OBJECTIVE. The proliferation of policy statements from the American Academy of Pediatrics presents pediatricians with an increasing amount of health advice to deliver, yet no quantitative estimates of pediatric health advice expectations exist in the literature. The objective of this study was to quantify and characterize verbal health advice that pediatricians are expected to deliver to patients/guardians.
METHODS. The authors read and coded the 344 American Academy of Pediatrics policy statements that are contained in the American Academy of Pediatrics' Pediatric Clinical Practice Guidelines and Policies, Third Edition, and identified 57 policies that contained health advice directives that are broadly relevant to pediatric practice. We extracted the individual advice text to a database in which we also coded its date of issue, its theme, and whether (1) it was duplicated in another policy, (2) a screening question was required to identify a target population for the advice, (3) handouts or other aids to delivering the advice were referenced in the policy itself, or (4) the text of the statement referred to evidence of the effectiveness of office-based delivery of the advice.
RESULTS. These 57 policies were found to contain 192 discrete health advice directives that pediatricians are expected to deliver to patients/guardians. Seven (4%) of these directives originated before 1993, and 185 (96%) were created from 1993 to 2002. After removal of the 30 (16%) duplicates, safety advice composed 67%, media use composed 12%, substance abuse composed 5%, environmental health hazards composed 4%, development/emotional health composed 4%, sexuality and pregnancy composed 3%, nutrition composed 2%, and miscellaneous composed 3%. In 41% of the directives, a screening question was required to identify the target population for the advice. Aids to delivering advice were referenced in 20% of the policies. In no policy statements did the text refer to evidence that office-based counseling was an effective method to achieve the desired health or behavioral outcome.
CONCLUSIONS. We examined the American Academy of Pediatrics policy statements and found 162 different verbal health advice directives on which pediatricians should counsel parents and patients throughout childhood. The expectation that delivery of all of this advice can be achieved is unrealistic. Moreover, none of the reviewed statements were found to include an evidence-based discussion of the efficacy of the suggested advice. In light of these findings, we suggest that committees should consider both the feasibility and the evidence of efficacy of office-based health advice when generating future policy statements.
Each year in the United States, close to 24 million well-child visits occur, representing almost 15% of all office visits of children who are younger than 15 years.1 Health advice constitutes a significant component of these visits. Recommendations for the content of pediatric health advice derive from several sources, including Bright Futures,2 a collaborative effort of the Maternal and Child Health Bureau and the American Academy of Pediatrics (AAP); the AAP's Guidelines for Health Supervision3; the United States Preventive Health Task Force4; and the policy statements of the AAP.5 Over time, these recommendations have framed expectations of the content and the quantity of advice that pediatricians will deliver in the office setting with the intention of modifying patients' knowledge and behavior. Pediatricians are expected to counsel patients on a wide array of behaviors, including injury prevention, personal safety, environmental health, media use, nutrition, sexual health, substance abuse, child development, and promotion of literacy.
The ever-increasing volume of recommended health advice has led physicians to question whether adequate time is available in the office visit,6 parents to question whether they are receiving the advice that they desire,7 and some to suggest that the well-child visit needs to be redesigned entirely.8 Although policy statements from the AAP constitute a critical source of expected health advice to be delivered by pediatricians, no systematic characterization of the totality of this information exists.
We sought to examine the volume and the variety of verbal health advice directives that are contained in the body of the AAP's active policy statements for 20039 to determine the number of individual items of advice and to track the rate of increase in the number of these statements over time. We documented the themes that are addressed by these items, the age groups to whom they apply, how many items require screening questions to identify specific targeted populations, and how often items reference written aids to be used to reinforce the messages that they contain. We also examined how often the policy statements contain text that referred to evidence from the literature to support the effectiveness of the advice.
Policy Statements of the AAP
The AAP committees create policy statements on topics that are relevant to child health; these are published in Pediatrics after their approval and are available on the AAP's Web site (www.aap.org). Frequently, policy statements contain specific statements that are addressed to practicing pediatricians and include recommendations for verbal health advice to be delivered to patients during office visits. We termed such statements “verbal health advice directives.” We also use the shorter terms “advice directives” and “directives” to have the same meaning in the text of this article. Once a policy is created, the issuing committee may review it periodically and reaffirm, modify, or retire the policy. Therefore, the body of active policies is dynamic, and for the purposes of this study, we used a compendium of policies published in 2003, compiled in a CD entitled Pediatric Clinical Practice Guidelines and Policies, Third Edition.9 All 357 AAP policies were read and coded. We excluded from our analysis 13 technical reports and the “clinical practice guidelines.” Our analysis included clinical reports, which in 2003 were not separated from policy statements in the compendium or on the AAP's Web site.
Definition of Verbal Health Advice Directives
Two authors (P.B. and R.G.) read and coded all 344 policy statements that were contained in the CD to identify text within each policy that specified advice to be given by pediatricians to their patients at the time of the office visit. Policy statements often include a recommendations section; however, we searched the entire text of each policy for these verbal health advice directives. Because of differences in phrasing and lack of uniformity of writing style between policies, we used the following standard to define verbal health advice: Is the physician directed to say something to the patient or guardian to prevent an adverse physical or psychological outcome or to promote physical or psychological health or functional outcome of the child?
Verbal health advice directives could be preceded by any of the following terms: advise, counsel, recommend, discuss, encourage, initiate a discussion, remind, and convey. We excluded recommendations that began with “educate” or “promote” because we interpreted this as encompassing nonverbal efforts.
When the recommendation contained a verbal health advice directive by the above definition, the relevant text in the recommendation was extracted to an electronic database described below. Although the majority of recommendation statements contained only a single verbal health advice directive, when a recommendation sentence contained multiple statements that needed to be delivered separately, each 1 of the statements was considered a separate and distinct directive. For example, in the policy entitled “Reducing the Number of Deaths and Injuries From Residential Fires,”10 the following statement is included in the first recommendation: “As part of office anticipatory guidance, parents should be counseled about fire and burn prevention including adequate supervision of children, use of smoke alarms, escape plans, safe behavior in fires, and initial treatment of burns (stop, drop, and roll/cool and call), and other fire and burn prevention messages.”
On the basis of our definition, this recommendation for verbal health advice contained 5 separate verbal health advice directives to be delivered to parents. Because we were interested in quantifying the volume of these directives for the practicing general pediatrician, we focused on advice that generally was applicable to healthy children and excluded those that related to children with specific and rare diseases, such as phenylketonuria, or advice that was directed specifically toward very narrow subsets of children, such as is contained in the policy regarding the care of foster children. Furthermore, we attempted to capture only those verbal health advice directives that were to be delivered in the office and excluded all other recommendations from our analyses.
For each verbal health advice directive the following data were coded:
Exact text that contained the message to be delivered
Date of issue of the policy that contained the advice directive
Whether its content was duplicated by 1 or more directives in other policies
Theme of the advice directive (eg, safety, media, sexual health)
The age group to which the advice was targeted; we used the following categories: (a) to be delivered to parents of children of all ages, (b) infant, (c) infant and toddler, (d) toddler and child, (e) child and adolescent, or (f) adolescent
Whether a screening question would be required to identify a target population of behavior before delivering the message
Whether the policy explicitly recommended that the advice be included in anticipatory guidance; for coding purposes, we considered the following terms and phrases to be synonymous with anticipatory guidance: (a) health supervision practices, (b) well-child visit, (c) during routine evaluations, (d) routine education, (e) primary health care clinical preventive services, (f) routine part of risk behavior assessment, (g) routine history taking, and (h) all pediatric office visits
Whether an aid to deliver the verbal health advice directive, such as a handout, was referenced directly in the text of the policy
Whether the text of the policy statement referred to evidence to support the effectiveness of delivering the advice in the office setting in terms of either behavioral or health outcomes
Duplicate Verbal Health Advice Directives
Duplicate directives (eg, recommendations for safe sex) were identified within each theme. For each set of duplicates, the first to be issued chronologically was retained for the subsequent analyses.
Reliability of Categorizations
After compilation of all of the verbal health advice directives that were contained in the policies, the first and second authors reviewed all of the entries and reached agreement on all of the entries to the database that were used for the subsequent analyses. All 4 authors agreed on the final contents of the database.
Quantity of Verbal Health Advice Directives
Figure 1 shows the breakdown of policy statements that were reviewed and the verbal health advice directives that were identified. Of the 344 policy statements that were contained in the third edition, 57 (17%) were found to contain a total of 192 directives. The complete text of these is available in Appendix 1. Table 1 presents a representative sample of verbal health advice directives with the titles of the policies from which they were taken.
Growth of the Advice Directives Over Time
Figure 2 presents the number of AAP polices that contained verbal health advice per year as a proportion of the total number of policies for that year. Figure 3 presents the number of verbal health advice directives per year and the cumulative total number of advice directives from 1987 to 2002. Seven advice directives that were in effect in 2003 originated in policies that were issued before 1993, whereas 185 were derived from policies that were issued from 1993 to 2002. These figures show that the growth of verbal health advice is attributable predominantly to the accumulation of active policies that contain advice rather than a marked growth of the proportion of advice-containing policies. The data for Figs 2 and 3 are based on a retrospective analysis of the policies that are contained in the AAP's third edition of Clinical Practice Guidelines and Policy Statements rather than a prospective year-by-year analysis.
Duplicates and multiples of the same advice directive were found for many topics, including car seat use, bike helmet use, the need for protective equipment for skating and skateboarding, the danger of guns, excessive media use, the negative influence of media, use of condoms, abstinence from sex, substance abuse, and several other topics. Of the 192 verbal health advice directives, 30 (16%) were duplicates. After these were removed, 162 unique directives remained to form the basis of the subsequent analyses.
Characteristics of Verbal Health Advice Directives
Table 2 presents the number of advice directives for each age group and their distribution by theme. When the verbal health advice directives that are pertinent to all age groups are combined with the number that are directed toward each age group, the total number for each age group varies from a minimum of 53 for infants and toddlers to a maximum of 81 for children and adolescents. When all groups are combined, 67% pertain to safety and injury prevention. Advice directives regarding electronic media use and prevention of substance abuse constitute the second and third largest categories of advice when all groups are combined.
Forty-one percent require a screening question to identify a target population, and 28 screening questions are associated with these advice directives. A complete list of the screening questions is presented in Appendix 2. For the entire set of verbal health advice directives, 39% are recommended explicitly for inclusion in anticipatory guidance efforts. A small percentage (20%) provides reference to an aid or handout to facilitate their delivery. Finally, none of the policies that contained these directives included text that directed the reader to evidence that office-based delivery of the advice had effectively changed health-related behaviors or improved the target health outcomes for children.
Recommendations regarding the frequency with which the advice should be delivered almost universally were absent from policy statements that were reviewed for this study. Exceptions to this observation were found in statements that recommended particular advice be given at every visit, such as is found in the following directive: “Inquiry about tobacco use and smoke exposure is critical at all pediatric office visits.”11 We also found significant variability in the wording of the endorsement to deliver the verbal advice. Examples of this variability are “… provide patients with health advice …,” “… should recommend …,” “… should promote …,” “… should incorporate sun protection advice …,” “… should counsel or provide …,” “… can actively help raise awareness that …,” “… have an obligation to encourage lifestyle …,” “… can share information about …,” “Pediatricians need to educate themselves and parents …,” “… may need to be reminded …,” “… should discuss to emphasize… .”
Finally, we found several examples of the advice directives that we considered to be overreaching in various ways. Examples of this are “Clinical practice guidelines for the prevention and management of youth violence should include violence prevention counseling and screening as early as the prenatal visit … and continuing into adulthood.”12 “Pediatricians should alert and educate parents when positive media opportunities arise either educational or informative.”13 “The pediatrician should address the tendency of some parents to deny that their teenagers might be unsafe drivers.”14
We have compiled what, to our knowledge, is the first comprehensive inventory of verbal health advice directives to pediatricians that are embedded in the policy statements of the AAP. We have characterized their number, their thematic content, and the target populations to whom they should be addressed. We detail the magnitude and the breadth of verbal health advice in AAP policies that pediatricians are expected to deliver in the normal course of practice. Moreover, our analysis demonstrates that there has been remarkable growth of this expectation over time, especially for such topics as injury prevention, the effect of electronic media and technology on children's lives, environmental health hazards, nutrition, and other means of health promotion. Expectations for increased verbal health advice also have grown with increasing awareness of the “new morbidities” that concern the developmental, social, and emotional outcomes of children as well their sexual and reproductive health—elements of care that formerly were considered to be within the purview of the family.15
Our findings are relevant to other evidence from both pediatricians' and parents' perspective that the volume of advice that is delivered during the anticipatory guidance component of well-child care frequently is problematic. Surveys of pediatricians' performance and published commentaries indicate that many are struggling to complete all of the recommended advice in the allotted time for well-child visits.16–19 When parents are studied, they also express dissatisfaction with how well pediatric primary care visits address their expectations for adequate communication.20–22 More advice may not be the answer to this dissatisfaction, because recent research has identified a threshold for the amount of advice that is delivered in anticipatory guidance and can be recalled by parents.23
The growth of preventive services is not limited to pediatrics or related purely to anticipatory guidance. Yarnall et al6 estimated that a family or general practitioner would consume 7.4 hours each working day on prevention alone. In the case of pediatric care, the introduction of 8 new vaccine requirements for children since 1987 and the associated counseling efforts that they entail have not been associated with any decrease in expectations for the other aspects of well-child care.
Helping practitioners manage the increasing volume of advice that is associated with anticipatory guidance clearly is a concern of the AAP, and suggested options include recruiting nonphysician office personnel, the creation of computerized screening instruments to identify areas of particular need and/or interest, and outsourcing some of the advice to community partners or to other forms of public health advocacy efforts.19 In fact, in the 344 AAP policies that we examined for this study, we found 279 instances in the recommendations section of the policy statements in which the AAP recommends that pediatricians involve themselves in public health approaches to the policy issue (data available on request). However, within the policy-making statement process as a whole, it is unclear on what basis prevention advice is assigned to office-based delivery as opposed to public health efforts.
Of primary concern regarding the growth of verbal health advice directives is the systematic lack of reference in the text of the policy statements as to whether evidence exists that they are effective. The evidence basis of anticipatory guidance and well-child care in general is an area of longstanding interest.24–29 This subject was reviewed systematically by Moyer and Butler recently.30
The idea that verbal health advice directives should be presented to practitioners in conjunction with a brief synopsis of the evidence of their efficacy has appeal for the following reasons. First, it would expand the role of evidence-based medicine in the domain of well-child care. As the preeminent national organization representing practitioners of a science, the AAP has a significant role to play in encouraging pediatricians whenever possible to hold up proposed therapeutic interventions to the scrutiny of evidence. Second, in this era of evidence-based medicine, practicing pediatricians find themselves subject to “quality of care” evaluations by insurance entities on the basis of whether the delivery of verbal health advice has been documented despite a lack of evidence of effectiveness for the majority of the recommended verbal health advice. Making this information explicit could align measurements of quality of care with efforts of proven benefit for children. Last, in practice, improved access to the evidence base for the elements of anticipatory guidance offers a potential mechanism for practitioners to use to make rational decisions about what specific information to deliver to specific groups in the face of time constraints during the office visit. Implicit in a decision to make the evidence of anticipatory guidance more readily available to pediatricians is the risk that they might abandon much valued office-based advice. We believe that this is unlikely to occur because practitioners understand that lack of evidence of effectiveness is not evidence of lack of effectiveness and that much of what is sought and welcomed by parents may not be supported by evidence.
This study documents many instances in which health advice is recommended for delivery; however, the details of their implementation are left unanswered, such as (1) what is the target population for this advice? (2) How should the target population be identified? (3) How often should the advice be delivered, and at which age should it first be given? (4) How should it be stated most effectively? (5) Is a handout available? Although several potential strategies have been outlined for choosing verbal health advice to deliver, including an age-based strategy, an epidemiologic strategy (that would target high-risk areas in the practitioner's practice population), and a strategy that is driven by parental preference, the main barrier for practitioners who seek to make an informed choice is a paucity of data that are available to answer these critical questions.
It can be argued that the intrinsic ambiguities regarding verbal health advice that is presented in AAP policies are deliberate. They reflect 2 concerns: (1) that good well-child care has to be individualized and (2) medical legal concerns. In terms of the second concern, some have raised issues regarding the implications of more strictly codifying this advice set because defining strict criteria and expectations for the delivery of office-based advice might expose providers to medicolegal liability for failure to prevent the innumerable adverse health outcomes that are targeted by this advice set.31
We recognize certain limitations of the current study. Numerous judgments had to be made in identifying and describing these directives when this was not made explicit by the policy itself, such as the presumed target age of the advice, the theme of the advice, whether a screening question was necessary, etc. Despite the subjective nature of these judgments, we reached consensus on the final data set, and this consensus should have acted to underestimate the amount of advice directives, our primary finding. Another limitation of our study was that we focused on polices that were effective for 2003, and AAP polices are reviewed and updated continuously. Nevertheless, review of the active polices that were accessed in January 2006 revealed that 53 of 57 of the advice-containing polices that we characterized had been reaffirmed or revised32 and others have been added.
We believe that the findings of this study suggest policy recommendations for the AAP. Given the findings herein and that several AAP committees have created advice that is duplicative, we suggest that there is a need to create a central function within the AAP policy-making process that oversees and manages the recommendations for generation of verbal health advice. To some extent, the recent efforts to modify Bright Futures already may be incorporating this recommendation. Most urgent, there is a need to manage more actively the expectation of the volume of advice that is delivered during well-child care. When advice is recommended, an explicit acknowledgment of whether it has a basis in evidence and a grading of the evidence when it exists will permit pediatricians to make informed choices about the advice. In some instances, it may be that verbal health advice directives that are recommended for inclusion in the well-child visit more appropriately belong in the arena of public health efforts rather that being delivered during individualized patient care.
The content of the well-child visit is receiving increasing scrutiny with respect to its individual components and its ability to improve child health outcomes.8,28–31 Since the issuance of the edition of the third edition of the AAP policy statements that we investigated, the AAP has begun to examine critically the well-child visit to address these issues. We believe that the findings of this review can prove useful to the AAP in this important reevaluation enterprise and in the long run can yield more efficient and effective health care delivery for children and adolescents.
APPENDIX 1: VERBAL HEALTH ADVICE DIRECTIVES
Pediatricians should counsel parents concerning the hazards of having toy firearms in the house.
Pediatricians can help families to identify unsafe parenting practices and behaviors of children that may predispose them to abuse and/or abduction. Children should be taught:
Their full name, address, and phone number (including area code); practices to prevent abuse or abduction should be given equal emphasis with other safety issues.
How to call the 911 emergency number; practices to prevent abuse or abduction should be given equal emphasis with other safety issues.
To avoid contact with strangers, including never getting into a stranger's car, and to beware of enticements of candy, money, etc; practices to prevent abuse or abduction should be given equal emphasis with other safety issues.
Never to tell anyone on the phone that they are home alone, and never to open the door to a stranger; practices to prevent abuse or abduction should be given equal emphasis with other safety issues.
That no one has the right to touch them, and that they have the right to say no; practices to prevent abuse or abduction should be given equal emphasis with other safety issues.
That they should tell their parents if anyone asks them to keep a secret.
Pediatricians can make parents aware of the predictable daily variation in ozone, especially the tendency to peak in the afternoon. This awareness is essential in areas with recognized high ozone levels.
Parents need to be advised that swimming lessons for children <4 years of age will not provide drown proofing and may lead to a false sense of security.
Parents need to be advised that rigid, motorized pool covers are not a substitute for 4-sided fencing, because pool covers are not likely to be used appropriately and consistently.
Pediatricians should alert parents to the dangers that standing water presents to children. Parents need to be advised that they should learn CPR; and they should keep a telephone and equipment approved by the US Coast Guard (eg, life preservers, life jackets, shepherd's crook) at poolside.
Pediatricians should advise families with residential swimming pools to install a fence that separates access to the pool from access to the house.
Pediatricians should counsel parents of children ages 5 to 12 that children need to be taught to swim. In addition to rules for safe swimming in pools, parents and children need to know the various safety requirements for swimming in natural bodies of water, such as lakes, streams, rivers, and oceans.
Pediatricians should counsel parents of children ages 5 to 12 that children need to be taught never to swim alone or without adult supervision.
Pediatricians should counsel parents of children ages 5 to 12 that children should be required to use an approved personal flotation device whenever riding on a boat or fishing, and preferably while playing near a river, lake, or ocean.
Pediatricians should counsel parents of children ages 5 to 12 that children need to understand why jumping or diving into water can result in injury. Parents should know the depth of the water and the location of underwater hazards before permitting children to jump or dive.
Pediatricians should counsel parents of children ages 5 to 12 that parents and children need to recognize the drowning risks in cold seasons. Children should refrain from walking, skating, or riding on weak or thawing ice on any body of water.
Pediatricians should counsel adolescent patients about other risks of drowning. Teenagers also need counsel about the dangers of alcohol and other drug consumption during aquatic recreation activities (eg, swimming, diving, and boating).
Pediatricians should alert parents to the dangers that standing water presents to children. Parents need to be advised that they should never—even for a moment—leave children alone in bathtubs, spas, or wading pools, near irrigation ditches, post holes, or other open standing water. They should remove all water from containers, such as pails and 5-gallon buckets, immediately after use.
Thus, practical, specific advice about condom use and other forms of safer sex should be included in all sexuality education and prevention discussions.
As part of anticipatory guidance and poison prevention measures, parents should be made aware of common camphor-containing products and the potential dangers of these products.
As an adjunct to the pediatrician's anticipatory guidance efforts, it is recommended that: Pediatricians promote parental participation in either the American Heart Association's Pediatric Basic Life Support Course or the American Red Cross's Infant and Child CPR Course.
Pediatricians should encourage parents to assure that all caretakers are Basic Life Support (BLS) certified.
In summary, divorce is so common and such a critical experience for children that pediatricians should ask about family and marital discord periodically during well-child visits.
Physicians caring for infants and preschool children should advise parents about the following issues. The appropriate use of currently approved child safety restraints needs to be discussed. Use of a car seat should begin with the first ride home from the hospital.
Parents need to be reminded of the importance of using their own seat belts.
Smoke detectors in the home should be installed and maintained.
Hot water temperatures should be set between 120°F and 130°F to avoid scald burns.
Window and stairway guards/gates are necessary to prevent falls.
Discourage the use of infant walkers.
Medicines and household products should be kept out of the sight and reach of children.
These items should be purchased and kept in original childproof containers.
Physicians caring for infants and preschool children should advise parents about the following issues.
Parents need to have a 1-ounce bottle of syrup of ipecac in the home for use as advised by the pediatrician.
Because very young infants drown most commonly in bathtubs and buckets while unsupervised, advise parents to empty and properly store buckets immediately after use and to never leave infants or young children in the bathtub without constant adult supervision.
Backyard swimming pools or spas need to be completely fenced to separate them from the house and yard.
Although children younger than 5 years old often take swimming lessons, they should never swim unsupervised. It is unlikely that infants can be made water safe; in fact, the parents of these infants may develop a false sense of security if they believe that their infant can swim a few strokes.
It is important that parents become trained in infant and child cardiopulmonary resuscitation and learn how to access their local emergency care system (eg, 911).
Traffic safety advice to the parents of elementary school age children begins to be more focused on the child's behavior.
The use of seat belts should continue to be emphasized.
Remind children and parents that no one should ride in the bed of a pickup truck.
All-terrain vehicles should not be used by children <16 years of age.
Review safe pedestrian practices.
Approved bicycle helmets should be worn on every bike ride.
The use of protective equipment for in-line skating and skateboarding needs emphasis.
Children 5 years of age and older should be taught to swim and, at the same time, taught appropriate rules for water play.
Children must never be allowed to swim alone.
Coast Guard–approved personal flotation devices (PFDs) should be worn by every child engaged in any boating activity.
Adults who supervise children participating in organized sports programs need to emphasize the importance of safety equipment for the particular sport.
Adults who supervise children participating in organized sports programs need to emphasize the importance of appropriate physical conditioning for that sport.
Because of the dangers that in-home firearms, particularly handguns, pose to young children, parents should be encouraged to keep handguns out of the home.
If parents choose to keep a firearm in the home, the unloaded gun and ammunition must be kept in separate locked cabinets.
Discuss the role of alcohol in teenage motor vehicle accidents.
Discuss alcohol use in water-related activities for teens, especially as it relates to diving injuries.
Appropriate physical conditioning for that sport.
Encourage seat belt use.
Motorcycle helmets and bicycle helmets should be worn on every ride.
The use of protective equipment for in-line skating and skateboarding needs emphasis.
Adolescents participating in organized sports programs need to be reminded of the importance of safety equipment for their particular sport.
If parents choose to keep a firearm in the home, the unloaded gun and ammunition must be kept in separate locked cabinets.
In-home firearms are particularly dangerous during adolescence due to the potential for impulsive, unplanned use by teens resulting in either suicide, homicide, or other serious injuries.
When preemployment physical examinations are performed on children and adolescents for work permits, physicians should inquire about the type of work intended. If the work is in clear violation of the law or involves toxic or hazardous exposures, the physician should advise against such employment.
For newborns whose mother's HIV serostatus was not determined during the recent pregnancy or the postpartum period, the infant's health care provider should educate the mother concerning the potential benefits of HIV testing for her infant and the possible risks and benefits to herself of knowing the child's serostatus and recommend HIV testing for the newborn.
Efforts should be made, through strong media campaigns and during anticipatory guidance, to educate parents about the hazards and lack of benefits of walkers. The particular risk of walkers in households with stairs should be emphasized.
Pediatricians are encouraged to emphasize to parents and teenagers repeatedly the paramount importance of safe driving behavior.
During office visits, pediatricians can address risk factors, especially driving while impaired by alcohol or other drugs and nighttime driving.
Pediatricians are encouraged to counsel parents that adolescents, despite their physical maturity, are still developing their driving skills and need time to master this complex task by practicing while supervised in a low-risk environment.
Pediatricians should advise parents that their parenting responsibilities include the following: Supervising novice drivers in a vehicle.
Parents should be advised that in 32 states, they have the authority to request that the Department of Motor Vehicles revoke the license of their minor child.
The pediatrician should address the tendency of some parents to deny that their teenagers might be unsafe drivers.
Pediatricians should advise parents that their parenting responsibilities include the following: Ensuring the mechanical safety of any car used by a teenager.
Pediatricians should advise parents that their parenting responsibilities include the following: Showing that they expect responsible driving behavior from their teenagers and imposing penalties for irresponsible actions.
Pediatricians should advise parents that their parenting responsibilities include the following: Establishing driving behavior limits on their teenagers, such as limiting the number and age of passengers, restricting nighttime driving for novice drivers, and delaying the onset of unsupervised driving as they see fit.
Pediatricians should advise parents that their parenting responsibilities include the following: Setting a good driving example (eg, no drinking and driving, no speeding, and requiring all occupants to use safety belts).
Parents should monitor music exposure and purchase.
Pediatricians should counsel parents to monitor television viewing … TV exposure to … sex drugs and violence should be regulated by parents.
Pediatricians should counsel parents to become media literate.
Educate at-risk patients about the medical risks of boxing and provide information that supports the Academy's opposition to the sport; and encourage young athletes to participate in sports in which intentional head injury is not the primary objective.
Pediatricians should inform parents about the health hazards of passive smoking and provide guidance on smoking cessation.
It is appropriate for the pediatrician to inquire about anabolic steroid use during routine health maintenance visits because of the general health risks and the general distribution of the population at risk.
Pediatricians should include tobacco, alcohol, and other drug use in their anticipatory guidance discussions, beginning with the prenatal visit.
Children, adolescents, and their families should be informed that even recreational use of alcohol, tobacco, and other drugs by children and adolescents regardless of amount or frequency is illegal and has potential health consequences.
Children and their parents should appreciate that injuries are particularly common in novice skaters, roller hockey players, and those performing tricks.
Full protective gear needs to be used at all times, including a helmet, wrist guards, knee pads, and elbow pads.
The helmet should be certified by the American National Standards Institute (ANSI), the American Society for Testing and Materials (ASTM), the Snell Memorial Foundation, or the Consumer Product Safety Commission.
Skaters performing tricks need special heavy-duty protective gear.
Special attention should be paid to the needs of novice skaters to avoid injuries. They should skate on an indoor or outdoor rink, rather than on a path or street.
Truck-surfing or skitching should be prohibited for all skaters under any circumstance.
The type and fit of the skates should be carefully considered when they are purchased or rented and should be appropriate for the child's size, ability, and purpose.
Skaters should vigilantly watch for road debris and defects, which may precipitate a loss of balance.
Children with large-muscle motor skill or balance problems and those with any uncorrected hearing or vision deficit should skate only in a protected environment. Appropriate areas include a skating rink or outdoor area where the skater is either alone or where no motor vehicle or bicycle traffic occurs and where all other skaters and pedestrians travel in same direction.
They should be trained to react appropriately to these and other rapidly occurring and unpredictable circumstances by learning to stop quickly and fall safely and by avoiding traffic.
Instruction in skating by a teacher certified by the International In-Line Skating Association is recommended.
Special attention should be paid to the needs of novice skaters to avoid injuries. Inexperienced children should not attempt to do tricks.
Pediatricians should provide anticipatory guidance to parents of all infants and toddlers including information on potential risk factors for lead exposure and specific prevention strategies that should be tailored for the family and for the community in which care is provided.
Clinical practice guidelines for the prevention and management of youth violence should include violence-prevention counseling and screening as early as the pediatric prenatal visit and continuing into adulthood.
Pediatricians should encourage adolescents to postpone early coital activity. Abstinence counseling is an important role for all pediatricians.
Pediatricians should help ensure that all adolescents who are sexually active have knowledge of and access to contraception.
Advice to parents should include the following: encouraging careful selection of programs to view.
Advice to parents should include the following: co-viewing and discussing content with children and adolescents.
Advice to parents should include the following: teaching critical viewing skills.
Advice to parents should include the following: limiting and focusing time spent with media.
Advice to parents should include the following: being good media role models by selectively using media and limiting their own media choices.
Advice to parents should include the following: creating an electronic media-free environment in children's rooms.
Advice to parents should include the following: avoiding use of media as an electronic infant-sitter.
Advice to parents should include the following: emphasizing alternative activities.
Pediatricians should urge parents to avoid television viewing for children under the age of 2 years.
Although certain television programs may be promoted to this age group, research on early brain development shows that infants and toddlers have a critical need for direct interactions with parents and other significant caregivers (eg, child care providers) for healthy brain growth and the development of appropriate social, emotional, and cognitive skills. Therefore, exposing such young children to television programs should be discouraged.
Pediatricians should also alert and educate parents when positive media opportunities arise, either educational or informative.
Pediatricians should incorporate sun protection advice into their health supervision practices.
Pediatricians should actively support the goal of achieving calcium intakes in children and adolescents comparable to those in recently recommended guidelines. The prevention of future osteoporosis, as well as the possibility of a decreased risk of childhood and adolescent fractures, should be discussed as potential benefits to achieving these goals.
Adolescents may need to be reminded that low-fat dairy products, including skim milk and low-fat yogurts, are good sources of calcium that are not high in fat.
The seriousness of the behavioral consequences of marijuana use is sufficient to cause great concern and should prompt the pediatrician to counsel young people against any use of the drug. A discussion of drug use, including the use of marijuana, should be a routine part of primary health care clinical preventive services for every child and adolescent.
Pediatricians should encourage and promote sexual abstinence to their adolescent patients at every opportunity.
Pediatricians need to counsel their sexually active patients about the consequences of sexual activity, including pregnancy and STDs.
Pediatricians should ask questions about depression, suicidal thoughts, and other risk factors associated with suicide in routine history-taking throughout adolescence.
During routine evaluations, pediatricians need to ask whether firearms are kept in the home and discuss with parents the risks of firearms as specifically related to adolescent suicide. Specifically for adolescents at risk of suicide, parents should be advised to remove guns and ammunition from the house.
Pediatricians and other health care professionals are encouraged to support schools in their efforts to promote physical activity and fitness by assessing activity patterns as part of routine health maintenance and providing advice about how physical activity levels can be increased.
During anticipatory guidance, families should be asked, either by direct questioning or intake survey, about the kinds of recreational activities in which they engage.
Individual patient and parent education about the hazards of all ATVs should continue.
As part of office anticipatory guidance, parents should be counseled about fire and burn prevention including adequate supervision of children.
As part of office anticipatory guidance, parents should be counseled about fire and burn prevention and use of smoke alarms.
As part of office anticipatory guidance, parents should be counseled about fire and burn prevention and safe behavior in fires.
As part of office anticipatory guidance, parents should be counseled about fire and burn prevention and initial treatment of burns (stop, drop, and roll/cool and call).
The child athlete, family, and coach should be educated by the pediatrician about the risks of heat injury and strategies for prevention.
No passengers should be transported in the cargo area of a pickup truck or a nonpassenger section of any vehicle.
Trips should be planned in advance so that an appropriate seat position and restraint device are used for each passenger.
Compatibility should be checked between the vehicle seat (front and back seats) and the car safety seat before purchasing a vehicle or a child safety seat.
Infants in rear-facing car safety seats should not be placed in front passenger seats when an airbag is present and activated. If no appropriate rear seating position is available, only place the infant in the front passenger seat if an airbag on/off switch is installed and turned off.
Car safety seats should fit completely on the rear seat of the pickup truck and can be properly secured facing the rear for infants younger than 1 year or weighing <20 pounds, and facing forward for older children. The addition of a tether may improve the security of a car safety seat.
All forward-facing car safety seats should be installed using a top tether in addition to the vehicle belt.
Teenagers should agree that they will not ride or transport others in the cargo area of a pickup truck.
Students entering college, especially those who will be living in dormitories, and their parents should be informed during routine prematriculation medical visits about the increased risk of meningococcal disease and potential benefits of immunization as well as limitations of the vaccine, primarily the lack of protection against serotype B meningococcal disease (Evidence Grade II-2).
Availability of HIV testing should be discussed with all adolescents and should be encouraged with consent for those who are sexually active or substance users.
Pediatricians should encourage discussions between patients and their families on the effect of media on sexual attitudes, beliefs, and behaviors.
Pediatricians should help parents and adolescents identify inappropriate use of sexual images in the media, including portrayals of unsafe sex.
Parents should be encouraged to be primarily and intimately involved in the health education and health supervision of their children.
Prevention guidance should include helping adolescents understand the responsibilities of becoming sexually active.
All adolescents should be counseled about the correct and consistent use of latex condoms to reduce risk of infection.
Pediatricians and other health care professionals should educate patients and their parents about the effects of television, including violent and aggressive behavior.
Pediatricians and other health care professionals should help parents recognize the extent of their children's media consumption.
Pediatricians should recommend that parents limit children's total media time (with entertainment media) to no more than 1 to 2 hours of quality programming per day.
Pediatricians should recommend that parents remove television sets from children's bedrooms.
Pediatricians should recommend that parents discourage television viewing for children younger than 2 years, and encourage more interactive activities that will promote proper brain development, such as talking, playing, singing, and reading together.
Pediatricians should recommend that parents monitor the shows children and adolescents are viewing. Most programs should be informational, educational, and nonviolent.
Pediatricians should recommend that parents view television programs along with children, and discuss the content.
Pediatricians should recommend that parents use controversial programming as a stepping-off point to initiate discussions about family values, violence, sex and sexuality, and drugs.
Pediatricians should recommend that parents use the videocassette recorder wisely to show or record high-quality, educational programming for children.
Pediatricians should recommend that parents support efforts to establish comprehensive media-education programs in schools.
Pediatricians should recommend that parents encourage alternative entertainment for children, including reading, athletics, hobbies, and creative play.
Pediatricians are urged to inform parents about the dangers of guns in and outside the home.
Inquiry about tobacco use and smoke exposure is critical at all pediatric office visits.
The dangers of environmental tobacco smoke and the risk of role modeling tobacco use should be discussed with parents and caretakers who smoke and reinforced with culturally and ethnically appropriate written information and cessation referrals.
Discussion and anticipatory guidance about smoking and tobacco use should ideally begin by 5 years old, with particular emphasis on resisting the influence of advertising and rehearsal of peer-refusal skills.
Pediatricians should advise the parents of children who live in multiple-story dwellings to supervise small children at all times, especially if windows are open.
Pediatricians should advise the parents of children who live in multiple-story dwellings to install locks on windows to prevent sliding windows not intended for egress from opening >4 in.
Pediatricians should advise the parents of children who live in multiple-story dwellings to open double-hung windows from the top only.
Pediatricians should advise the parents of children who live in multiple-story dwellings that fixed guards, commonly used to prevent intrusion, should not be used, because they may prevent egress in the case of fire.
Pediatricians should advise the parents of children who live in multiple-story dwellings to install operable window guards on second- and higher-story windows (unless prohibited by local fire regulations). Window screens will not prevent falls from windows.
Pediatricians should advise the parents of children who live in multiple-story dwellings to discourage or prohibit children from playing on fire escapes, roofs, and balconies, especially those that are not adequately fenced with vertical bars that have openings of 4 in or less.
Pediatricians should advise the parents of children who live in multiple-story dwellings to avoid placing furniture, on which children may climb, near windows or on balconies.
Pediatricians should advise the parents of children who live in multiple-story dwellings to encourage the use of ground-level safe play areas, such as public parks and playgrounds.
Pediatricians should routinely discuss the use of fruit juice and fruit drinks and should educate parents about differences between the two.
Pediatricians are urged to actively support and encourage the correct and consistent use of reliable contraception and condoms by adolescents who are sexually active or contemplating sexual activity. The responsibility of males as well as females in preventing unwanted pregnancies and STDs should be emphasized.
Pediatricians should provide preventive counseling to their adolescent patients regarding avoidance of high-risk situations that could lead to sexual assault.
It is appropriate for the pediatrician to initiate a discussion of the known advantages of breastfeeding.
Risks involved with use of anabolic steroids and other bodybuilding supplements are appropriate topics for discussion with any adolescent interested in getting bigger and stronger.
Pediatricians should strongly advise against the use of alcohol and illicit drugs as well as the nontherapeutic use of approved psychoactive drugs by children and adolescents.
Pediatricians should discuss the hazards of alcohol and other drug use with their patients as a routine part of risk behavior assessment, with special attention when there are risk factors for problem drinking, such as a family history of alcoholism.
Pediatricians should use prenatal and preventive child health care visits as an ideal opportunity to explore the family history and attitudes regarding alcohol use and discuss with parents the effects of positive and negative role modeling on their children.
Pediatricians should discuss the issue of adolescent parties with alcohol and discourage parents from allowing underage drinking at home or other locations.
Pediatricians should educate parents and children about the dangers of fireworks. Children and their families should be counseled to attend public fireworks displays rather than purchase fireworks for home use.
Pregnancy and lactation are ideal occasions for physicians to urge cessation of smoking.
Therapy is begun without direct advice from health care providers; therefore, instruction regarding appropriate pain and fever therapy should be incorporated into well-child visits. Pediatricians should reassure parents that although some parental anxiety over fever is understandable, the primary reason to treat fever is for patient comfort and that complete normalization of the temperature is not necessary and may not be possible.
Pediatricians should emphasize that any helmet involved in a crash or otherwise damaged should be discarded and replaced.
Pediatricians should encourage parents and other child care providers to require children to wear a bicycle helmet when they begin riding tricycles or other wheeled vehicles or toys.
Pediatricians should encourage parents to wear a helmet when bicycling to model safe behavior for their children.
Pediatricians should inform parents and patients of the importance of wearing a bicycle helmet and the dangers of riding without one.
Pediatricians should remember, and remind their patients' families, that if we do not buy or use entertainment media that are harmful to children, these media will no longer be produced.
Pediatricians should convey the following information to parents: all children should travel properly restrained on aircraft.
Pediatricians should convey the following information to parents: a child is best protected when properly restrained in a CSS (child safety seat) appropriate for the age, weight, and height of the child, meeting standards for aircraft until the child weighs >40 lb and can use the aircraft seat belt.
Pediatricians should convey the following information to parents: Families should explore options for ensuring that each child has an aircraft seat.
Children younger than 5 years should not use skateboards; instead, parents and pediatricians should encourage them to undertake activities that are more developmentally appropriate.
Pediatricians should advise parents to strongly recommend that all skateboarders wear a helmet and other protective gear (including wrist guards, elbow pads, and knee pads) to prevent or reduce the severity of injuries resulting from falls.
For optimal protection, pediatricians should counsel parents of most children (those who weigh >12 lb at 4 months of age) to encourage use of a convertible car safety seat that will accommodate them rear facing at higher weights.
Parents should be advised that the rear vehicle seat is the safest place for children of any age to ride. Any front-seat, front-facing passengers should ride properly restrained and positioned as far back as possible from the front air bag on the passenger side.
Parents should be instructed to read the vehicle owner's manual and child restraint device instructions carefully. When the car safety seat is installed in the car, it should be tested for a safe, snug fit in the vehicle to avoid potentially life-threatening incompatibility problems between the design of the car safety seat, vehicle seat, and seat belt system.
Parents should consider placing children and car safety seats away from all air bags, choosing a vehicle without side air bags in the rear seat, or deactivating side air bags in rear seats if children are transported in adjacent positions.
Pediatricians should counsel parents on the use of nonpowered scooters according to the following CPSC recommendations: Children younger than 8 years should not ride scooters without close adult supervision.
Pediatricians should counsel parents on the use of nonpowered scooters according to the following CPSC recommendations: Children should not ride scooters in streets, in traffic, or at night.
Pediatricians should counsel parents on the use of nonpowered scooters according to the following CPSC recommendations: Children should wear helmets, knee pads, and elbow pads while using scooters.
Pediatricians should discuss family functioning in anticipatory guidance and offer advice pertinent to divorce as appropriate.
Pediatricians can recommend safe, inexpensive toys appropriate for the age and the developmental level of their patients.
Pediatricians can encourage thoughtful, creative parental selection of toys and discourage the belief that a good toy must be trendy or expensive.
Pediatricians can discourage the purchase of toys for children as bribes and remind parents that their positive attention and interaction are the most effective rewards to encourage good behavior.
Pediatricians can caution parents about being influenced by the marketing of toys that purport to contribute in a specific manner to the development, especially intellectual or motor development, of infants and young children.
Pediatricians should emphasize that toys can never substitute for appropriate interactions between the child and parent or caregiver.
APPENDIX 2: SCREENING QUESTIONS
The following screening questions are required to identify target populations or behaviors for verbal health advice:
Do you roller-skate or in-line skate?
Do you play sports?
Are you a college student living in (or planning to live in) dorms?
Do you drive or have access to a car?
Do you live in a multiple story dwelling?
Do you have a swimming pool or spa at your home?
Do you or your child ride a bicycle?
Does your child skateboard or ride a scooter?
Do you have firearms at home?
Do you ride motorcycles?
Have you ever considered boxing as a sport you may want to participate in?
How do you feel about your body image/eating practices?
Do encounter violence at home or elsewhere?
Do you smoke?
Do you qualify for WIC?
Do you drink alcohol?
Are you sexually active?
Have you considered using anabolic steroids?
What kind of recreational activities do you engage yourself in?
Have you ever considered riding in an ATV?
Regarding calcium intake:
What do you drink, either white or chocolate milk with your meals?
Do you drink milk with meals, snacks, or cereal or any other time of the day?
Do you eat cheese, yogurt, or other dairy products such as cottage cheese?
Do you drink calcium-fortified juices or eat and calcium-fortified foods?
Do you eat any of the following: broccoli, tofu, oranges, or legumes (dried peas and beans)?
Do you take any vitamin or mineral supplements?
Are the child's parents married/separated/divorced?
Do you require child care services for your child?
Do you (plan to) work?
Do you use illicit drugs/substances?
Does your child have “toy” firearms at home?
Do you live on a farm or visit friends/family who live on a farm?
Does your child ride in airplanes?
- Accepted May 23, 2006.
- Address correspondence to Peter F. Belamarich, MD, Montefiore Medical Center, 111 E 210th St, Department of Pediatrics, Rosenthal 4, Bronx, NY 10467. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
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