Rudolph's Pediatrics, 22nd Ed.

CHAPTER 10. Well-Child Care

Judith S. Shaw and Judith S. Palfrey

Health supervision visits, the cornerstone of primary care pediatrics, provide health care professionals the opportunity to promote the optimal health and well-being of children and their families in the communities in which they live. The value of contributing to and influencing the developmental trajectory of a child cannot be overstated. Through promoting children’s health, nurturing their growth, anticipating their needs, and guiding their families, the health care professional supports and contributes to the healthy and positive development of children.

Children have many “homes” where they receive care, but it is the medical home that looks after their health. Health supervision entails a variety of interrelated activities, including health promotion, prevention, surveillance and management, and the coordination of care for children and youth with special health care needs. Going beyond diagnosis, management, and treatment of health-related problems, the medical home is foremost a place for promoting health and building on the recognized strengths of the child and family. Although most children remain healthy, there is an increasing population of children living with chronic illness, disability, and other special needs. The health care professional is in a unique position to coordinate the often complex care, advocate for appropriate services, and facilitate optimum communication among the various individuals involved.

Caring for children’s health provides many rewards and challenges. The interplay between environmental influence and factors intrinsic to the child becomes evident in many aspects of pediatric health and development. Continuity care is based on a developmental framework that recognizes the constancy of growth and change throughout childhood. Appreciating the impact of physical and psychosocial health not only on the child but on the people in the child’s life, the health care professional has responsibilities beyond the traditional medical model that include health promotional activities such as consideration for emotional, spiritual, and environmental health and for community and societal health as well as their influences on the child’s future development.

During time spent with a child, the health care professional’s goal is to establish as much as possible the child’s healthy growth and development with no deviations from the optimal developmental trajectory. However, when a deviation occurs, it should be detected early, receive all available appropriate treatment, and include a plan for preventing future sequelae or problems. Through the regular health supervision visits that take place throughout the child’s life, a special bond between the health care professional and the child and family often develops. This partnership is no longer unidirectional in which a health care professional imparts guidance and wisdom to a receptive child and family. In the past, health supervision visits were dictated by a periodicity schedule, and although their frequency is virtually unchanged, the visits are now parent driven and as interactive as possible. Effective health promotion involves a bidirectional relationship of receptivity that values the agenda and needs of the family while recognizing the importance of providing services essential to the health and well-being of the child and family.

This chapter provides an overview of health supervision of infants, children, and adolescents; covers specific aspects of the visits and other important areas pertaining to health supervision; and discusses considerations in the office practice to support excellence in health supervision.

HEALTH SUPERVISION GUIDELINES

INTRODUCTION

The goal of primary care pediatrics is to facilitate optimal health and well-being of children and their families. This is accomplished through a variety of interrelated activities, including problem solving and management, problem prevention, health promotion, and the coordination of care for children with special needs. The traditional focus on problem diagnosis and management has been broadened to include screening for disease and its precursors in an asymptomatic population. Pediatric providers have long recognized the value of preventive programs such as mass immunization and continue to lead the way in this area through an emphasis on regular health surveillance, anticipatory guidance, and involvement in community-based prevention strategies. Emphasis is placed on the related concept of health promotion, whereby optimal health and well-being is positively encouraged. These areas form the foundation for current recommendations for health supervision guidelines.

At each visit, the developmental level of the child dictates both the approach to the patient and much of the visit’s content. In pediatrics, the therapeutic alliance includes both the child and the family; the importance of establishing a trusting longitudinal relationship cannot be overemphasized.

The American Academy of Pediatrics’ Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents1 is a consolidation of the many health supervision guidelines into a single set of guidelines for health care professionals. These guidelines, based on the latest evidence and expert opinion on standards of care, offer a roadmap for the health professional to follow and provide a new structure for health supervision in primary care.

WHAT IS NEW IN BRIGHT FUTURES

Experienced health professionals see the well-child visit as an opportunity to improve the health and well-being of children and their families. However, most report feeling tension as they seek to provide care that includes a personal assessment of the child’s health and the family’s ability to promote continued health in the limited time available during office encounters.

Resolving this tension is important to the success of the visit and is key to family and health professional satisfaction. Bright Futures proposes solutions to improve the organization of clinical processes and well-child care. Using the Bright Futures materials, a health care professional working with office staff can create effective encounters that meet their goals of disease detection, disease prevention, and health promotion.

The third edition of Bright Futures was revised following a careful examination of the evidence supporting each recommendation, and with a goal of improving the structure and format for delivery of primary care (see Table 10-1).

Table 10-1. Summary of Changes to the 2007 American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care

Timing and Classification of Visits

Every child should have an evaluation within 3 to 5 days of birth or within 2–4 days after discharge from the hospital.

Age 12 months is now considered early childhood instead of infancy.

In addition to previously recommended age-level visits, well-child checks are now recommended for children 30 months, 7 years, and 9 years old.

Measurements

Body mass index measures are now recommended for all children ages 2 years and older.

Weight for length should now be assessed for all children ages 2 years and younger.

For blood pressure measurement, a risk assessment of children (considered at high risk) from birth through age 30 months is recommended.

Sensory Screening

Risk assessments for vision and hearing problems are now recommended for children at ages 7 and 9 years.

Developmental/Behavioral Assessment

Developmental screening is now separate from developmental surveillance. Developmental screening (structured) is recommended at ages 9 months, 18 months, and 30 months. Developmental surveillance is recommended at all other ages.

Autism screening is recommended at ages 18 months and 24 months.

A psychosocial/behavioral assessment is recommended at all visits for all ages. A risk assessment for drugs and alcohol use is to be performed at all visits for ages 11 to 21 years.

Physical Examinations

A physical examination is included at all ages, including the new visits recommended at ages 30 months, 7 years, and 9 years.

Procedures

Hereditary/metabolic screening is now called newborn metabolic/hemoglobinopathy screening and is recommended for children up to and including age 2 months.

Immunizations are now recommended at all ages, including ages 30 months, 7 years, and 9 years.

Hematocrit or hemoglobin screening is now recommended at age 12 months. Risk assessments are now to be done at ages 4 months, 18 months, 24 months, and all ages 3 years and above. No risk assessment is required at age 15 months or 30 months. The risk assessment now recommended for all children ages 11 through 21 years replaces the recommendation for just assessing menstruating adolescents annually.

A routine urinalysis is no longer required at any age.

A risk assessment for lead is now recommended for children ages 6, 9, 12, 18, and 24 months and 2, 3, 4, 5, and 6 years. A recommendation for testing is now included at ages 12 months and 24 months for Medicaid or high-prevalence areas.

For tuberculosis screening, a risk assessment has been added for ages 1 month and 6 months. It has been deleted from ages 15 months and is not included at age 30 months.

Cholesterol screening is now called dyslipidemia screening. A risk assessment should now be done at ages 2, 4, 6, 8, and 10 years and annually from 11 to 17 years. A dyslipidemia screening should be done once during the period from 18 to 21 years, preferably at 20 years.

Pelvic examinations are now called cervical dysplasia screening. A risk assessment is now done for all ages from 11 to 21 years, starting within 3 years of onset of sexual activity or age 21, whichever comes first. The recommendation for routine pelvic examination and pap smear for ages 18 to 21 years has been removed.

Oral Health

Dental referral is now called oral health. A risk assessment is done at ages 6 and 9 months. A referral to a dental home should be made at 12, 18, 24, and 30 months. If a dental home is not available for children of those ages, an oral health risk assessment should be done. If the primary water source is deficient in fluoride, consider oral fluoride supplementation.

At the visits for 3 and 6 years, it should be determined whether the patient has a dental home. If the patient does not, a referral should be made to one. If the primary water source is deficient in fluoride, consider oral fluoride supplementation.

Note: The most recent visit periodicity schedule is available at http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf.

Source: Reprinted with permission from Hagan J, Shaw J, Duncan P, eds. Bright Futures: Health Supervision Guidelines for Infants, Children and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007:210, table 1.

OVERVIEW OF THE BRIGHT FUTURES VISIT

Bright Futures outlines the health supervision visit using four areas of importance: context, priorities, health supervision, and anticipatory guidance (Table 10-2).

The “Context” section in the new Bright Futures recommendations provides a brief overview of the child at different age levels, including the developmental tasks and milestones to be achieved, thereby setting the context for the visit. It points out the unique attributes, strengths, and assets of the child and special considerations for ensuring healthy growth and development.

For the “Priorities for the Visit” section, the Bright Futures Expert Panel identified 5 priority topics to be discussed during visits once the concerns of the child and family have been elicited and addressed.

Table 10-2Bright Futures Visit Outline, Using a Strength-based Approach

A. Context (brief overview of developmental tasks and milestones usually achieved at specific age levels)

B. Priorities for the Visit

• The first priority is to attend to the concerns of the parents.

• The Bright Futures Expert Panel has given priority to 5 additional topics for discussion in each visit.

C. Health Supervision

C1. History

C2. Observation of Parent-Child Interaction

C3. Surveillance of Development

C4. Physical Examination

• Assessment of Growth

• Younger than 2 years: weight, length, head circumference, and weight-for-length

• Older than 2 years: weight, height, and BMI

• Listing of particular components of the examination that are important for the child at each age visit

C5. Screening

• Universal Screening

• Selective Screening

• Risk assessment

• Action if risk assessment is positive

C6. Immunizations

C7. Other Practice-based Interventions

D. Anticipatory Guidance

• Information for the health care professional

• Health promotion questions for the 5 priorities for the visit

• Anticipatory guidance for the parent and child

Source: Reprinted with permission from American Academy of Pediatrics, Summary of Changes Made to the 2007 AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule).

“Health Supervision” includes six subsections: “History” offers questions relevant to the child and family to assess interval and past medical history. “Observation” provides ideas for observing the child and family as a starting point for the visit. “Surveillance of Development” suggests questions for assessing developmental milestones and tasks at those visits when a structured developmental screening tool is not used. “Physical Examination” emphasizes that a complete physical examination “is included as part of every health supervision visit” and describes aspects of the examination that are important for a child of specific ages. “Screening” provides tables for universal (done for all children) and selective (based on risk assessment) screening. The tables list the method of screening and the action to take if the risk assessment is positive. “Immunizations” refers readers to the appropriate Web sites for the most current recommendations.

The “Anticipatory Guidance” section describes in more detail each of the 5 priorities identified by the Expert Panel, including sample questions and guidance in the exact words that the clinician could use.

CONDUCTING A HEALTH SUPERVISION VISIT

PRIORITIES

Primary care pediatrics is changing as health care professionals are challenged to provide more service in less time and with shrinking reimbursement. The luxury of extended face-to-face time between the patient and clinician is disappearing. Health care administrators approach health supervision visits as a business, limiting nonreimbursed activities, seeking greater efficiencies, measuring return on investment and relative-value units. Recognizing that the long list of anticipatory guidance topics that could and should be discussed at each visit was unrealistic, and in response to a plea from health care professionals to help focus the topics, the Bright Futures authors were challenged with how to design a comprehensive visit, yet acknowledging the limited time available during the visit, to hone in on those areas most important to a child at each age level. The first priority is to attend to the concerns of the child and parents. Beyond that, the Bright Futures Expert panel developed 5 priorities through an exhaustive process considering and reviewing the available evidence, expert opinion, and numerous discussions with experts in preventive services.

In addition to 5 priorities for each visit, Bright Futures provides detailed information about each priority along with sample questions, dialog, and anticipatory guidance. The numerous individuals who contributed to the writing of Bright Futures recognized that it was important to explain not only what should be done but also how to do it and how to say it. For example, rather than just recommending “screen for domestic violence,” Bright Futures offers the clinician sample questions such as “Because violence is so common in many people’s lives, I’ve begun to ask about it. I don’t know if this is a problem for you, but many children I see have parents who have been hurt by someone else. Some are too afraid or uncomfortable to bring it up, so I’ve started asking about it routinely. Do you always feel safe in your home? Are you scared that your partners or someone else may try to hurt you or your child?” It offers anticipatory guidance such as “One way that I and other health care professionals can help you if your partner is hitting or threatening you is to support you and provide information about local resources that can help you.”

HISTORY TAKING

For a more detailed discussion of interview techniques, see Chapter 4.

Taking a History Process

As with any health encounter, the history is the central element of the health supervision visit. The way in which the history taking is conducted sets the tone for the entire visit. The information that is gleaned sets the agenda for the visit and for subsequent visits. In most cases, the information obtained by history affirms that the child is doing well on all health and developmental parameters. The history also affords the family the chance to voice concerns about any aspect of the child’s health and development that they would like more information or guidance about. Through a careful history taking, the child health clinician and parent can identify those areas that require further discussion or action. Occasionally during the history taking, a serious unmet health, developmental, or social need is uncovered. When this occurs, the clinician and family can readjust the content of the visit and establish a plan of consultations and further visits to meet the child’s and family’s need.

Health supervision visits are best accomplished when parents and providers see the enterprise as a shared task or partnership. It is helpful for the child health provider to make this partnership explicit by using words like we and uswhen taking a history. The history helps align the expectations of the parent with those of the provider.

The parents and clinician should be seated during history taking to emphasize the importance of the activity and show that the clinician is eager to listen to the parents’ answers and concerns. The clinician should record the information at the time of history taking (ideally in an electronic form). The clinician should also review with the family the prescreening questionnaire that may have been completed. While the computer is a valuable tool for recording and monitoring information, the child health clinician should make it a point to face the parents during the history taking and establish eye contact whenever possible. The history should be taken in the family’s preferred language whenever feasible. Even the best interpreter often miscommunicates key questions and answers. While conducting a child supervision history through an interpreter, the clinician should not hesitate to ask the interpreter to rephrase a question or answer if the information seems unclear. (See Chapter 15 for further discussion of culturally competent care.)

Table 10-3. History Taking at First and Subsequent Visits to the Practice

Initial History at First Visit

Pregnancy information

Age and health of the mother, parity, other pregnancy losses

Use of drugs and/or alcohol during pregnancy

Prenatal care

Birth history

Length of gestation

Birth weight

Delivery complications

Infections, jaundice, or other cause for hospitalization

More extensive questioning for premature and low-birth-weight babies

Health history

Has the child been diagnosed with any health condition?

Is the child taking any medications prescribed by a health provider?

Is the child taking any home remedies or complementary therapies?

Has the child been hospitalized at any time? What for?

Is the child allergic to medicines, foods, other?

Social history

Who lives at home with the child?

What type of living arrangement is it: house, apartment, etc?

Was the housing stock built before 1957? If so, has it been deleaded?

Does the family have current financial problems?

Employment of parents

Daycare arrangements

Other concerns or stresses on the family (a family member who is ill, in jail, or unemployed; domestic violence; community violence; uncertain citizenship status)

History at Subsequent Visits

Interim health events

Has the child had any health events since the last visit?

If so, is the child on any new medicines or health regimes?

Interim social events

Have there been any major changes at home (eg, new baby, move, new job or loss of a job, death in the family, domestic violence event, community violence event)?

Feeding/sleep/elimination patterns (infants)

Is the child being breastfed? How often? Any concerns?

If on formula, which one? How often? Any concerns?

Is the child receiving solid food? Tolerating well?

Does the child receive vitamin and iron supplements?

How much water does the child drink? Is the water fluoridated?

What is the child’s sleep pattern? Any concerns?

What is the child’s elimination pattern? Any concerns?

Eating/sleeping/elimination patterns (toddlers/preschoolers)

Questions about the solid foods in the child’s diet and weaning from breast or bottle

Questions about transition from crib to bed

How is toilet training going? Any concerns?

Eating/sleeping/elimination patterns (older children and adolescents)

Questions about the amount and type of food the children and adolescents are eating: Too much? Too little?

Unusual eating behaviors?

Questions about sleep patterns with an emphasis on an optimum sleep routine

Questions about daytime and nighttime wetting and/or soiling

Questions about sleep patterns with an emphasis on an optimum sleep routine

Questions about daytime and nighttime wetting and/or soiling

Activity (a formal developmental screen can substitute for the milestone questions)

For infants and toddlers, questions about milestone development

For older children and adolescents, questions about routine exercise and sports activities

Screen time (starting during toddler years)

How much television does the child watch? With an adult present?

What types of videogames does the child play, and how much time is spent playing?

For adolescents, are they involved in excessive online interactions?

Language, literacy, and numeracy (a formal developmental screen can substitute for this)

How often does the family read to the child?

Is the family concerned about the child’s language development?

For older children, what reading level has the child attained?

Are the parents concerned about the child’s progress in reading or in math?

School functioning (starting in preschool)

What are the teachers reporting about the child?

Has the family been attending regular parent-teacher meetings at the school?

What are the child’s interests and strengths?

If there are concerns, have they been adequately addressed?

Safety

Does the family have any safety concerns?

Is there a gun in the house? Is there a lock on the gun?

Have smoke detectors been installed in the home?

Is use of car seats and bicycle helmets reinforced?

The health supervision visit should be conducted in private, and the family should feel confident that the information they provide will be handled professionally and shared only with those who need to know the information for the benefit of the patient. With the advent of electronic recordkeeping, some parents may be wary about discussing information they consider personal. The child health clinician should take the time to explain how the records system works and that there are layers of security and privacy protection.

Taking a History Content

Certain elements are critical to medical history taking. First, the child health clinician should ask whether the parents are concerned about any pressing issues. If the child is sick on the day of the well-child visit, or if a destabilizing event has occurred in the household, such as a death or the loss of a job, these issues may take precedence over the more routine questions. Also, a probe for the parents’ concerns helps the clinician assure that they are addressed during the visit.

At a family’s first health supervision visit, additional baseline information about the family and child is gathered. At subsequent visits, changes since the last visit should be obtained. Table 10-3 provides suggestions for history taking at the first and subsequent visits.

OBSERVATION

The astute clinician utilizes all aspects of the visit to glean information about the child and family. Information is gained not only through physical examination and by asking questions but also by observing interactions between the child and family. Observation, while generally not formally taught, can provide important information about the child and family that may not be elicited through questions. Bright Futures provides a list of questions to ask at each visit to guide the clinician in observing the child and family. For example, at the 12-month visit, the clinician is prompted to observe the family interaction when the child is given a book as part of a Reach Out and Read program. Observing what the child does with the book and how the parents respond can provide important information about their interaction.

CONDUCTING A PHYSICAL EXAMINATION

Physical Examination Process

The physical assessment begins with obtaining and recording the child’s height, weight, head circumference (for infants and toddlers), and vital signs. This information is often collected by a nurse or clinical assistant. The height and weight should be recorded on a Centers for Disease Control growth chart. eFigures 10.1 through 10.12  are growth charts developed by the Centers for Disease Control and the World Health Organization for children from birth to age 20. These and additional charts for special populations can be found at: http://www.cdc.gov/growthcharts and http://www.who.int/nutrition/media_page/en . These charts indicate the child’s growth percentile. The clinic should have an alert system for children whose measurements are above or below clinically specified cutoffs or whose percentiles are shifting up or down. Body mass index should also be recorded and monitored to detect children who are at risk for undernutrition or overweight status. For further discussion of nutritional evaluation see Chapter 28. The approach to the child with poor weight gain is discussed in Chapter 30, and growth impairment is discussed in Chapter 522. The management of overweight or obesity is discussed in Chapter 32.

Ideally, vision and hearing screenings take place at selected health supervision visits along with other medical screening, such as for anemia, lead poisoning, developmental problems, and signs of autism, according to the American Academy of Pediatrics periodicity schedule found at http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf .

Table 10-4. Calming Techniques to Improve Examination Accuracy in Children Ages 1 to 4 Years

Preparation: Read stories about health check-ups or health visits before the appointment.

Parent contact: The child sits or lies in the parent’s lap or is held chest-to-chest by the parent.

Distraction:

Auditory: Gentle, relaxed, reassuring constant banter from the examiner or parent; singing or music; or nonsense buzzing noises or whispering.

Manual: The child holds a tongue blade in each hand or feels the stethoscope head, holds jingling keys, or brings dolls or toys to the appointment.

Visual: The otoscope is shown to the child while lighting the examiner’s palm, then the child’s, before the ear examination; or the examiner puts the otoscope into his or her own ear declaring, “See! It’s okay! Just a flashlight. Do you have a flashlight at home?”

Demonstration: A doll or stuffed animal is examined before the patient, or the child’s shoe is “listened” to with the stethoscope before listening to the patient.

Recruitment: Request the child’s help in holding the stethoscope head or tongue blade; “blowing out” the otoscope light; or while listening to the chest, ask the child to blow on a piece of tissue held in front of the mouth to encourage deep breathing.

Comfort measures:

Avoidance of fear-inducing actions: Avoid direct looks into the eyes of a young toddler until the eyes are examined; delay invasive portions of the examination (eg, otoscopy) until last; or examine toes or fingers first.

Pleasant office surroundings: Books, toys, and pictures or drawings on the walls.

Source: Reprinted with permission from Hagan J, Shaw J, Duncan P, eds. Bright Futures: Health Supervision Guidelines for Infants, Children and Adolescents. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2007:217, table 2.

An anxious child is difficult to examine. Using calming techniques can help put the child at ease, allowing for a stress-free, more accurate examination. Table 10-4 provides suggestions for calming prior to and during the examination. The physical examination should be conducted with the child wearing minimal clothing so the clinician can conduct the examination with fewer time lags. The clinician determines how comprehensive an examination to conduct depending on (1) the history, (2) the age of the child, and (3) how recently a comprehensive examination was recorded in the child’s record. Since children in the first 2 years of life come for health supervision visits frequently over the course of the year, it is often appropriate simply to conduct a targeted examination to follow up on previous findings. Bright Futuresdescribes the age-appropriate components of the physical examination that are important for each visit.

The child and family should be assured of privacy during the physical examination. Parents should always be present when children are examined. Teenagers should be given the choice of having their parent present. Teenagers should ideally be examined by a health care professional of the same gender or have someone of the same gender as the patient also present if the person doing the examination is of the opposite gender. The examination room should afford privacy for the child or adolescent, and the door should be kept closed while they are undressing or dressing and during the physical examination. See Table 10-5 for a description of the physical examination for a health supervision visit.

Closing the Visit

Health supervision visits are greatly enhanced when the clinician takes a minute or two at the end of the visit to review the high-priority areas that were emphasized in the visit. This is a great time for the clinician to reinforce the health promotion messages by handing out pamphlets and tip sheets such as those available through the American Academy of Pediatrics on a wide variety of topics. The Bright Futures Web site (http://www.aap.org/brightfutures ) provides a list of suggested brochures matched to the Bright Futures priorities. In addition, there are single-page visit-summary sheets for parents, one for each visit, with the priorities listed and the anticipatory guidance for each priority written for the parent and/or child. The brochures and summary sheets can be distributed before the visit to allow the clinician to point out the information or after the visit to reinforce what was discussed.

The end of the visit is also a good time for the clinician to model positive reinforcement techniques by praising the child for maintaining good health habits. A wonderful way to end the visit is by rewarding the child for his or her participation by giving an age-appropriate book from a program such as Reach Out and Read.

OTHER IMPORTANT AREAS

Privacy and Confidentiality

Issues of privacy and confidentiality may arise during any health supervision visit and for children of any age. They should be addressed as they arise. They must, however, be addressed during the adolescent years. Clinicians and practices are encouraged to establish rules of privacy and confidentiality and to share them with the children and families. Beginning in the early adolescent years (ages 11–14 years, according to Bright Futures), part of the visit may be conducted with the child alone. This is especially important for young adolescents who many not share certain information when a parent is present. Establishing a trusting relationship between the adolescent and clinician is extremely important at this stage of the young person’s development to assure the discussion of information that will help the clinician to support the adolescent’s health and development. Sharing is bidirectional as the clinician seeks to learn about the adolescent while sharing information to promote health, assessing for strengths and assets, and promoting a supportive and open environment for discussing issues that might transpire during the often tumultuous period of adolescence.

Table 10-5. Physical Examination

General Observation

The examination begins with a general observation of the child’s overall state of health and development. The clinician notes if the child’s size appears to be out of the average range; whether the child has any obvious signs of a chronic illness, condition, or disability; whether the child is particular active or withdrawn. The clinician takes particular note of whether there are overt signs of sadness.

Skin

The skin should be reviewed for eczema, café au lait spots, unusual moles, and other skin lesions.

Head

The child health clinician notes the shape of the head and, in infants, feels for the fontanels to assess whether they are open or closed. The scalp should be looked at for signs of infection (particularly tinea).

Eyes

The clinician assesses eye movements, pupillary size, and pupillary reaction. In infants, the clinician should establish at an early visit that the retinal red reflex is present.

Ears

Assessment of ear shape and of the tympanic membrane bilaterally.

Nose

Notation of patency of both nostrils.

Mouth

The clinician should establish the presence and health of teeth, look for clefts of the soft and hard palates, comment on the tonsils.

Neck

The clinician should look for cervical lymphadenopathy and comment on whether or not the thyroid is visible and/or palpable.

Lungs

Lungs should be assessed for unusual sounds such as wheezes, rales, and rhonchi. The clinician should record the child’s respiratory rate if it is not previously noted.

Heart

Size, location, and pulse should be recorded. The clinician should note if a heart murmur or other sound such as rub or gallop is appreciated.

Abdomen

The clinician should note whether the abdomen is protuberant or scaphoid, comment on presence of bowel sounds, and check for liver and or splenic enlargement.

Genitourinary

The clinician should inspect the child’s genitalia looking in boys for undescended testes, hypospadias, etc. In girls, an inspection of the vulva and external genitalia is usually sufficient during health supervision visits unless there are specific concerns. In sexually active teen age girls, a more comprehensive gynecologic assessment is in order.

Extremities

The clinician should look for range of motion at the joints and have the child walk a few yards in order to assess gait.

Spine

In older children and adolescents, a routine review for scoliosis should be performed.

During the visit, the physical examination may invoke embarrassment for young adolescents, and they may be uncomfortable responding to seemingly private, personal questions. Privacy during the physical examination is essential; many clinicians ask for a chaperone when conducting the physical examination of both girls and boys. Confidentiality is addressed with the assurance that information is not disclosed or shared with parents or anyone else unless the information indicates that someone is in immediate danger.

HEALTH SUPERVISION IN THE OFFICE PRACTICE

HOW DO I LOOK AT MY PRACTICE?

In the United States, it is reported that 38.3% of children received the recommended well-child care, according to a recent report on the quality of ambulatory care.2 Delivering high-quality primary care is an active process shared by all personnel in the primary care office.

The health supervision visit entails more than just the face-to-face time between the clinician and the child and parent. Other actions take place, such as completion of paperwork and questionnaires; psychosocial and developmental screening; interactions with nursing that may include history taking and immunization administration; and conducting, documenting, and plotting various anthropomorphic measures. These activities can consume considerable time, and when combined with a clinical encounter that is estimated to be 15 to 18 minutes, the actual time spent in the primary care practice can be substantial.

Given the significant amount of time the child and family spend on the entire visit, it is not surprising that increased attention is being paid to examining the effectiveness and efficiency of how care is delivered in the primary care setting. For further discussion of approaches to improving systems of care, refer to Chapter 5. Practice managers seek to make the encounter a valuable experience for the patient while limiting inefficiencies in the system of care. Time spent gathering information from the child and family prior to the clinical encounter can contribute to increased face-to-face time between the clinician and family. Examining the practice for ways to improve the system of care, streamline processes, and maximize the use of resources will help to create an environment that delivers high-quality primary care. eTable 10.1  provides a comprehensive list of tips and strategies for practice improvement.

BRIGHT FUTURES TOOLKIT

With the release of Bright Futures, health care professionals have the opportunity to reflect on their current system of care and consider new approaches to improving how that care is delivered. Owning a Bright Futures book and having knowledge of the recommendations does not translate into improved care. Making the guidelines “come to life” in the practice involves a proactive, systematic approach to guidelines implementation. Assuring adherence to guidelines and high-quality care is typically accomplished with the support of tools, materials, and strategies. The Bright Futures Toolkit provides a comprehensive set of tools and materials matched to the recommendations at each visit. Bright Futures anticipatory guidance handouts and summary sheets for parents and children are available for each visit, covering the five priorities and other visit interventions. Parent questionnaires cover screening questions to ascertain risks of each of the universal and selective screening topics. Questionnaires used prior to the visit can assess the parents’ and child’s concerns and needs and help to focus priorities for the visit. Clinical documentation forms align with the clinical recommendations at each visit.

The tools that accompany the Bright Futures guidelines are a resource for the practices that want to implement the guidelines. Despite this resource, each practice must decide what to implement, how, and when in order to best meet the practice’s unique needs. Knowing the most efficient and effective way to replace previous tools and methods and to phase in a new approach will challenge all practices faced with implementation. Those with electronic medical records systems must review their existing systems and match them to the Bright Futures recommendations and guidelines. Many companies are working to align their electronic medical records templates and child health sections with the new Bright Futures guidelines, so for some practices, a software upgrade may smooth the transition. There is no one “correct” way to implement new guidelines; there are many.

An emerging focus on systems improvement through quality improvement is one approach to implementing new guidelines. Recent attention to quality improvement, prompted by the recognition of medical errors and the increasing evidence of poor health care quality, has prompted clinicians to reexamine their own practices and how care is delivered. Many practices now participate in quality improvement activities and share methods and strategies for implementation as they learn from each other. Physician li-censure recertification in many specialties, including pediatrics, will require competence in quality improvement as demonstrated by participating in or carrying out practice-based quality improvement. A common approach is using the principles of quality improvement, such as the model for improvement,3which involves choosing an area for improvement, typically based on data, and then completing the plan-do-study-act (PDSA) cycle of improvement; see Table 10-6. For example, a practice wants to improve its rates of lead screening at the 12-month visit. The data may come from a recent audit by the insurer or public health authorities, or it may have been researched by a curious clinician. Once the area for improvement is identified, the PDSA approach is applied, making small, sequential, and incremental changes, often referred to as tests of change, toward the ultimate goal. The plan, for example, is to implement a system to prompt all clinicians that the lead screening is due. They will do the prompting for 1 week and will study by examining 5 to 8 charts of 12 month olds seen during that time to see if the lead screening was done. Once the data has been collected, the practice will act on the results by determining if their approach achieved the desired result of increasing lead screening. If the prompting system does not achieve the desired results or is deemed cumbersome or inappropriate for the practice, then a new test is implemented with a new PDSA cycle. While the approach is simple in concept, applying PDSA can be a challenge, starting with choosing an area for improvement. In our example, the practice may choose to improve lead screening rates, but this goal requires further clarification: Does the practice want to improve the ordering of lead screening tests or improve the documentation of the screening values in the charts? Each option requires a different approach and consequently a different PDSA cycle. Further information on these methods can be obtained from the Improvement Guide3 or online resources such as the Institute for Healthcare Improvement (http://www.ihi.org ). Using quality improvement principles help practices to systematically examine how they deliver care and what aspects of that care might be amenable to change.

Table 10-6. PDSA (Plan-Do-Study-Act) Worksheet for Testing Change