Well Child Care in Infancy: Promoting Readiness for Life

2013 William B. Pittard III. All rights reserved.

No part of this book may be reproduced, stored in a retrieval system, or transmitted by any means without the written permission of the author.

Published by AuthorHouse 12/14/2013

ISBN: 978-1-4817-5241-1 (sc)

ISBN: 978-1-4817-5240-4 (hc)

ISBN: 978-1-4817-5239-8 (e)

Library of Congress Control Number: 2013919237

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Contents

Dedication

Foreword

Preface

Chapter 1   Well Child Care: Components, Benefits, History, and Future Need

Chapter 2   Continuity of Care

Chapter 3   Well Child Care Screening

Chapter 4   Well Child Care Parental Anticipatory Guidance in the Preschool Years: Clinical Effectiveness

Chapter 5   Routine Immunizations Birth

to Six years: Clinical Effectiveness

Chapter 6   Well Child Care in a Changing US Delivery System

Chapter 7   Well Child Care: A Prudent Investment for the Future

References

About the Authors

About the Book

Dedication

This book is dedicated to my wife, Judith Dowty Pittard, who has been supportive and understanding throughout more than forty-two years of marriage; to James N and Sarah B Laditka, who served on my PhD dissertation committee and provided pre- and postdoctoral public health guidance and understanding necessary for writing this book; and to John H. Kennell and Marshal H. Klaus, who individually served as surrogate fathers to me throughout my neonatal-perinatal training and early academic career.

Foreword

Over 150 years ago, author Charles Dickens made note that close to half of the coffins made in England in the mid-1800s were sized for children. Today, relatively few children in the United States die from disease or accidents. Pediatricians are the true champions of disease and accident prevention. They have worked persistently to research and improve nutrition, disease prevention, medications, vaccines, accident prevention, and parental guidance and education; they emphasize the importance of a nurturing environment. Without question these preventative measures are why children today are healthy and why, thankfully, there is little need for small coffins in our country.

The authors of this book have compiled a comprehensive synopsis of best practices in preventive pediatric medicine. This volume sets forth the recognized standards of care for children. Although children in the United States generally have access to health care meeting these standards, it is an unfortunate fact that many children living elsewhere do not. As a profession, we should take on the endeavor of providing standards-based care to all children across the world, reducing the need for small coffins everywhere.

Children’s hospitals and their specialized staff may dramatically save a child’s life on occasion, but keep in mind that primary care physicians, practicing preventive medicine on a daily basis, have the greatest impact on children’s health. It is these physicians who are responsible for saving thousands of lives every year.

Charles P. Darby, Jr., MD

Professor Emeritus of Pediatrics

Medical University of South Carolina

Charleston, South Carolina

September 18, 2013

Preface

Well child care represents preventive health services for children provided by physicians and other health care providers. These services include screening for normal growth and visual, hearing, and social/emotional development; immunizations; and parental child health education and reassurance, often referred to as parental anticipatory guidance. Although preventive care for children serves as a health care paradigm today and is broadly accepted by providers and parents as something of paramount importance for normal child development, utilization has been limited for more affluent children by high co-pay insurance requirements and for low-income children, where care is government funded, by lack of awareness of its availability and the benefit to children.

Empiric documentation of clinical effectiveness for well child care, other than for immunizations, has been extremely slow in development. As far back as 1973, the American Academy of Pediatrics (AAP) recognized this information gap and requested that investigators address this issue. Nevertheless, effectiveness for the non-immunization well child care components has been reported only in the last six years. The difficulty created by this lack of information was compounded by an Institute of Medicine (IOM) report in 1990 indicating that correcting the under-use of needed health care such as well child services, while increasing the quality of care, tends to be associated with increased cost. Therefore, although public and private insurance administrators want improved quality of care, with clinical effectiveness unproven and cost likely to be increased, their incentive to implement methods to increase well child care utilization has been limited.

This book on well child care has been written for individual and population health care workers interested in the well-being of children. Thus the primary stakeholders include parents, health care providers, and health insurance/Medicaid policy makers and administrators. The purpose of this book is to increase awareness by all stakeholders, but particularly by health insurance administrators of the preventive care benefits for preschool children to facilitate the implementation of methods to increase well child care utilization and improve health status for children.

Although well child care immunization data are included in this book, the focus is on the more recent findings confirming clinical effectiveness for the non-immunization or screening, developmental assessment, and parental anticipatory guidance components.

Each chapter author is an accomplished child care specialist with several years of clinical experience. The book serves to close the information gap created by the long delay in confirming clinical effectiveness for well child care. By summarizing the more recent findings, this book provides justification for the potential added costs to well child care provision by introducing methods to increase preventive care utilization. Each chapter is written to be read in a stand-alone fashion, with some recognized background information redundancy between chapters. The book first provides a global overview of well child care benefits and history; it explores the specific elements of well child care (continuity/quality, screening, parental anticipatory guidance, and immunizations). Then it explores the influence of government policies and private sector primary care provider (PCP) health care delivery, offering ideas for improved care. Last, chapter seven summarizes and discusses how available outcome data indicate preschool well child care is a prudent investment for the future of children.

Chapter 1

Well Child Care: Components, Benefits, History, and Future Need

William B. Pittard III, MD, PhD, MPH

Introduction

Well child care is designed to promote optimal physical, social, and cognitive development for children birth through twenty years. A broadly accepted manifestation of success for this preventive care in the preschool years is increased time without illness and readiness for first grade learning. Increased wellness time should promote greater opportunity for playing and interacting with other children and adults, facilitating socialization, school readiness, and more long-term life success (1, 2). Specifically, well child visits in the preschool years include an assessment of physical growth, anticipatory guidance for parents or caregivers, immunizations, and screening procedures for illness and abnormal vision, hearing, and cognitive development (3-5).

This chapter presents an overview of well child care, describing its components and anticipated benefits for children. The history of governmental recognition of need for well child care and its funding for low-income children includes the Children’s Bureau; the Sheppard-Towner Act; the American Academy of Pediatrics (AAP); Medicaid and the confrontations and controversies surrounding its early and periodic screening, diagnosis, and treatment (EPSDT) benefit for children; and the establishment of the State Children’s Health Insurance Program (SCHIP). The chapter concludes with a look at future needs for maternal and child preventive care.

Components and Benefits

Well child visits offer clinicians an opportunity to identify and address problems that might impede optimal growth and development. The AAP recommends frequent well child/EPSDT visits in the preschool years, including six visits in year one, three visits in year two, two in year three, and one visit annually thereafter (6, 7). An initial visit during the prenatal period provides child health education and anticipatory guidance for soon-to-be parents, and post-delivery visits offer age appropriate immunizations, developmental and sensory evaluations, assessment of nutrition status and oral health, and age-specific parenting education. Parents of children with the recommended number of visits in infancy should receive more information than parents of children with fewer visits about cognitive stimulation for their children and about avoiding risks to cognitive health such as lead exposure, accidents, and under-nutrition (8-10). Recommended topics for parental anticipatory guidance include advice regarding physical activity, appropriate use of health care services, parent-child reading, and avoidance of household toxins (7). Developmental screening includes assessment of height and weight, vision, hearing, language skills, and behavior; the screening is designed to facilitate the early implementation of corrective measures for any abnormality detected with improved health outcomes (11).

Despite the benefits of well child care, it is not always utilized. Due to cost and lack of information confirming well child care effectiveness, privately insured children have been reported to under-use well child care particularly in the preschool years (6, 12, 13). In contrast, despite government funding, the Medicaid EPSDT/well child benefit is more likely to be underutilized by low-income children than well child care by privately insured children (1, 7, 14).

Although providing well child care involves cost, not using well child visits often results in still greater medical cost. Low-income children also more frequently use emergency department and in-hospital, non-primary care provider services for non-urgent ambulatory care sensitive condition (ACSC) diagnoses than higher income children (1, 14, 15). ACSC diagnoses include asthma; seizure; cellulitis; ear, nose, and throat infections; bacterial pneumonia; kidney and urinary tract infections; and gastrointestinal infections and are illnesses routinely treated in a primary care provider (PCP) office setting (16). Increased use of ACSC ED visits has been directly associated with both inadequate EPSDT/well child care utilization by Medicaid-insured children and by lack of a regular medical home by low-income children (17, 18). These characteristics may reflect lack of awareness by low-income parents of the availability of EPSDT and its beneficial effects on the physical, social, and cognitive development of children (7).

History

The Children’s Bureau

The history of well child care in America began with publicly recognizing the need to identify the causes for and methods to prevent maternal and child mortality. With this issue in mind, President Theodore Roosevelt called a conference in Washington DC in 1909, subsequently referred to as the first White House Conference on Children (19). A significant recommendation from this conference was for the establishment of a federal Children’s Bureau. After much debate in Congress, President William Howard Taft approved and signed the Children’s Bureau into law on April 9, 1912 (20).

The mission for this bureau was to investigate and report on all matters pertaining to the welfare of children and child life among all classes of our people (19, 20). Bureau staff initiated studies to identify the social and economic factors contributing to maternal and child morbidity and mortality in both rural and urban settings. The bureau also initiated the routine registration of all births nationwide and the publication of guidelines regarding appropriate prenatal and infant care; these guidelines were presented at professional meetings and were made available to the public.

The Sheppard-Towner Act and the Academy of Pediatrics

Early Children’s Bureau findings led to yet another pivotal Congressional action strongly endorsed by the newly established contingency of women voters. This action was known as the first Maternity and Infancy Act (or the Sheppard-Towner Act) of 1921 (19, 21). The act provided maternal and child health services such as maternal outreach education and support through pregnancy and postpartum, as well as instruction regarding parenting and child health needs. These activities were funded through federal grants-in-aid and matching state funds. With these monies, so-called Sheppard-Towner clinics were established in all but three states (Connecticut, Illinois, and Massachusetts), where opposition was strongest to government-sponsored support for the health of mothers and children. During the Congressional debates preceding approval of the Sheppard-Towner Act, many larger cities launched maternal and child health (MCH) activities on their own. Although with this legislation the concept of public responsibility for child health was established, just as today there was much uneasiness and opposition to the concept of government-sponsored health care. Actual outcome data assessing the effectiveness of these maternal and child clinics were unavailable, but enactment was carried on the face validity of their likely benefit (22). Those opposed to federal grants-in-aid for maternal and child health ultimately won, and in 1929 the Sheppard-Towner Act was not continued.

The physician contingency supporting the Sheppard-Towner Act (20) drove the formation of the American Academy of Pediatrics (AAP). In a section meeting of the 1922 American Medical Association (AMA) in St. Louis on diseases of children, the section recognized that the act promoted the welfare of mothers and children, and it elected to approve the Sheppard-Towner Act. However, at the same AMA meeting, the House of Delegates viewed this act as an infringement on the entrepreneurial boundaries of practicing physicians, declared it to be little more than a socialistic scheme, and reprimanded the section’s action. The discord created by this controversy ultimately resulted in the establishment of the AAP in June 1930, which was primarily composed of physicians in favor of the Sheppard-Towner Act. At its founding, the AAP’s stated mission was education, public health, and issues affecting child health.

The Children’s Bureau, with increased power from the Sheppard-Towner Act, was able to establish well child clinics throughout rural America and to firmly establish the societal mindset that there is need for government support for the maintenance of good health (preventive care) from birth through the preschool years. Indeed, the benefit of appropriate dietary and sleep habits for child health was established by the bureau as a health care paradigm, as was the need for well child care to facilitate normal development.

Dr. Borden Veeder, author of Preventive Pediatrics (1926) and professor of pediatrics at Washington University, predicted that Sheppard-Towner clinics would be replaced by preventive care physicians (pediatricians) (23, 24). In other words, he predicted that well child care would become the primary component of some future practices. Between 1928 and 1935 it was reported that approximately 40 percent of pediatric office visits were for well child or preventive care