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.
Pediatric health supervision (well-child care) is intended to prevent disease or injury and to promote health for individual children and adolescents. Recommendations have expanded rapidly since preventive care was incorporated into American pediatric practice in the 1930s, dramatically broadening the obligations of primary care physicians. Health supervision is now an axiom of American pediatric practice, valued by both parents and pediatricians.1,2 In 1994, 20% of physician visits made by children up to 15 years of age were for well-child care; in 2001, that number increased to >30% of visits.3,4 A substantial body of research has focused on ways to increase the participation of clinicians in pediatric preventive care, and pediatric training includes a significant emphasis on preventive care.5–11 The rate of provision of preventive services is used as a quality measure by regulators and health plans, which indicates clearly the value society places on these activities.
Professional organizations, government agencies, health insurance-related organizations, and other groups have made extensive and sometimes conflicting recommendations regarding what should be included in well-child visits. A recent evaluation noted wide variation in recommendations for adolescent preventive care.12 Concerns regarding the volume of recommendations and whether these interventions were effective developed as early as the 1970s, and calls appeared for evaluation of the components and the whole of well-child care.1,13
Rigorous evaluation of preventive interventions is essential but is subject to bias because of noncompliance, differences in motivation among individuals and organizations participating in preventive care, and temporal changes in outcomes; in addition, rigorous evaluation of such programs can be costly.14 Useless or harmful programs can be far more costly, however, and discontinuing preventive interventions can be quite difficult once they have become politically popular.
The purpose of this study was to describe the available evidence base for commonly recommended clinical preventive services for children. Recommendations for immunizations have been reviewed elsewhere and are not reviewed here.
We sought recommendations for pediatric preventive health services from nationally prominent groups of different types (governmental, professional, and insurance-related). Recommendations for pediatric clinical preventive services made by the American Academy of Pediatrics (AAP),15 the Bright Futures project,16 the US Preventive Services Task Force (USPSTF),17 the American Medical Association Guidelines for Adolescent Preventive Services (GAPS),18 the American Academy of Family Practice (AAFP),19 the Canadian Task Force on Preventive Health Care (CTF),20 and the Institute for Clinical Systems Improvement (ICSI)21 were tabulated (available from the authors on request). (The AAP Guidelines for Health Supervision III are being merged with the Bright Futures guidelines and are substantially the same; therefore, the Bright Futures document was used for this study.) Consistencies and conflicts among the recommendations were noted. Recommendations that were common to ≥2 of the organizations were included in the review.
Rigorous evidence for each intervention was sought in the literature, with high-quality systematic reviews being sought first. Reviews were considered to be of high quality if the search for studies was comprehensive and the quality of the included studies was assessed. Both randomized and controlled nonrandomized trials were then sought for dates following the search date of the most recent review or for all dates if no reviews were found. If clinical trials were not found (either in reviews or in the subsequent search), then rigorous evidence for preventive interventions was considered not to be available.
Population, Interventions, and Outcomes
We considered generally healthy children between birth and 18 to 21 years of age. Children with chronic illnesses and special health care needs were not considered separately in this review, although much of what applies to healthy children also applies to such children. The interventions listed were in 3 categories, ie, behavioral counseling to reduce risky behavior or increase healthy behavior, screening (through examinations or other procedures), and prophylaxis. We did not address process or systems issues such as confidentiality or periodicity. We focused on health outcomes, including primary and secondary prevention of disease and disability, improvements in overall health and well-being of the child, optimal developmental and behavioral outcomes, and increases in healthy behaviors.
We sought published evidence by using a search strategy based on those developed by McKibbon et al22 and Shojania and Bero,23 in the following databases: Medline, the Cochrane Library (the Cochrane Database of Systematic Reviews, the Database of Reviews of Effectiveness, and the Cochrane Controlled Trials Register), ACP Journal Club CINAHL, and PsycInfo. Source documents for recommendations (such as the documents of the USPSTF and the CTF) were examined, bibliographies of relevant studies were scanned, and experts were informally surveyed to identify other studies. We searched the proceedings of the Pediatric Academic Societies, 1997-2003, for relevant abstracts that had not yet been published in full. Unpublished evidence reports and theses were sought in searches of the Internet with the Google search engine. To maximize search sensitivity for studies of screening, systematic reviews and clinical trials in general (rather than specific conditions) were sought for all pediatric age groups together with the MeSH term “mass screening,” with “screen” or “screening” as text words.
Inclusion and Exclusion Criteria
Studies were included if they directly addressed a well-child care intervention and a health outcome or a change in health risk behavior. Studies of changes in health knowledge and attitudes were excluded. Studies of interventions in nonclinical settings (eg, schools or other community settings) were excluded, as were studies of other uses of tests used for screening (eg, for diagnostic or management purposes). Some systematic reviews included both trials and observational studies; however, only the results from clinical trials were included in this evaluation. Meta-analyses of individual trial data were outside the scope of this study.
We sought evidence that counseling in clinical settings changes health-related behavior or health outcomes. In general, the 7 agencies agreed on recommendations for counseling (Table 1). Counseling directed at injury prevention constituted the largest group of recommendations for counseling interventions. Several high-quality systematic reviews and subsequent trials addressed injury prevention. Modest benefits of counseling were found in some studies for seat belt and car seat use (odds ratio [OR]: 1.3), bicycle helmet use (OR: 0.76 for not using helmets), safe road-crossing behavior (relative risk [RR]: 1.6-1.7), smoke alarm use (RR: 1.14-1.72), and safe tap water temperature (OR: 2.3). Evidence of no effect (OR or RR near 1, with narrow confidence intervals) was found for brief counseling regarding seat belt use, “childproofing,” poison prevention, and firearm safety.24–33 No trials were found that addressed counseling in clinical settings to prevent motorcycle crashes, drowning, pedestrian injuries, alcohol-related injuries, choking, lead poisoning, or sun-related injuries.
In addition to counseling for injury prevention, counseling is recommended to decrease exposure to violence and to prevent smoking, drinking, and drug use. Reviews of violence prevention found no trials of brief counseling in an office setting; intensive multimodal interventions were only modestly effective.34–36 Exposure to passive smoking was not affected by brief counseling; more intensive interventions showed modest effects (absolute risk reduction: 2.7%; number needed to treat [NNT]: ∼25),32,37–39 and no studies of office-based counseling to prevent smoking among adolescents were found.40 Reviews of prevention of alcohol use among young people found 1 trial; studies of interventions in settings other than primary care settings (educational and community group settings) showed evidence of ineffectiveness.41,42 An increase (OR: 1.30 at 36 months) in alcohol drinking among children in the intervention group was shown in 1 trial of office-based interventions.32
Recent reviews and trials of sexually transmitted disease (STD) and pregnancy prevention found mixed results; intensive counseling resulted in decreased incidence of STDs (absolute risk reduction: 7%; NNT: 14 for signs of STDs) or pregnancy (OR: 0.4), but brief, office-based counseling did not.43–48 Counseling regarding diet, counseling to prevent obesity, and counseling to increase physical activity are closely related. No trials of primary care interventions to prevent obesity among children were found, although 1 is in progress.49,50 Tailored counseling, providing written materials, focusing on a physical activity rather than multiple preventive recommendations, and using other health care professionals modestly increased physical activity (effect size: ∼ 0.1 SD).51,52 One randomized, clinical trial of dietary education to prevent anemia showed no difference between groups that received specific dietary counseling at preventive care visits and those that received standard health education.53
Systematic reviews of breastfeeding promotion, in a variety of settings including the primary care office, found evidence that one-on-one health education may enhance the initiation of breastfeeding among low-income women but that multifaceted interventions coupled with changes in hospital procedures have greater effects.54–57 The effectiveness of counseling to promote supine sleep (to prevent sudden infant death syndrome) has not been demonstrated in clinical trials.58
Two systematic reviews on counseling to prevent dental caries found no discernible effect on caries and determined that few definitive conclusions about the effectiveness of oral health promotion can be drawn from the currently available evidence.59,60 No reviews or trials addressing the prevention of baby-bottle tooth decay were found.
Screening activities in the physician’s office include laboratory tests and many of the routines of well-child care, such as growth monitoring, physical examinations, developmental and behavioral assessments (including the office-based use of questionnaires), and specific testing of hearing and vision. Recommendations for screening that were made by ≥2 of the included organizations are listed in Table 2. Disagreements among recommendations were more common for screening interventions than for counseling or prophylaxis.
Although they are commonly recommended, no trials evaluating the yield of repeated physical examinations during the course of well-child care were found.61–63 One large trial (n = 9712) of 1 versus 2 newborn examinations showed no difference in the use of health care resources between the 2 groups.64 Aspects of repeated examinations, including growth monitoring, routine blood pressure measurement, scoliosis screening, and screening for signs of physical and sexual abuse, have not been rigorously evaluated,65–67 and concerns have been raised that false-positive screening examinations for child abuse may cause significant harm.34 A systematic review of developmental assessments identified no randomized trials of screening that addressed health outcomes.68
Screening for vision and hearing difficulties is widely recommended, although recommendations vary for when, how, and what type of problems should be sought. Reviews of vision screening found no trials of office-based vision screening or the commonly used screening tools.69–72 One recent trial in the United Kingdom evaluated an intensive visual screening protocol with professional orthoptists; this resulted in less amblyopia and better visual acuity at 7.5 years in the intensive screening group (NNT: ∼100 for amblyopia).73 No trials that evaluated office-based hearing screening were found.
No trials evaluating screening for tuberculosis, screening urinalysis, cholesterol or lipid screening (universally or for children at high risk),74 or screening for anemia or lead levels75 were found. Screening for STDs such as chlamydia and human immunodeficiency virus is supported by randomized trials.76–81 No trials of screening adolescent male or female subjects for gonorrhea or human papillomavirus (HPV)82 or screening adolescent female subjects for cervical cancer83 were found.
We did not review the evidence for immunizations, because it is reviewed regularly and comprehensively by the Advisory Committee on Immunization Practices and the Committee on Infectious Diseases of the AAP; the USPSTF considers routine childhood immunizations to be supported by strong evidence.84 For these and other Food and Drug Administration-regulated prophylactic agents, the evidence is fairly strong, as might be expected. Evidence for folate supplementation is strong85 and iron supplementation decreases anemia, but trial results regarding developmental outcomes are mixed.86–96 Evidence for fluoride supplementation and newborn ocular prophylaxis is limited97–101 (Table 3).
In the past several decades, the importance of careful scientific evaluation of routines of care has been recognized. The use of traditional “expert consensus” methods of developing clinical recommendations has given way to a systematic and explicit process for reviewing evidence and linking recommendations directly to the quality of the scientific findings.102–104 The CTF and USPSTF grew out of this new understanding. Increasing sophistication of the process of systematic review has led to the use of explicit strategies for searching for and evaluating evidence.
Of the recommendations reviewed for this report, those of the USPSTF, the CTF, and the AAFP are explicitly based on systematic reviews of the evidence. GAPS and the ICSI state that evidence was reviewed, but the methods and content of the evidence reviews are not available for independent appraisal. Recommendations of the AAP and Bright Futures are based on expert consensus, without explicit reference to the evidence. We found widely varying quality of evidence for the interventions we evaluated. For many, no data are available from clinical trials. For others, such as some injury prevention interventions and prevention of neural tube defects, several high-quality trials support the use of the interventions. In some areas, trials have been performed but are of poor quality or are too small to rule out an important effect. As the need for high-quality evidence is increasingly recognized, more trials addressing preventive interventions have been published or are underway.
The number of behavioral counseling recommendations that have been made by different organizations is very large. In this review, 17 counseling interventions were recommended by ≥2 agencies, many of which apply to several age groups. For each of the 29 recommended well-child visits, Bright Futures suggests between 80 and 100 discrete counseling interventions. Hundreds of other counseling recommendations are included in policy statements and committee reports of organizations such as the AAP.
Repeated intensive programs of counseling that are reinforced over time are more likely to change health behaviors or outcomes than are single or brief interventions during well-child care visits. This does not appear to be attributable to a lack of power (related to small sample size) in existing studies but is attributable to the inherent difficulty of changing complex human behaviors.105 Klassen106 suggested that counseling that requires a simple action and for which reinforcement is important may be best suited to the primary care setting.
Trials have shown some brief behavioral counseling interventions to be modestly effective. For example, physician advice to quit smoking results in 2.0% to 2.5% greater quit rates at 1 year (NNT: 40–50), with a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness.107–110 Although these data come from studies of adults, they demonstrate that, in specific situations, brief counseling can have clinically important effects.
Unlike diagnostic tests, which are applied to people who have come forward desiring treatment of symptoms, screening tests are applied to individuals without prior concerns or symptoms of disease. Some screening interventions are mandated by payers (such as the TennCare requirement for a standardized, validated, developmental-behavioral/mental health screening at all well-child visits) or are used to assess the quality of health care providers.111 Traditional criteria for screening programs (eg, the condition should be an important health problem; the test should be accurate, simple, and acceptable; and the condition should be improved with early treatment112) do not address the potential harms of screening and do not require proof that screening and early treatment are effective.113 In general, this kind of evidence comes from clinical trials, except in rare cases in which observational evidence of benefit is overwhelming (eg, screening of newborns for phenylketonuria disease).114,115 Very few of the recommended screening interventions that were reviewed are supported by evidence from clinical trials. This lack of strong evidence may partially explain the conflicts among agencies in recommendations for screening.
Advances in technology may alter the impetus to provide screening during routine health care examinations. For example, during pelvic examinations, patients can be screened for cervical cancer, chlamydial infection, gonococcal infection, and/or HPV infection. Among these, the evidence is most persuasive for chlamydia screening. Now that effective noninvasive screening tests for chlamydia are available, screening for gonorrhea, HPV, and cervical cancer must be proved to be effective to justify costly, invasive, time-consuming screening pelvic examinations.116
The costs and potential adverse effects of the recommended aspects of well-child care have not been evaluated adequately. Costs include not only the direct costs of physician and staff time, laboratory costs, and costs of agents used in prophylaxis but also costs to parents, such as time lost from work and costs of transportation. The most obvious potential harms are in the realm of prophylaxis (for example, potential adverse effects of fluoride supplementation or iron supplementation), but potential harms are equally important and perhaps are less readily apparent for screening and counseling.
Behavioral counseling may result in a paradoxical increase in an unhealthy behavior or an unexpected decrease in a healthy behavior. In a trial of pediatric practice-based behavioral counseling, drinking of alcohol significantly increased in the intervention group, compared with the control group.32 A study of brief advice to parents of asthmatic children to stop smoking revealed a tendency for parents in the intervention group to smoke more and to have a reduced desire to quit.38 Extremely brief discussions of sensitive subjects (dictated by the realities of practice) might also result in harm to the physician-patient relationship.117
Because the patients do not initially seek help for the problem that is the focus of screening, those with false-positive test results immediately suffer harm (having thought previously of themselves as well).115 Additional harm from false-positive screening test results may occur if follow-up testing is expensive or invasive or if treatment is instituted for disease that is clinically unimportant. The case of neuroblastoma screening is a strong reminder that predicted benefits may not be borne out in clinical practice.118–120
When ineffective or less effective interventions displace more effective interventions, children are deprived of the more effective interventions. Although time per visit has increased, the average remains ∼15 minutes.3 Yarnall et al121 estimated that it would require 7 to 8 hours per working day for a primary care physician to provide the preventive services recommended by the USPSTF, making it unfeasible to provide even this limited list of preventive services within the current structure of practice.
Our study is limited, in that we sought only systematic reviews and clinical trials; we did not consider observational studies, although many of the systematic reviews included them. When dramatic results are found in observational studies, clinical trials may not be appropriate. It is well known, however, that observational studies may be misleading: many years of prophylactic use of postmenopausal hormone therapy were supported by strong observational evidence, but benefit was not shown in high-quality clinical trials.122 We also could not evaluate the effects of individual clinical preventive interventions as part of community efforts. The added value of individual counseling in areas such as smoking cessation, automobile restraint use, and sudden infant death syndrome prevention is very difficult to determine and was beyond the scope of this study.
The establishment of national guidelines for the care of asymptomatic persons requires unequivocal scientific evidence.123 Research is urgently needed but is hampered by methodologic challenges and limited resources. The time scale is long for many important outcomes; many conditions of interest are adult diseases with behavioral precursors in childhood. Measurement of relatively rare outcomes for which there are multiple likely risk factors means that any change that is caused by a single intervention will be very difficult to detect, even if it is real and potentially important. The number of patients required for studies may be prohibitively large.124 Furthermore, even when efficacy in controlled circumstances has been demonstrated, this may not translate into effectiveness in actual situations in pediatric practice. When an intervention is shown not to be effective, it might have been tested in the wrong population or at the wrong age or time.125 Cost analyses have generally addressed health care costs rather than societal costs; these analyses are particularly challenging when the time to outcome is long and accurate cost accounting is difficult. The importance of considering patient-important health outcomes cannot be overstated, but such data may be very difficult to obtain. Intermediate outcomes, such as satisfaction with care and patient-provider bonding, do not have the same ultimate importance for patients or society as do actual health outcomes and cannot substitute for health outcomes.
Limited resources for research must be used as efficiently as possible. Three priorities stand out: establishing how best to implement interventions that are already known to be effective, setting research priorities in an explicit and scientifically supportable manner, and investigating how systems of care may influence the effects of individual interventions.
Although considerable effort has been devoted to improving provider compliance with evidence-based guidelines, noncompliance remains common.126 Reasons include time, oversight, systems issues, patient refusal, and conscious decisions not to follow guidelines.127,128 Research on how best to implement interventions that are already known to be effective has been a focus of the Agency for Healthcare Research and Quality in its Translating Research into Practice initiative.129 These efforts should continue to be a priority and should focus on preventive services for children.
The research agenda for unproven but promising interventions must be carefully constructed, with an explicit method based on systematic estimates of the magnitude of clinically preventable burdens and the cost-effectiveness of each service.130 Such a priority-setting effort should include addressing how individual preventive interventions function when bundled with other interventions. The AAP-sponsored Pediatric Research in Office Settings network and other practice-based research networks provide an important venue in which to address these research needs and also provide an opportunity for frustrated physicians to contribute to knowledge in this area.
Finally, evidence is needed regarding the global well-child experience, what systems of care best serve patients, and in what settings such care should be provided. Some preventive services may be more effective or more cost-effective when delivered at the community level rather than the individual level, or some combination of these may be optimal.
In the meantime, the policy implications of the relative lack of evidence supporting our traditions of well-child care must be addressed. Judging health benefits on the basis of scientific evidence provides a rational foundation for directing resources toward effective services and away from services that have been shown to be ineffective, dictating caution with interventions for which the balance of benefits and harms is unclear.131 It may be better to accept fewer interventions as effective, with the knowledge that they are based on solid scientific findings, and to recognize the need for research regarding other interventions.132
Even in the absence of high-quality evidence, recommendations for preventive interventions are needed. Recommendations should include a clear description of the supporting evidence, and those making recommendations should address the potential consequences of implementing the recommendation. From where will the resources (time and money, if needed) to implement the recommendation come, when does a new recommendation replace an old one, and how will each new recommendation fit with current recommendations?
Mandates for care and quality assessments by governments and payers should be based as much as possible on proven interventions. State laws and regulations that mandate the use of unproven screening tests such as the Denver Developmental Screening Test and that judge Medicaid providers on the basis of whether they provide mandated but unproven services must be reassessed. New measures under development for evaluation of health systems on the basis of the recommendations of Bright Futures and other groups133,134 should include explicit references to whether the recommended interventions are supported by research.
The number of office-based preventive care interventions recommended by various groups far exceeds the capacity of the health care system as it currently functions. This review of recommendations for well-child care reveals substantial gaps in supporting evidence for these many recommendations. Although lack of evidence of effectiveness must not be construed as evidence of lack of effectiveness, critical examination of preventive interventions is essential. Current practice and assessments of quality of care should be based on interventions with strong scientific support. Highest priority must be given to implementation research and to setting of priorities for research into the many unproven interventions that have been recommended.
This work was supported in part by a grant from the Agency for Healthcare Research and Quality.
- Accepted May 26, 2004.
- Address correspondence to Virginia A. Moyer, MD, MPH, Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School, 6431 Fannin St, Box 2.106, Houston, TX 77030. E-mail:
No conflict of interest declared.
Dr Moyer is a member of the US Preventive Services Task Force.
- ↵Charney E. Well child care as axiom. In: Charney E, ed. Well-Child Care: Report of the 17th Ross Roundtable on Critical Approaches to Common Pediatric Problems. Columbus, OH: Ross Laboratories; 1986:1–7
- ↵Olson LM, Halfon N, O’Conner K, Inkelas M. Health supervision for infants and toddlers: do parents and pediatricians agree? Pediatr Acad Soc Abstr.2002
- ↵Cherry DK, Burt CW, Woodwell DA. National Ambulatory Medical Care Survey: 2001 summary. Adv Data.2003;(337) :1– 44
- Hered RW, Rothstein M. Preschool vision screening frequency after an office-based training session for primary care staff. Pediatrics.2003;112(1) . Available at: www.pediatrics.org/cgi/content/full/112/1/e17
- Hillman AL, Ripley K, Goldfarb N, Weiner J, Nuamah I, Lusk E. The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care. Pediatrics.1999;104 :931– 935
- Margolis PA, Stevens R, Bordley WC, et al. From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children. Pediatrics.2001;108(3) . Available at: www.pediatrics.org/cgi/content/full/108/3/e42
- ↵Task Force on the Future of Pediatric Education. The future of pediatric education. II. Organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century: a collaborative project of the pediatric community. Pediatrics.2000;105 :157– 212
- ↵Richmond TK CS, Freed GL. Variation in practice guidelines for adolescent care. Pediatr Acad Soc Abstr.2003. Abstract 28
- ↵Hoekelman RA. What constitutes adequate well-baby care? Pediatrics.1975;55 :313– 326
- ↵American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for preventive pediatric health care. Pediatrics.2000;105 :645
- ↵Green M, PJ, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 2nd ed. rev. Arlington, VA: National Center for Education in Maternal and Child Health; 2002
- ↵US Preventive Services Task Force. Guide to Clinical Preventive Services. 3rd ed. Rockville, MD: Agency for Healthcare Research and Quality; 2002
- ↵American Medical Association. Guidelines for Adolescent Preventive Services. Chicago, IL: American Medical Association; 1997. Report OP020997
- ↵American Academy of Family Physicians. Policy Recommendations for Periodic Health Examinations. American Academy of Family Physicians; 2002
- ↵Canadian Task Force on Preventive Health Care. Evidence-Based Clinical Prevention. Canadian Task Force on Preventive Health Care. Available at: www.ctfphs.org. Accessed July 1, 2003
- ↵Institute for Clinical Systems Improvement. Institute for Clinical Systems Improvement Health Care Guideline. Institute for Clinical Systems Improvement; 2001
- ↵McKibbon A, Eady A, Marks S. PDQ Evidence-Based Principles and Practice. Hamilton, Canada: BC Decker; 1999
- ↵Bass JL, Christoffel KK, Widome M, et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics.1993;92 :544– 550
- Munro J, Coleman P, Nicholl J, Harper R, Kent G, Wild D. Can we prevent accidental injury to adolescents? A systematic review of the evidence. Inj Prev.1995;1 :249– 255
- ↵Waters E, Shield J, Nolan T, Green J, Elkington J, Moller J. Evidence-based health promotion. In: Child Injury Prevention 4. Victoria, Australia: Victorian Government Department of Human Services; 2001. Available at: www.dhs.vic.gov.au/phd0103075. Accessed July 1, 2003
- Duperrex O, Bunn F, Roberts I. Safety education of pedestrians for injury prevention: a systematic review of randomised controlled trials. BMJ.2002;324 :1129
- Grossman DC, Garcia CC. Effectiveness of health promotion programs to increase motor vehicle occupant restraint use among young children. Am J Prev Med.1999;16(suppl) :12– 22
- ↵Harborview Injury Prevention and Research Center. Available at: http://depts.washington.edu/hiprc. Accessed November 1, 2002
- ↵Stevens MM, Olson AL, Gaffney CA, Tosteson TD, Mott LA, Starr P. A pediatric, practice-based, randomized trial of drinking and smoking prevention and bicycle helmet, gun, and seatbelt safety promotion. Pediatrics.2002;109 :490– 497
- ↵Grossman DC, Cummings P, Koepsell TD, Marshall J, D’Ambrosio L. Effectiveness of firearm safety counseling in pediatric primary care. Pediatr Acad Soc Abstr.1999;APA120
- ↵MacMillan HL. Preventive health care, 2000 update: prevention of child maltreatment. CMAJ.2000;163 :1451– 1458
- American Academy of Pediatrics, Task Force on Violence. The role of the pediatrician in youth violence prevention in clinical practice and at the community level. Pediatrics.1999;103 :173– 181
- ↵Cooper W, Lutenbacher M, Faccia K. Components of effective youth violence programs. Pediatr Acad Soc Abstr.2000;1075
- ↵Irvine L, Crombie IK, Clark RA, et al. Advising parents of asthmatic children on passive smoking: randomised controlled trial. BMJ.1999;318 :1456– 1459
- ↵Christakis D, Garrison MM, Ebel BE, Wiehe SE, Rivara FP. A systematic review of pediatric smoking prevention interventions delivered by care providers. Pediatr Acad Soc Abstr.2003;3205
- ↵Garrison MM, Christakis D, Ebel BE, Wiehe SE, Rivara FP. A systematic review of smoking cessation interventions for adolescents. Pediatr Acad Soc Abstr.2003;3206
- ↵Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G, Breen R. Primary prevention for alcohol misuse in young people. Cochrane Database Syst Rev.2002;(3) :CD003024
- ↵Yamada J, DiCenso A, Feldman L, et al. A systematic review of the effectiveness of primary prevention programs to prevent sexually transmitted diseases in adolescents. In: Effective Public Health. Ontario, Canada: Ontario Ministry of Health; 1999:1–73
- Boekeloo BO, Schamus LA, Simmens SJ, Cheng TL, O’Connor K, D’Angelo LJ. A STD/HIV prevention trial among adolescents in managed care. Pediatrics.1999;103 :107– 115
- ↵Oakeshott P, Kerry S, Hay S, Hay P. Condom promotion in women attending inner city general practices for cervical smears: a randomized controlled trial. Fam Pract.2000;17 :56– 59
- ↵DiCenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. BMJ.2002;324 :1426
- ↵Campbell K, Waters E, O’Meara S, Kelly S, Summerbell C. Interventions for preventing obesity in children. Cochrane Database Syst Rev.2002;(2) :CD001871
- ↵McCallum Z, Wake M, Waters E, et al. A primary care intervention for childhood overweight/obesity (LEAP): methodology of a randomized controlled trial. Pediatr Acad Soc Abstr.2003;1406
- ↵Childs F, Aukett A, Darbyshire P, Ilett S, Livera LN. Dietary education and iron deficiency anaemia in the inner city. Arch Dis Child.1997;76 :144– 147
- de Oliveira MI, Camacho LA, Tedstone AE. Extending breastfeeding duration through primary care: a systematic review of prenatal and postnatal interventions. J Hum Lact.2001;17 :326– 343
- ↵Sikorski J, Renfrew MJ, Pindoria S, Wade A. Support for breastfeeding mothers. Cochrane Database Syst Rev.2002;(1) :CD001141
- ↵Amin S, Raju T. The role of lactation enhancement strategies: a systematic analysis. Pediatr Acad Soc Abstr.2002;2323
- ↵Creery D, Mikrogianakis A. Sudden infant death syndrome. Clin Evid.2002;(7) :367– 376
- ↵Barlow J, Stewart-Brown S, Fletcher J. Systematic review of the school entry medical examination. Arch Dis Child.1998;78 :301– 311
- ↵Stickler GB. Are yearly physical examinations in adolescents necessary? J Am Board Fam Pract.2000;13 :172– 177
- ↵Bundy DG, Feudtner C, Rivara FP. Preparticipation physical evaluations for high school athletes: a critique of a de facto national screening program. Pediatr Acad Soc Abstr.2002;1265
- ↵Glazener CM, Ramsay CR, Campbell MK, et al. Neonatal Examination and Screening Trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants. BMJ.1999;318 :627– 631
- ↵Garner P, Panpanich R, Logan S. Is routine growth monitoring effective? A systematic review of trials. Arch Dis Child.2000;82 :197– 201
- ↵Panpanich R, Garner P. Growth monitoring in children. Cochrane Database Syst Rev.2000;(2) :CD001443
- ↵Leaver JM, Alvik A, Warren MD. Prescriptive screening for adolescent idiopathic scoliosis: a review of the evidence. Int J Epidemiol.1982;11 :101– 111
- ↵Snowdon SK, Stewart-Brown SL. Preschool vision screening. Health Technol Assess.1997;1 :1– 83
- Snowden SK, Stewart-Brown SL. Preschool Vision Screening: Results of a Systematic Review. York, United Kingdom: National Health Service Centre for Reviews and Dissemination, University of York; 1997
- ↵Hartmann E, ed. Vision Screening in the Preschool Child: Proceedings of a Conference Held September 1998. Washington, DC: US Department of Health and Human Services; 1999
- ↵Williams C, Northstone K, Harrad RA, Sparrow JM, Harvey I, Team AS. Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial. BMJ.2002;324 :1549
- ↵Nelson HD, Helfand M. Screening for chlamydial infection. Am J Prev Med.2001;20(suppl) :95– 107
- Andersen B, Olesen F, Moller JK, Ostergaard L. Population-based strategies for outreach screening of urogenital Chlamydia trachomatis infections: a randomized, controlled trial. J Infect Dis.2002;185 :252– 258
- Ostergaard L, Andersen B, Moller JK, Olesen F. Home sampling versus conventional swab sampling for screening of Chlamydia trachomatis in women: a cluster-randomized 1-year follow-up study. Clin Infect Dis.2000;31 :951– 957
- Low N, Egger M. What should we do about screening for genital chlamydia? Int J Epidemiol.2002;31 :891– 893
- ↵McCrory DC, Matchar DB. Evaluation of cervical cytology. In: Evidence Report: Technology Assessment (Summary). Rockville, MD: Agency for Health Care Policy and Research; 1999:1–6. Publication 99-E010
- ↵US Preventive Services Task Force. Childhood immunizations. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996:767–790
- ↵Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. In: Cochrane Review: The Cochrane Library. Oxford, United Kingdom: Update Software; 2002
- ↵Martins S, Logan S, Gilbert R. Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia. In: Cochrane Review: The Cochrane Library. Oxford, United Kingdom: Update Software; 2002
- Martins S, Logan S, Gilbert R. Iron supplementation for improving psychomotor development and cognitive function in infants under the age of one. In: Protocol for a Cochrane Review: The Cochrane Library. Oxford, United Kingdom: Update Software; 2002
- Geltman Pl, Meyers AF, Bauchner H. Daily multivitamins with iron to prevent anemia in infancy: a randomized clinical trial. Clin Pediatr.2001;40 :549– 554
- Geltman Pl, Meyers AF, Brugnara C, Villon I, Wu YA, Bauchner H. Daily multivitamins with iron to prevent anemia in infants: a randomized clinical trial. Pediatr Acad Soc Abstr.2003;3286
- Ziegler EE, Jiang T, Nelson SE, Jeter J. Iron supplementation of breast-fed infants: a pilot study. Pediatr Acad Soc Abstr.2000;1396
- Aziz K, Andrews WL, Harding SV, Friel JK, Courage ML, Adams RJ. Full-term breastfed infants may benefit from iron supplementation from 1 to 6 months: a randomized controlled trial. Pediatr Acad Soc Abstr.2002;1093
- Lozoff B, De Andraca I, Castillo M, Smith J, Walter J, Pino P. Behavioral and developmental benefits of preventing iron-deficiency anemia in healthy full-term infants. Pediatr Acad Soc Abstr.2001;132
- ↵Gera T, Sachdev HP. Effect of iron supplementation on incidence of infectious illness in children: systematic review. BMJ.2002;325 :1142
- ↵Kapoor VS, Whyte RK, LaRoche GL. Interventions for preventing ophthalmia neonatorum. In: Protocol for a Cochrane Review: The Cochrane Library. Oxford, United Kingdom: Update Software; 2002:4
- ↵Hoekelman RA. An appraisal of the effectiveness of child health supervision. Curr Opin Pediatr.1989;1 :146– 155
- ↵Klassen TP. Primary care counselling for injury prevention: where is the evidence? Inj Prev.1995;3 :147– 148
- ↵Silagy C, Stead LF. Physician advice for smoking cessation. In: Cochrane Review: The Cochrane Library. Oxford, United Kingdom: Update Software; 2003
- Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence: A Clinical Practice Guideline. Rockville, MD: Agency for Healthcare Research and Quality; 2000. AHRQ Publication 00-0032
- ↵Evaluation Studies Workgroup. Design of a Health Indicator System: A “How-To” Manual for State Medicaid Programs. Providence, RI: Rhode Island Department of Human Services; 2000
- ↵Wilson J, Jungner G. Principles and Practice of Screening for Disease. Geneva, Switzerland: World Health Organization; 1968
- ↵Gray JAM. Screening. In: Evidence-Based Healthcare: How to Make Health Policy and Management Decisions. London, United Kingdom: Churchill Livingstone; 1997:46–53
- ↵Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ.2002;325 :870
- ↵Agency for Healthcare Research and Quality. Quality Research for Quality Health Care: A Report From the AHRQ on Recent Activities and Future Directions. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication 01–0018
- ↵Rimer BK, Glanz DK, Rasband G. Searching for evidence about health education and health behavior interventions. Health Educ Behav.2001;28 :231– 248
- ↵Bethell C, Peck C, Schor E. Assessing health system provision of well-child care: the Promoting Healthy Development Survey. Pediatrics.2001;107 :1084– 1094
- ↵Fergusson DM, Horwood LJ, Beautrais AL, Shannon FT. A controlled field trial of a poisoning prevention method. Pediatrics.1982;69 :515– 520
- ↵Amin SC, Raju T. The role of lactation enhancement strategies: a systematic analysis. Pediatr Acad Soc Abstr.2002;2323
- Bundy DG, Feudtner C, Rivara FP. Preparticipation physical evaluations for high school athletes: a critique of a de facto national screening program. Pediatr Acad Soc Abstr.2002;1265
- ↵Cooper WO, Lutenbacher M, Faccia K. Components of effective youth violence programs. Pediatr Acad Soc Abstr.2000;1075
- ↵Filipek PA, Accardo PJ, Ashwal S, et al. Practice parameter: screening and diagnosis of autism: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology.2000;55 :468– 479
- ↵Geltman PL, Meyers AF, Brugnara C, Villon I, Wu YA, Bauchner H. Daily multivitamins with iron to prevent anemia in infants: a randomized clinical trial. Pediatr Acad Soc Abstr.2003;3286
- Ziegler EE, Jiang T, Nelson SE, Jeter J. Iron supplementation of breast-fed infants: a pilot study. Pediatr Acad Soc Abstr.2000;1396
- Lozoff B, De Andraca I, Castillo M, Smith J, Walter J, Pino P. Behavioral and developmental benefits of preventing iron-deficiency anemia in healthy full-term infants. Pediatr Acad Soc Abstr.2001;132
- ↵Aziz K, Andrews WL, Harding SV, Friel JK, Courage ML, Adams RJ. Full-term breastfed infants may benefit from iron supplementation from 1 to 6 months: a randomized controlled trial. Pediatr Acad Soc Abstr.2002;1093
- Copyright © 2004 by the American Academy of Pediatrics