Well baby care goes beyond the guidelines

General pediatric practice has its own rhythms. Some of these rhythms are seasonal, defined in large measure by infectious diseases but also including certain chronic disease reviews, and some are defined by the school calendar, including back-to-school physical examinations, school sports physical examinations, vacation-based camp physical examinations and mid-semester school performance visits.

Throughout the year, however, there are also the well baby visits, often felt to be the core of what we as general pediatricians hold dear as the essence of our profession.

How an individual pediatrician practices within these patterns is defined by our own conceptualization of what it is to be a general pediatrician and the structural limitations of our practices.

Our approach to comprehensive care with its demands of well baby, toddler, school-age, and adolescent/young adult care, acute care medicine, and hospital-based care distinguishes us as primary care pediatricians.

Although infinitely complex and frequently changing, general pediatric practice remains enormously rewarding. Frequently forgotten in discussions of primary care pediatrics is the special quality of the well baby visit.

It is easy to get caught up with the specifics of the age-based well exam schedule and guidelines for what are the key elements of each visit. However, the magic of pediatric practice is not the specifics. When I close the exam room door and enter the world of well baby visits, I enter a privileged domain: a visit enjoined from both the patient and, most importantly at these early ages, by the infant’s parents, and by me as their pediatrician in order to affect a more perfect future for their child. It is a relationship I enter that has few boundaries and lasts until the patient’s adulthood. During the course of this time, my role changes from a distinctly family focus to a specific patient focus; nevertheless, throughout this timeline the context of the relationship remains longitudinal, comprehensive and driven by the critical elements of what it means to be a pediatrician.

Useful without being intrusive

The well baby visit is a very individualized experience, thus my overall frustration with any defined protocol of care. To me, guidelines are an intrusion into my relationship with my patients and imply that one can substitute me for any generic “health care provider,” and as long as the correct form is followed, the outcome will be the same.

Clearly, the role of guidelines as suggestions of best practice and testimony to the multiple individual and public health imperatives of care is unquestionably useful. Their intrusion, however, into the privileged world of the well baby visit needs careful consideration and balance — attributes often difficult to achieve, therefore giving rise to a certain degree of ongoing tension in the practice of pediatrics.

Of course, medical practice is in itself changing at a rapid rate. Our professional organizational response to this change and to both the imperatives of “best practice” and that of health care reform is to build a system-of-care model based on guidelines including those for well, preventive care. In such a construct, individual health care and public health care lines are easily blurred, adding a further level of tension to practice even before playing the easy game of affixing blame to any of the myriad forces at work in the health care arena.

Although some adult-based models of chronic illness have supportive outcome data, no evidence for the effectiveness of guideline-based pediatric well care exist. Despite the lack of data, community and state models are being put into place that link office-based care to hospital and regional networked care with information sharing all motivated by a presumption

of quality care. There is also the additional conviction that such comprehensive care will be provided at less cost. Quality and cost discussions without data seem to me to be a strange brew.

Perhaps it is because of the underlying flaw in our health care system, the lack of universal coverage, that we are facing this intrusion, even if well-intentioned, into primary care practice. We are being asked to create a hybrid fix, of private and public health design, which has always been at play in pediatrics (eg, immunizations), but never with so universal aspirations.

Regardless of the motivation, it appears that every potential source of health care advocacy has weighed in on suggestions for pediatric periodic health care assessments — policy statements of the AAP, United States Preventive Services Task Force (USPSTF), and the Maternal and Child Health Bureau are widely distributed; however, there are also no lack of state and local health care initiatives nor individual health insurance company “quality” programs and managed-health care company “expectations.” Very few are evidence-based or outcome tested, and although well-intentioned, are nevertheless troublesome to the average practitioner who is attempting to provide the best possible care to their patients.

Streamlining advice

Since Racine and colleagues (Pediatrics. 2006; 118: e964) noted 162 different verbal health advice directives on which pediatricians should counsel patients throughout childhood, the AAP has made an attempt with the new edition of Bright Futures (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition, 2008, AAP) to more rigorously evaluate such suggestions.

The new Bright Futures is a useful and comprehensive volume. It expands on previous editions in a continually evolving philosophy of care that emphasizes health promotion at the family, clinical practice, community, health system and policy levels.

It specifically addresses themes of health promotion such as:

• family support;
• child development;
• mental health;
• healthy weight;
• healthy nutrition;
• physical activity;
• oral health;
• healthy sexual development and sexuality;
• safety and injury prevention; and
• community relationships and resources.

At the clinical practice level it provides a detailed guide to health supervision visits and attempts to explain the context of well child care. It is a careful product, representing its many and varied stakeholders and is likely to be the backbone of system reform projects and electronic medical record programs.

What we truly need our well baby visits to be is not complicated.

We must provide longitudinal, family-centered care that rests on excellence in pediatric knowledge and skill, and that is culturally sensitive, developmentally based, and is comprehensive in addressing appropriately identified anticipatory guidance.

It is unrealistic to expect adherence to any one set of specific guidelines; which, even if followed with fidelity, would not be truly reflective of best practice as measured by prospective outcomes, because there is no such data. What are we to do? I suggest covering the fundamentals with due diligence.

The key elements of the well baby visits have not changed and continue to be the basis for our care — history, observation, examination, surveillance and screening and guidance. Most importantly, we need to provide well child care in the context of the practice of pediatric medicine with the expertise, warmth, caring, and often humor of our profession. We owe this to our patients and to ourselves.

William T. Gerson, MD, is a Clinical Professor of Pediatrics at the University of Vermont College of Medicine and an Infectious Diseases in Children Editorial Board member.