Evidence Based Well Child Visits

1. Evidence BasedWell Child Visits Robert L. Ringler, Jr., MD, FAAFP Portsmouth Family Medicine Residency Eastern Virginia Medical School 15 March 2008, 1500 � USAFP, Portland, OR

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

4. Promoting Healthy Outcomes Disease Prevention Health Promotion and Anticipatory Guidance Early Detection of Disease

5. Well Child Visits Parent and youth concerns Preventive services Structured developmental screening Establish community linkages Recall and reminder system Practice detects special health care needs & ensures they receive preventive services

6. Health Outcomes Healthy weight and BMI Normal BP, vision, hearing Pursuing healthy behaviors: Nutrition Physical activity Safety Sexuality Substance use

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

8. Health Promotion Themes Promoting Family Support Promoting Child Development Promoting Mental Health Promoting Healthy Weight Promoting Healthy Nutrition Promoting Physical Activity Promoting Oral Health Promoting Healthy Sexual Development & Sexuality Promoting Safety & Injury Prevention Promoting Community Relationships and Resources

9. Promoting Healthy Weight Normal or healthy weight: BMI <85th Overweight: BMI =85th but <95th Obese: =95th % rising rapidly between 1988-2004

10. Screening for Overweight and Obesity One or more parents are obese One or more siblings are obese Family with low income Chronic disease or disability that limits mobility BMI for age Comprehensive physical assessment

11. Second level assessment & screening Family Hx: early CVD, lipids, obesity, DM2 BP for age, gender, height >90th � prehypertensive >95th � HTN FLP � Total >200, low HDL, high trig Large ? in BMI: 2-3 points in 1 yr Concern about weight

12. Actions for providers Plot BMI routinely Address BMIs before they reach 95% Identify �at risk� children

13. The Well Child (Health Supervision) Visit Disease detection Disease prevention Health promotion Anticipatory guidance

14. The Well Child (Health Supervision) Visit Subjective: Parent and child concerns Surveillance of development Nutrition, activity, sleep Home, school, mental health, strengths Safety, substances, puberty Objective: BMI, vision, hearing, other screening Physical Examination

15. The Well Child (Health Supervision) Visit Assessment: Well child Normal physical and emotional development Plan: Anticipatory Guidance Immunizations

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

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

18. Rationale for clinical decisions Clinical evidence Practice guidelines Colleagues Decision support systems Experience Habit Judgment Preferences

19. Evidence basis for preventive health issues Evidence-informed rather than evidence-driven Satisfactory studies uncommon Few studies evaluate effectiveness of components of PE (considered screening interventions) and counseling interventions

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

21. Evidence Based Recommendations USPSTF recommends: Structured breastfeeding education and behavioral counseling programs to promote breastfeeding (B recommendation)

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

23. Evidence Based Recommendations USPSTF recommends against: Routine screening for testicular cancer Routine screening of asymptomatic adolescents for idiopathic scoliosis

24. Universal Screening � Bright Futures Newborn Metabolic and Hemoglobinopathy Essential public health responsibility State laws Development � 9/18/30m Standardized tests

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

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

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

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

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

30. Selective Screening Hearing (4/6/12/15/18m, 2/2.5y) � Joint Committee on Infant Hearing Caregiver concern* FHx* of perm childhood hearing loss NICU >5d In utero infections (CMV*, herpes, rubella, syphilis, toxo) Craniofacial abnl Physical findings like white forelock Syndromes assoc with hearing loss or progressive/late onset hearing loss* Neurodegenerative disorders* Culture-positive postnatal infx assoc with sensorineural hearing loss - meningitis (bacterial, herpes, varicella) Head trauma req hosp, esp basal skull/temporal bone fx* Chemotherapy* * Delayed onset hearing loss

31. Selective Screening Anemia (4m) � AAP Prematurity LBW Use of low-iron form, infants not getting iron-fortified form Early introduction of cow�s milk Anemia (18m, annual 2y+) � AAP Special health needs Low-iron diet (eg, non-meat diet) Environment (eg, poverty, limited food)

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

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

34. Selective Screening TB (1/6/12/18m, annually @2y) � AAP Annual skin test: HIV-infected children Incarcerated adolescents Risk factor questions: Has a family member or contact had TB? Has a family member had a positive TB skin test? Was your child born in a high-risk country (other than US, Canada, Australia, New Zealand, Western Europe) Has your child traveled (had contact with resident populations) to a high-risk country for >1 wk?

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

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

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

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

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

40. Selective Screening HIV Testing (13-21y visits) � CDC Routine screening unless prevalence documented <0.1% (1 per 1000) Discussed with all adolescents; encouraged for all who are sexually active

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

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

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

44. Efficient Well Child Visits Patient preparation Denver Developmental screening Lead screening (high risk areas) Screening questionnaires CHAT questionnaire Pediatric Symptom Checklist: cognitive, emotional, and behavioral problems CRAFFT: screen for drug and alcohol use

45. Efficient Well Child Visits Well child forms EMR or Paper forms Reminders for appropriate history Reminders for physical examination Reminders for anticipatory guidance Reminders for immunization, screening tests

46. Efficient Well Child Visits Patient education handouts Appropriate reading levels Age appropriate Things to watch for before next visit

47. Questions?