Pediatric News Turns 50

Well-child care: Steady growth in breadth and content


Fifty years ago in 1967, the American Academy of Pediatrics published a “Suggested Schedule for Preventive Child Health Care.” It was, in essence, the first periodicity schedule for well-child visits.

Described by AAP officials at the time as an “amalgamation of schedules used in various clinics and private offices,” it charted out the frequency and basic content of visits from 1 month through 6 years of age, and offered a simple list of items to be considered for guidance and discussion in all visits from 6 years on.

Rate of well-care office visits highest for infants, 2012
Today, the specialty’s schedule for well-child visits, known as the Periodicity Schedule, charts out 31 visits through age 21 years and includes an evidence-driven list of developmental/behavioral assessments and other screenings – from autism screening to depression screening and dyslipidemia screening – in addition to traditional components like measurements and physical exam.

It is updated in real time, and is accompanied by an expansive package of Bright Futures recommendations, guidelines, and tools (including forms, handouts, and questionnaires) for health promotion and guidance. Together, the Periodicity Schedule and Bright Futures guidance reflect decades of steady change in the breadth and content of well-child care – and more recently, in some of its processes.

“When I started practicing [in 1979], developmental surveillance meant asking a few questions about developmental milestones, observing, and maybe lifting a few questions from the Denver Scale [the Denver Developmental Screening Test] to support our surveillance,” said Joseph F. Hagan, Jr., MD, a pediatrician in Burlington, Vt., and coeditor of Bright Futures.

Courtesy of Katie Jean Photography

Dr. Joseph Hagan

As for psychosocial issues, “you’d just keep your ears open, your eyes open,” he recalled. “And in those days, if your exams were normal you’d just write [in the chart], ‘physical exam normal’ and ‘development normal.’ ”

Jack Swanson, MD, a pediatrician in Ames, Iowa, and a member of the Bright Futures Steering Committee, has similar recollections of well-child care in the early 1970s. “The developmental milestones were just questions and nothing more formal. Nutrition was a big [anticipatory guidance] issue, and some safety,” he recalled.

In early pediatric visits, “parents were interested in Dr. [Benjamin] Spock’s recommendations about feeding and raising their baby… and we used to make our own [anticipatory guidance] handouts,” he said. And in the later years, “an adolescent visit used to be every 2 or 3 years.”

Dr. Jack Swanson

Well-child care of the 1960s and 1970s grew at least partly out of efforts to strengthen the nation’s military through early preventive care. The Early and Periodic Screening, Diagnostic, and Treatment benefit was added to Medicaid in 1967 to promote healthy child development and ameliorate conditions that were believed to be causing disability in young military recruits.

“During the Vietnam War, there weren’t enough people who were healthy enough, physically fit enough, to be mustered into the Army,” said Peter Rappo, MD, a pediatrician in Brockton, Mass., who chaired the AAP’s Committee on Practice and Ambulatory Medicine in the late 1990s.

Dr. Rappo became interested in the history of preventive pediatric care after discovering a Children’s Year Campaign (1918-1919) poster in an antiques market. The poster’s message – “The Health of the Child is the Power of the Nation” – remained relevant through the Vietnam War. “I’d like to think that [childhood preventive services] were all about the kids,” he said, “but at the end of the day, it was about military issues too.”

Still, interest in the 1960s in the long-term implications of early-life development fed research that eventually led to an explosion of new science in the 1990s on the importance of early brain development and early life experiences. This scientific literature combined with greater societal interest in school readiness helped drive development of research-based instruments for developmental screening, said pediatrician Edward L. Schor, MD, formerly a vice president at the Commonwealth Fund and now a senior vice president for programs and partnerships at Lucile Packard Foundation for Children’s Health.

“Development was the first topic … of screening instruments,” he said. The tools have “not only increased the quality of care, they also have increased the efficiency of care, because the time to ask and answer these questions was shifted to the waiting room.”

Their use is far from universal, but increasing. Results of the Periodic Surveys administered to a national random sample of AAP members show that pediatricians’ use of at least one formal screening instrument to identify children through 36 months of age at risk for developmental delay increased from 23% in 2002 to 45% in 2009 and 63% in 2016. (And in 2016, 81% reported “always/almost always” using at least one formal screening tool for autism.) The data was presented at the annual meeting of the Society of Developmental and Behavioral Pediatrics September 2016.

For Dr. Rappo’s practice in Massachusetts, the adoption of developmental and behavioral health screening questionnaires for all ages was spurred by a 2007 mandate requiring formal screening for children and adolescents in MassHealth, the state’s combined Medicaid–Children’s Health Insurance Program.

“We all knew intuitively this is what we should be doing, so we also sat down with insurers to talk about why this is important for kids,” he said. Reimbursement improved, and most importantly, he said, use of the tools “has tremendously improved our opportunities for opening up discussions with parents about developmental-behavioral issues.”

The well-child visit of 50 years ago was much more of “a physician-generated, physician-led visit,” said Dr. Swanson. “The pediatrician knew what was needed, and at the end, we’d ask if there were any questions. Today, the first question recommended by Bright Futures is ‘Do you have any questions for the visit?’”

According to a 2009 focus group study involving 282 pediatricians and 41 nurse-practitioners, clinicians agree that eliciting and prioritizing parent concerns is a top priority in well-child care. Yet there’s also some unease. Some said in the focus group discussions that they feel constrained by the Periodicity Schedule, for instance, or feel tension between inviting parents’ concerns while simultaneously addressing the content recommended by professional guidelines (Pediatrics. 2009 Sep;124[3]:849-57).

Indeed, policies and recommendations for health promotion and anticipatory guidance (some consensus-based, some evidence-based or evidence-informed) mushroomed throughout the 1980s and 1990s, Dr. Swanson said. Combined with the increase in recommended screenings through the 1990s and 2000s – and in recent years, the increasing need for discussions to address vaccine concerns, mental and behavioral health issues, and obesity and overweight problems – there are real pulls and tugs.

The time allotted to well-child visits may have increased slightly for some pediatricians – to just over 20 minutes – but overall, visit length hasn’t changed much over the past few decades. “It has pretty much stayed the same, averaging between 15 and 20 minutes,” said Dr. Schor.

Offering guidance to clinicians in prioritizing questions and issues has been a goal in the last two editions (2008 and 2016) of the Bright Futures recommendations – formally called the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. “The joke was that if you did a Bright Futures well-child visit according to the old Bright Futures, you’d do one in the morning and one in the afternoon,” said Dr. Hagan.

The first edition came out in 1994, after a multidisciplinary group convened by the Maternal and Child Health Bureau at the Health Resources and Services Administration, and the Medicaid Bureau (then part of the Health Care Financing Administration) established the Bright Futures Children’s Health Charter to improve children’s health. The second edition was released in 2000 and updated in 2002, at which point the AAP established the Bright Futures National Center.

Previsit screening tools included in the new edition are aimed at assessing and prioritizing anticipatory guidance issues, Dr. Hagan said, noting too that the Periodicity Schedule and Bright Futures recommendations make distinctions between universal and selective screening. “By design,” he emphasized, “there’s more anticipatory guidance than you might ever accomplish in one visit, because we want to be thorough enough to provide a context – a schema – to deal with the issues.”

Oftentimes, he said, “what parents want to talk about is what you want to talk about.” And pediatricians “develop a skill set to temporize, to figure out what needs to be covered today, and what can be dealt with better at a later time,” Dr. Hagan said. “If you tell kids, for instance, ‘I can help you with this, I just have to get more information,’ they hear that there’s help on the way. Then you follow through.”

Dr. David Chung is shown during a well-child visit. Courtesy of Pediatric Associates of Brockton

Dr. David Chung

David Chung, MD, who joined Dr. Rappo’s practice in 2000, often explains to parents that “the well-child visit is a mile wide and an inch deep, and if there’s an issue that’s complicated, it requires its own visit so that we can go a mile deep on that one.”

Overall, his well-child visits “have gotten much more involved with the emotional well-being of children.” Given that emotional issues and behavioral issues “tend to take a longer time to discuss and unravel,” he sets aside consultation times near the end of the day for families who need to discuss these issues.

And he routinely devotes time – starting at the 2-month visit – to discuss screen time and media use. “I believe that technology is making our children sick,” he said, noting that in his nearly 17 years of practice he has seen increasing numbers of children and adolescents with depression, anxiety, anger, and attention deficit/hyperactivity disorder. “The AAP has done a pretty good job of raising the point, but I don’t think it has hit home with parents yet.”

For Dr. Chung, electronic medical records and systems have enabled him to better flag issues for follow-up over the course of well-child visits, leading to “better longitudinal care.”

Surveys and questionnaires filled out by parents in his practice’s waiting room are scanned into charts, he noted, and adolescents can mark answers on a proprietary confidential risk questionnaire that subsequently gets scrambled so that no one but the provider can understand the responses.

Other potential impacts of electronic systems have yet to be realized, he and others said. Some pediatric practices, Dr. Schor said, have begun engaging with families ahead of well-child visits through the use of a computerized questionnaire that elicits areas and issues of interest. Such outreach may help families feel more invested and committed to attending the visits, particularly those that don’t involve immunizations or school/sport forms, he said.

Families are “not [always] buying what we’re selling [for well-child care],” said Dr. Schor, who has served on AAP committees and has written several well-cited articles on preventive pediatrics care.

Insurance coverage for well-child care got a boost in 2010 when Bright Futures was cited in the Affordable Care Act as the standard of what well-child care should accomplish, and its recommended screenings and services were required to be covered by insurers without cost-sharing.

In the long-run, he said, rethinking the roles of nonphysicians in anticipatory guidance and developmental and psychosocial screening – in interpreting results of questionnaires, for instance – may be essential for well-child care. Outside of large health care systems, “the use of personnel [has been] pretty much been unchanged over the years,” he said. “We need to ask, how can we use each individual’s skills and training most efficiently? How can we retrain and reorganize our patient flow?”

This may be especially important as well-child care increasingly considers family psychosocial issues such as housing, food insecurity, family violence, and other family social stressors. Maternal depression screening made its way into the Periodicity Schedule in February 2016, and Dr. Schor predicts that the schedule will include “family psychosocial risk screening” in another several years.

For now, the newly revised Bright Futures guidelines – and much of well-child care – places an increased emphasis on the social determinants of health, which Dr. Hagan said reflects the “long-standing, logical conclusion that we reached back in the 1990s – that if families are healthy, kids will be healthy … and that family health is also linked to community health.”

Recommended Reading

Five quick ways HHS Secretary Tom Price could change the course of health policy
MDedge Pediatrics
Malpractice 2017: Do we need reform?
MDedge Pediatrics
CMS proposal seeks to stabilize individual insurance market
MDedge Pediatrics
Seema Verma dodges questions on how to improve CMS
MDedge Pediatrics
CMS spending projections come with a caveat
MDedge Pediatrics
Appeals court strikes down doctor gun gag law
MDedge Pediatrics
Cooperation must overcome polarization
MDedge Pediatrics
Want better patient engagement? Use social media
MDedge Pediatrics
Pregnancy medical home reduces hospital visits, overall costs
MDedge Pediatrics
CMS to alert docs of their MIPS status soon
MDedge Pediatrics