A two-year-old girl is brought in for her well child examination. Her parents have no concerns. Her current diet consists of chicken nuggets, fries, sweets, and salty snacks because ‚"she doesn't like our food." Father does not eat many vegetables either. She has a large vocabulary, speaks in two-word sentences, walks, runs and climbs, and makes a rudimentary circle. Toilet training has not yet begun. They let her brush her own teeth, which she does on most days, and she does not like her parents to help her. She stays up past midnight and spends a lot of time on the computer tablet during the day and before sleeping. She lives with her mother, father, 3- and 4-year-old brothers, grandparents, and paternal aunt and her child in government-subsidized housing. They are concerned that they might lose their housing since the aunt is not a registered member of the household, but she has nowhere else to go. They have not been worried about having enough food. Father smokes cigarettes outside.
Exam: VS are normal. Height is at the 75th percentile and weight is at the 90th percentile with a BMI at the 83rd percentile. She is awake, alert and has a screaming tantrum when her father takes away the cell phone she had been watching videos on. She does become interactive when that is over. 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.
Since the parents have no questions, you have 7 minutes left in the visit, what shall we talk about?
This example gives us an idea of the amazing number of opportunities that the pediatrician has to offer advice in any given visit. Even without the specific information given above, the 4th edition of AAP's Bright Futures has 28 bullets of anticipatory guidance suggested for the 2-year-old well visit (1). The child above might benefit from changing a number of things that came up in the evaluation which are the following: inadequate diet, inadequate sleep, excessive screen time, impending overweight, dental caries, temper tantrums, toilet training, paternal smoking, and risk of homelessness. Some of these overlap with the Bright Futures recommendations and some are in addition to them. Since it took a minute to make the list, there are 6 minutes left in the visit.
So, what is anticipatory guidance? This term is not one used outside of pediatrics. Originally it was coined as developmentally anticipatory advice for parents. Pediatricians knew what children were likely to learn next and what challenges this would raise in keeping them safe, healthy, and developing normally. In our desire to help families, pediatricians came up with a number of topics to cover at well visits. The American Academy of Pediatrics (AAP) teamed up with the Maternal and Child Health Bureau to publish the Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents that is currently in its 4th edition. This series of publications is one resource outlining the periodicity of well child care including anticipatory guidance. A pocket Bright Futures handout that summarizes anticipatory guidance points for each well child visit ages can be reviewed at the Bright Futures Pocket Guide (1).
This has expanded markedly over time. Bright Futures focusses on safety, health maintenance and developmental optimization. The current Bright Futures list for well visits, in addition to assessing health, growth, and development, recommends covering the following themes (1):
Promoting Lifelong Health for Families and Communities
Promoting Family Support
Promoting Health for Children and Youth with Special Health Care Needs
Promoting Healthy Development
Promoting Mental Health
Promoting Healthy Weight
Promoting Healthy Nutrition
Promoting Physical Activity
Promoting Oral Health
Promoting Healthy Sexual Development and Sexuality
Promoting the Healthy and Safe Use of Social Media
Promoting Safety and Injury Prevention
All these themes are important to the health and well-being of our patients, their families, and our communities. The question that each of us needs to ask is: What, if anything, can I effectively help this family change today? And how? An important part of answering this question is knowing which if any of these issues is foremost in the family’s list of priorities and what they are willing to discuss. Another important issue is realizing that if it is not a two-way discussion between the provider and parents, meaningful change is much less likely to happen. The reality of the amount of time the pediatrician has with the patient and caregivers during the office visit must be taken into consideration. A recent study of adult care revealed that adult primary care physicians would need to work 26.7 hours/day to meet the care guidelines while taking care of an average number of patients (2). A similar study has not been done in pediatrics. However, there have been several assessments of the amount of time spent in well visits. In 2011 a survey of parents found that 33% had less than 10 minutes with their primary care physician at well visits, 47% between 11 and 20 minutes, and 20% over 20 minutes (3). This makes it even more important that the time spent is useful. The wide number of topics that have been suggested to be covered can be reviewed in Bright Futures. There are a few ways that have been shown to be effective in helping families change for the better. Specifically, we can improve child sleep patterns, improve child language development, and have an impact on the prevention of some injuries (4).
In literacy promotion strategies such as Reach Out and Read, pediatricians giving books at well visits between the ages of 6 months and 5 years and recommending that parents read to their children everyday have resulted in parents being more likely to list books among their children’s favorite toys and increases the number of parents reading out loud to their children. These children have higher receptive and expressive language scores with a dose dependent response and may even increase well child visit attendance for at risk families (5-7). Of special note is that this is most effective in low-income groups.
Programs that provide the tools necessary to carry out the advice given can be effective. Examples include giving out a thermometer to measure water temperature when advising that hot tap water should be kept under 120 degrees F and providing a trigger lock when talking about safe gun storage. Providing either guidance without the physical tool is much less effective (8,9).
There is little or no research evaluating the efficacy of giving multiple pieces of advice compared to one piece of advice. For example, if it is effective to advise parents to read to a child while giving them a book, what is the magnitude of the effect if gun safety advice with or without a trigger lock is added? The minimal evidence we have is invariably studying one intervention at a time and not a group of interventions as is advised by Bright Futures.
Going back to our case, the best way to be effective might be to find out what the family would most like to change and approach this using motivational interviewing to help them make the changes that they choose. One needs to recognize that the only issue this family might have energy for could be their housing risk.
It is worth paying careful attention to the evidence that the advice itself would have a beneficial effect if it were carried out by the family. Pediatricians in the United States were recommending from at least the mid 1950’s until 1992 that infants sleep on their stomachs. It made sense to them at the time since it was thought to prevent choking on spit ups. There was no evidence to support this. Compared to the change in the rate of sudden infant death syndrome (SIDS) after the Back to Sleep program was implemented (sleeping babies on their backs is safer), incorrect pediatric anticipatory guidance led to approximately 3600 babies dying from SIDS per year prior to this realization (10). It is our goal to give good advice effectively. But perhaps we should consider not giving made up advice that is not evidenced-based at all.
Questions
1. 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 physical activity in children.
2. What is the appropriate position for young infants to sleep?
a. Infants should sleep on their backs.
b. Infants should sleep on their stomachs.
c. Infants should sleep in whatever position they get the most sleep.
d. Infants should sleep on their side or back.
3. Which of the following themes are included in Bright Futures 4th edition?
a. Safe use of social media.
b. Pet safety in households with children.
c. Oral health.
d. a and c.
e. a, b, and c.
4. All the following are true about the Reach Out and Read Program EXCEPT:
a. It can improve receptive language in participants.
b. It can improve expressive language in participants.
c. It may increase attendance at well childcare.
d. Is especially effective for upper middle-class children.
References
1. Hagan JF, Shaw JS, Duncan PM (eds). Bright Futures Pocket Guide, 4th edition. 2017. American Academy of Pediatrics, Elk Grove Village, IL. https://downloads.aap.org/AAP/PDF/Bright%20Futures/BF4_POCKETGUIDE.pdf?_ga=2.17626234.275635018.1677271657-183993155.1677271657
2. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. J Gen Intern Med. 2023;38(1): 147-155. doi: 10.1007/s11606-022-07707-x
3. Halfon N, Stevens GD, Larson K, Olson LM. Duration of a well-child visit: association with content, family-centeredness, and satisfaction. Pediatrics. 2011;128(4):657-664. doi: 10.1542/peds.2011-0586
4. Nelson CS, Wissow LS, Cheng TL. Effectiveness of anticipatory guidance: recent developments. Curr Opin Pediatr. 2003;15(6):630-635. doi: 10.1097/00008480-200312000-00015
5. Needlman R, Fried LE, Morley DS, et al. Clinic-Based Intervention to Promote Literacy, A Pilot Study. Am J Dis Child. 1991;145(8):881-884. doi: 10.1001/archpedi.1991.02160080059021
6. Needlman RD, Dreyer BP, Klass P, Mendelsohn AL. Attendance at Well-Child Visits After Reach Out and Read. Clin Pediatr (Phila). 2019;58(3):282-287. doi:10.1177/0009922818822975
7. High PC, LaGasse L, Becker S, et al. Literacy promotion in primary care pediatrics can we make a difference? Pediatrics. 2000;105(4 Pt 2):927-934. PMID: 10742349
8. Katcher ML, Landry GL, Shapiro MM. Liquid-crystal thermometer use in pediatric office counseling about tap water burn prevention. Pediatrics. 1989;83(5):766-771. PMID: 2717292
9. Carbone PS, Clemens CJ, Ball TM. Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community. Arch Pediatr Adolesc Med. 2005;159(11):1049-1054. doi:10.1001/archpedi.159.11.1049
10. CDC Sudden Unexpected Infant Death and Sudden Infant Death Syndrome. Trends in SUID Rates by Cause of Death, 1990-2022. https://www.cdc.gov/sudden-infant-death/data-research/data/sids-deaths-by-cause.html accessed June 23, 2025
Answers to questions
1. a. Bright futures is a collaboration between the AAP and the Maternal Child Health Bureau outlining well childcare visit content including anticipatory guidance.
2. a. Infants should always be put to sleep on their backs.
3. d. Pet safety is not one of the major themes of Bright futures.
4. d. Reach Out and Read has the largest effect on low income children.