The article “Evidence-Based Community Pediatrics: Building a Bridge From Bedside to Neighborhood”1 explains the importance of using scientific evidence as the foundation of community pediatrics interventions. This commitment to evidence-based community-level health activities by pediatricians is a natural next step in the evolution of pediatrics as we return full circle to the origins of the specialty.
In the United States, child heath supervision had its beginnings in the milk stations and child health centers of large cities, to which infants were brought to be fed, weighed, examined, and immunized against contagious diseases. In 1967, the American Academy of Pediatrics (AAP) established guidelines for child health supervision.
However, there are indications that practitioners are not meeting the objectives of well-child care for many children.
Health education is a major component of child health supervision. These educational efforts cover topics ranging from nutrition to injury prevention. There is little evidence, however, to support health education alone as an approach to behavior change.
Child health supervision is designed for children who have competent parenting, overall good health, and satisfactory growth and development. These conditions, unfortunately, are lacking for too many children.
Some studies have demonstrated that mothers who have the following characteristics are less likely to comply with AAP-recommended child health supervision schedules: (1) unemployed, (2) raising their children alone, (3) poor, (4) young, (5) frequently changing residences, (6) inadequate prenatal care, (7) members of a minority group, and (8) poorly educated.2–4 In 1 study, only 40% of children enrolled in a managed care plan attended all of the recommended visits, while 25% attended no well-child visits at all.5
The AAP guidelines for health supervision visits are controversial because of concerns about the value of what is done during visits and the insufficient supply of health care professionals (eg, pediatricians, family medicine practitioners, nurse practitioners, physician’s assistants) to deliver such care to all children.6 The Congressional Office of Technology Assessment study group observed: “The health status of children in particular (and the population in general) is far more strongly determined by social and economic factors than by the nature of medical care; hence, the contribution that well-child care can make to health outcomes is likely to be modest…”7 It concluded that well-child care, as now performed (other than immunization), has no overall effect on childhood mortality or morbidity and exerts little influence on developmental and social-functioning outcomes.7 In 1990, the Canadian Task Force on Periodic Health Examination reached the same conclusion.8
Practitioners need to change their perspective on traditional professional roles and methods and focus on the goal of meeting the health needs of all children. Changing health maintenance and disease prevention from the individual child to the community level is the next phase in the development of pediatric training. Twenty years ago, it was a big step to move pediatric training from the tertiary inpatient wards to the primary outpatient setting. Now, continuity clinics are an integral part of residency training. A similar integration for community health training is a remaining challenge.
Clinical training is generally hands-on (“see one, do one, teach one”), and community pediatrics training should be, too. Moreover, it should be based rigorously on scientific evidence of what helps, just as clinical training is moving toward evidence-based medicine. To have more practicing pediatricians working effectively to improve child health at the community level, we need to make available to residents the opportunity to participate in mentored community project experiences that follow the precepts outlined by Sanders et al.1 Then, the bridge from bedside to community will not only have firm foundations but also an impressive width and a long span.
- Accepted December 22, 2004.
- Address correspondence to Robert Hoekelman, MD, Department of Pediatrics, University of Rochester, 601 Elmwood Ave, School of Medicine and Dentistry, Rochester, NY 14642. E-mail:
No conflict of interest declared.
- Mustard CA, Mayer T, Black C, Postl B. Continuity of pediatric ambulatory care in a universally insured population. Pediatrics.1996;98 :1028– 1034
- ↵Newacheck PW, Hughes DC, Stoddard JJ. Children’s access to primary care: differences by race, income, and insurance status. Pediatrics.1996;97 :26– 32
- ↵Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. Pediatrics.1999;104 :536– 540
- ↵Chamberlin RW, Schiff DW, Rogers KD. Are routine periodic child health visits beneficial? In: Smith DH, Hoekelman RA, eds. Controversies in Child Health and Pediatric Practice. New York, NY: McGraw-Hill; 1981:181– 215
- ↵US Office of Technology Assessment. Healthy Children: Investing in the Future. Washington, DC: US Government Printing Office; 1998. Publication OTA-H-345
- Copyright © 2005 by the American Academy of Pediatrics