PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1511-1521 (doi:10.1542/peds.2004-1076)
Gaps in the Evidence for Well-Child Care: A Challenge to Our Profession
From the University of Texas-Houston Health Science Center, Houston, Texas
Background. Up to one third of visits to pediatricians involve health supervision (well-child care), and recommendations for office-based preventive interventions have dramatically expanded. We reviewed the evidence for the effectiveness of these interventions.
Methods. The well-child care recommendations of 7 major North American organizations were tabulated. Three types of health supervision interventions were recommended, ie, behavioral counseling, screening, and prophylaxis. For recommendations common to at least 2 of the 7 organizations, evidence of effectiveness was sought from systematic reviews and clinical trials. Immunizations were not considered for this review, because they have been reviewed elsewhere.
Results. Forty-two preventive interventions were recommended by 
2 of the organizations. Limited clinical trials show that counseling can change some health risk behaviors; repeated intensive counseling is most likely to be effective. Harmful effects were shown for a few behavioral counseling interventions. Trials have been conducted for only 2 of the recommended screening interventions; therefore, rigorous evidence supporting screening is very limited. Trials support the use of folate to prevent neural tube defects, trials of iron supplementation do not address developmental outcomes, and trials were not found for the other recommended prophylactic interventions.
Conclusions. Limited direct evidence was found to support the recommended interventions. Because a large number of interventions are routinely recommended and often mandated and because the implementation of any recommendation may cause harm (including the displacement of other beneficial activities), these recommendations should be based on the strongest possible evidence. When recommendations are made, supporting evidence should be clearly stated.
Key Words: mass screening • health services • primary prevention • preventive health services
Abbreviations: AAP, American Academy of Pediatrics • USPSTF, US Preventive Services Task Force • GAPS, Guidelines for Adolescent Preventive Services • AAFP, American Academy of Family Practice • CTF, Canadian Task Force on Preventive Health Care • ICSI, Institute for Clinical Systems Improvement • NNT, number needed to treat • OR, odds ratio • RR, relative risk • STD, sexually transmitted disease • HPV, human papillomavirus
Accepted May 26, 2004.
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