening to stories when they are read aloud at home and at school. There have been no significant changes to her social or family history. She lives with her parents who are married and one 6 year old older brother. She has never been hospitalized or undergone surgery.
Exam: VS are normal. Height is 97 cm (75%ile), and weight is 15 kg (75%ile). She is awake, alert and interactive. Her head is normal without any abnormal bruising patterns or irregularities in shape. Her pupils are equal, round and reactive to light with extraocular movements intact. The tympanic membranes are easily visualized, have good light reflexes and are without erythema. The nares are clear, without discharge. Oropharynx is moist and pink without erythema, exudates or other lesions. There are multiple dental caries present. There are twenty, cream colored teeth with superimposed plaque. Her neck is supple without lymphadenopathy. Her heart and lungs are normal. Her abdomen is soft and non-distended without organomegaly or masses. She has normal Tanner I female genitalia. Her extremities are normal. There are no signs of scoliosis. There is no rash. However, there is a mongolian spot on her lumbosacral region. Her neurological exam demonstrates good strength and muscle tone. DTR's are 2+ in the lower extremities. She has good coordination and a normal gait. There is also normal sensation to light touch.
The example above illustrates the sheer volume of opportunities for anticipatory guidance and health intervention that are present during every well child checkup. Although the task may seem daunting, pediatricians can navigate this important aspects of the visit more effectively by "addressing issues in depth rather than running through a number of issues superficially" (1). The guidance pediatricians provide must be tailored for each patient visit, keeping in mind their age, specific risk factors and family concerns.
Physicians are often portrayed in social media and perhaps mistaken by the public to be providers of acute care or managers of chronic medical conditions. Medicine is undergoing a transformation and pediatricians are being called to take on a more "broad view of healthcare and their role as promoters of health" (2). Physicians must manage medical problems and social, emotional and developmental concerns while placing equal emphasis on anticipatory guidance topics. Anticipatory guidance can be defined as the provision of current, relevant information allowing parents to "anticipate impending changes, maximize their child's developmental potential and identify their child's special needs" (3). Discussions on anticipatory guidance topics should facilitate formation of partnerships between physicians and patients and their families.
This role of the pediatrician, as a living guidebook for child rearing is not novel. The following statement made by B. R. Hoobler in 1917 reflects the historical nature of this role of the pediatrician: "If his confidence is to be retained, the physician must be as familiar with the proper manner of bathing a baby as he is with the treatment of pneumonia, and he may render the baby as notable a service in one instance as in the other. The doctor is taking the place more and more of the advice-offering neighbor, and it behooves him to be able to advise the mother correctly" (4).
Recently, the American Academy of Pediatrics (AAP) teamed up with the Maternal and Child Health Bureau to publish the third edition of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. This series of publications that provide an excellent resource for use in clinical practice and encompasses all of the recommended elements for anticipatory guidance. There are behavioral, developmental and anticipatory guidance topics relevant to a child at each age. A number of important topics for children age 0-5 years will be discussed in more detail below. A pocket Bright Futures handout that summarizes anticipatory guidance points for each well child visit ages can be printed from: https://brightfutures.aap.org/bright%20Futures%20Documents/BF3%20pocket%20guide_final.pdf
Oral health is a critical component of any child's overall health status. In fact, "dental caries are the most common chronic disease in children in the United States" (5). Specifically, the National Health and Nutrition Examination Survey (1999-2004) cites the prevalence of dental caries in children between the ages of 2 to 11 at 42%. The prevalence of dental caries in children less than 5 years old had decreased between 1970 and the 1990s but has been increasing since that time. It has been reported that "dental-related concerns lead to the loss of more than 54 million school hours each year" (6). Children may experience pain, poor weight gain, speech impairment and lower self-esteem among other complications of poor dentition. Specific topics to address during well child visits include frequency of tooth brushing, avoidance of bottle propping, dental appointments and identification of a fluoride source. Bottles or sippy cups at bedtime should be discouraged and infants should be weaned from the bottle by 15 months of age to preserve dentition. The contribution of sugary beverages (sodas, juices, etc.) to cavity development should be emphasized during parental education.
Recommendations for fluoride supplementation have been a popular discussion point in the world of pediatrics recently. The U.S. Department of Health & Human Services recently changed the recommended level of community water fluoridation from a range of 0.7-1.2 ppm down to 0.7 ppm. This change occurred in response to higher rates of fluorosis throughout the U.S. secondary to increasing exposure to fluoride through alternative sources. Fluorosis is of cosmetic concern only with almost all cases being mild to moderate, and manifesting as white markings on the teeth, which are actually more resistant to cavities. However, severe fluorosis, which is extremely rare in the U.S., can lead to dark stains with enamel pitting and is actually more susceptible to cavities. Parents may need reassurance that systemic effects of fluoride are only seen after "long term exposure to excessively high levels of fluoride, either ingested or inhaled", is extremely rare, and that mild to moderate fluorosis is safe (7).
The U.S. Preventative Services Task Force published an updated recommendation statement in May 2014 regarding prevention of dental caries in children from birth to 5 years of life (5). The recommendations focus on children less than 5 years of age who are more likely to see a pediatrician rather than a dentist. However, prevention of caries will continue to be a critical component of a child’s health after age 5. The three recommendations addressed routine oral screening examinations conducted by pediatricians, in-office fluoride varnish application, and oral fluoride supplementation for specific populations. In cases of exclusive well water use and areas without community water fluoridation (i.e., on Oahu in Hawaii), patients will need fluoride supplementation starting at 6 months of age. They also recommend application of fluoride varnish to primary teeth in all children, regardless of risk factors, prior to 5 years old with the goal of cavity prevention. The risk of fluorosis with these recommendations is minimal. An official recommendation regarding routine screening for caries by the pediatrician could not be made due to limited evidence. Both the AAP and ADA recommend an initial dental visit for all children by 12 months of age or 6 months after eruption of the first primary tooth.
Parents often cite concerns about their child’s eating patterns during well child visits, especially during the toddler years. Toddlers have developed some independence and this fact, coupled with their interest in exploring the world, often leads to conflict at the dinner table. They would prefer to choose their own foods and may not want to sit down for an extended period of time. Parents should be encouraged to avoid making special meals for picky eaters (include one enjoyable food and several others to sample with each meal), set a maximum duration for meal times, minimize distractions and avoid force-feeding or bribery. Family relationships are strengthened and good nutrition can be modeled when the entire family consistently eats together.
Generally sweets and juices should be avoided due to poor nutritional value and increased risk of decreasing the child's appetite for the protein, vegetables and other healthy foods that will encompass the meal. Hawaii’s "5210" health initiative is similar to programs in several other states, which were developed to promote healthy active living and reduce the prevalence of childhood obesity. The initiative encourages consumption of 5 or more fruits and vegetables daily, less than 2 hours of screen time daily, at least 1 hour of physical activity daily, and no sugary beverage consumption.
As pediatricians, we are uniquely positioned to offer parents advice about discipline. Parents should be involved in discussions about how discipline changes with respect to developmental age. Distraction is the best way to halt a behavior in infants and toddlers but changing the environment or temporarily removing privileges is often the best way for an older child. Discipline is most successful when it is understood as a form of teaching. In fact, the word discipline comes from the root word disciplinare, which means, "to teach or instruct". Encourage parents to teach or reinforce good behavior through praise and to model good behavior on a daily basis.
The AAP urges parents to "get curious, not furious". Parents that are effective in changing behavior among their children remain calm and try to identify the cause of the tantrum. Establishing routines can be helpful to reduce frequency of stressful or frustrating situations. Often a child may act out due to increased hunger or fatigue when schedules change. Time out can be an effective form of discipline when used consistently. There should be two to three warnings before the time out occurs to provide the child with an opportunity to change their behavior. A short explanation of why the behavior is not desirable and an alternative behavior should be provided. The duration for time out is recommended at 1 minute per year of age. The AAP does not recommend physical punishment since this increases aggressive behaviors and is often ineffective. Conversations about discipline can often be emotionally charged. As such, it may be best introduced by asking parents what sort of discipline they experienced through childhood. The pediatrician should remain non-judgmental to avoid conflict (8).
Beginning around 18 to 21 months of age, an introduction to toilet training is another important area of anticipatory guidance that can result in significant frustration among parents. Pediatricians have the opportunity to assess the child's readiness and manage parental expectations by explaining that toilet training is often a multistep process with frequent setbacks. A child should be able to express interest in potty training, should be able to imitate his/her parents, should be able to pull pants or skirts up or down and should be able to communicate the sensation of needing to urinate or defecate. It should be emphasized that punishment should be avoided during the toilet training period as it can be counterproductive and can easily escalate. In fact, "more child abuse occurs during toilet training than during any other developmental step" (9). Toilet training should be avoided when the child is ill or when there are social stressors (major changes such as moving, new school, etc.). A potty chair is often a very useful tool to support toilet training at home. There are many methods (including from Dr. Barton Schmidt) and self-help resources available to parents in preparation for toilet training, most of which are reasonably priced. Parents can be directed to the AAP website (http://www2.aap.org/sections/scan/practicingsafety/module7.htm) for toilet training which offers a module, details on the Barton Schmidt method as well as several other resources.
Studies have shown that "reading proficiency by the third grade is the most important predictor of high school graduation and career success" (10). As such, early literacy is another key component of anticipatory guidance. The AAP recommends that all parents read aloud to their young children and urges pediatricians to counsel parents on developmentally appropriate reading activities during well child checks. The AAP also recommends that pediatric offices "provide developmentally, culturally and linguistically appropriate books at health supervision visits for all high-risk, low-income children" (10). This recommendation has been successfully carried out on a large scale through the national "Reach Out and Read" program. Reading aloud promotes brain development and early literacy but also has significant long-term health implications. Low literacy levels create a barrier against access to health care which results in poor understanding of disease processes, increased hospitalization rates and higher mortality overall.
Safety is another very important issue to address with parents at each well child check. There are an average of 25 deaths per day equaling a little over 9000 deaths per year in the United Sates secondary to unintentional injury (11). In fact, unintentional injury is the leading cause of death in children between 1 and 19 years of age. Specifically, drowning is the primary form of unintentional injury in children between 1 and 4 years old with traffic injuries as the primary form in children 5 to 19 years old. With respect to car seats, children should ride in rear facing car seats until 2 years old. They may switch to forward facing car seats prior to their second birthday only if they have exceeded the weight or height maximum cited by the car seat's manufacturer. Once children outgrow the height or weight limitations for the forward facing car seat, they should be switched to a booster seat. Seat belts (without booster seats) will often fit appropriately once a child exceeds 4 feet 9 inches (145 cm) or after the child’s 8th birthday. Parents should be advised that correctly fitting seat belts would have the shoulder portion lying across the chest (rather than the neck) and the lap portion lying across the upper thighs (rather than the abdomen).
Generally, the AAP recommends that pediatricians promote five Rs: Reading together as a daily family activity; Rhyming, talking and singing together throughout the day; Routine times for meals, play and sleep; Rewards for everyday successes; and Relationships that are reciprocal, purposeful and nurturing (12). These five Rs highlight the important framework that supports all of the anticipatory guidance that we provide to our patients. Anticipatory guidance should be provided at each well child check in addition to reviewing the medical and social conditions that impact the health and wellness of the patient. This chapter merely serves as an introduction to anticipatory guidance. Other important topics in anticipatory guidance include hypertension, obesity, and smoking cessation. These are addressed in detail in separate chapters within this textbook. Some of the cited resources, such as the Bright Futures publication from the AAP, should be used to provide age appropriate anticipatory guidance in daily practice.
1. Until what age and weight should the rear-facing car seat be used?
2. AAP Bright Futures is:
. . . . . a. A commonly cited source of anticipatory guidance recommendations published by the American Academy of Pediatrics.
. . . . . b. A program for developmentally delayed children.
. . . . . c. A commonly cited diet program for overweight children.
. . . . . d. A program to increase the physical activity in children.
3. What is the leading cause of unintentional injury in children aged 1 to 4 years of age? And what about in children aged 5 to 19?
4. What stage of development is associated with the highest incidence of abuse? List several behaviors that a child may demonstrate to indicate "readiness" for this stage of development?
5. True/False: Both the AAP and ADA recommend an initial dental visit for all children by 2 years of age or 1 year after eruption of the first primary tooth.
1. Bunik M. Chapter 9 – Ambulatory & Office Pediatrics. In: Hay W, Levin M, Deterding R, Abzug M (eds). Current Diagnosis and Treatment, Pediatrics. 21st Edition. 2012, McGraw Hill, pgs 242 – 246.
2. Schuster MA, Duan N, Regalado M, Klein DJ. Anticipatory guidance: What information do parents receive? Pediatr Adolesc Med. 2000;154(12):1191–1198.
3. Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatric Dent 1997;19:8-11.
4. Hoobler B. The desirability of teaching students details concerning the care of the normal infant. Trans Assoc Am Teachers Dis Child. 1917;1143.
5. Moyer VA. Prevention of Dental Caries From Birth through Age 5 years: US Preventive Services Task Force Recommendation Statement. Pediatrics 2014;133(6):1102-1111.
6. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
7. Lewis C. Fluoride and Dental Caries Prevention in Children. Pediatrics in Review 2014;35(1):3-15.
8. AAP Practice Guideline on Effective Discipline. https://www2.aap.org/sections/scan/practicingsafety/Modules/EffectiveDiscipline/EffectiveDiscipline.pdf Accessed: May 1, 2015.
9. Toilet Training Guidelines: The role of the clinician in toilet training. https://www2.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module7/toilet_training_clinicians.pdf. Accessed July 4, 2015.
10. High PC, Klass P. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Policy Statement. Council on Early Childhood. Pediatrics 2014;134(2):404-409.
11. Protect the Ones You Love: Child Injuries are Preventable. CDC, Division for Unintentional Injury Prevention. http://www.cdc.gov/safechild/NAP/background.html. Accessed on May 2, 2015.
12. High PC. American Academy of Pediatrics Committee on Early Childhood, Adoption and Dependent Care & Council on School Health. School Readiness. Pediatrics 2008;121(4):e1008-e1015.
Answers to questions
1. Until age 2 (unless they exceed the car seat’s specific weight and height maximums prior to that age).
2. a. Bright Futures publications comprehensively cover the multiple facets of anticipatory guidance.
3. Drowning (1 to 4 years) and traffic injuries (5 to 19 years).
4. The age around potty training (2 to3 years). The child may pull down/up their pants/skirt and/or diaper off after urination, defecation, will be able to express the sensation of needing to go potty, may walk into the bathroom or a corner to use the bathroom, and will be able to imitate his/her parents.
5. False. They both recommend the initial dental visit for all children by 12 months of age or 6 months after eruption of the first primary tooth.