One of several timetables for recommended health supervision visits is illustrated in Figure 9–1. (Note: A PDF printable format of this figure is available from the American Academy of Pediatrics [AAP].) The federal Maternal and Child Health Bureau has developed comprehensive health supervision guidelines through their Bright Futures program. In areas where evidence-based information is lacking, expert opinion has been used as the basis for these plans. Recently revised Bright Futures Guidelines emphasizes working collaboratively with families, recognizing the need for attention toward children with special health care needs, gaining cultural competence, and addressing complementary and alternative care, as well as integrating mental health care into the primary care setting. Practitioners should remember that guidelines are not meant to be rigid; services should be individualized according to the child’s needs.
2019 Recommendations for Pediatric Preventive Health care. (Reproduced with permission from Hagan JF, Shaw JS, Duncan PM (eds): Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017. This document has been updated to reflect the 2019 recommendations for Preventive Pediatric Healthcare: Pediatrics 2019:143.)
During health supervision visits, the practitioner should review child development and acute and chronic problems, conduct a complete physical examination, order appropriate screening tests, and anticipate future developments. New historical information should be elicited through an interval history. Development should be assessed by parental report and clinician observation. In addition, systematic use of formal parent-directed screening tools, such as the Ages and Stages Questionnaire (ASQ) or the Parents’ Evaluation of Developmental Status (PEDS), is recommended. Growth parameters should be carefully recorded, and weight, length, or height, head circumference (up to age 3), and body mass index (BMI) (for > 2 years) should be plotted and evaluated using established growth charts (see Chapter 3). Vision and hearing should be assessed subjectively at each visit, with objective assessments at intervals beginning after the child is old enough to cooperate with the screening test, usually at 3–4 years of age.
Because fewer than 4% of asymptomatic children have physical findings on routine health maintenance visits, a major portion of the health supervision visit is devoted to anticipatory guidance. This portion of the visit enables the health care provider to address behavioral, developmental, injury prevention, nutritional issues, and school problems; and other age-appropriate issues that will arise before the next well-child visit.
PM (eds): Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
DEVELOPMENTAL & BEHAVIORAL ASSESSMENT
Addressing developmental and behavioral problems is one of the central features of pediatric primary care. The term developmental delay refers to the circumstance in which a child has not demonstrated a developmental skill (such as walking independently) by an age at which the vast majority of normally developing children have accomplished this task. Developmental delays are, in fact, quite common: approximately 18% of children younger than 18 years either have developmental delays or have conditions that place them at risk of developmental delays.
Pediatric practitioners are in a unique position to assess the development of their patients. This developmental assessment should ideally take the form of developmental surveillance, in which a skilled individual monitors development in multiple domains (gross motor, fine motor, language, and personal or social) over time as part of providing routine care. Developmental surveillance includes several key elements: listening to parent concerns, obtaining a developmental history, making careful observations during office visits, periodically screening all infants and children for delays using validated screening tools, recognizing conditions and circumstances that place children at increased risk of delays, and referring children who fail screening tests for further evaluation and intervention.
The prompt recognition of children with developmental delays is important for several reasons. Children with delays can be referred for a wide range of developmental therapies, such as those provided by physical, speech or language, and/or educational therapists. Children with delays, regardless of the cause, make better developmental progress if they receive appropriate developmental therapies than if they do not. Many infants and toddlers younger than 3 years with delays are eligible to receive a range of therapies and other services, often provided in the home, at no cost to families. Children aged 3 years and older with delays are eligible for developmental services through the local school system.
Several parent- and physician-administered developmental screening tools are available and should be utilized in order to more efficiently incorporate this process in the busy well-child care visit. The PEDS, ASQ, and the Child Development Inventories (CDI) are screening tests that rely on parent report. Other screening tools, such as the Denver II screening test, the Early Language Milestone Scale (see Chapter 3, Figure 3–1), and the Bayley Infant Neurodevelopmental Screener, involve the direct observation of a child’s skills by a care provider. All developmental screening tests have their strengths and weaknesses. The Denver II is familiar to many pediatric providers and is widely used. However, whereas the Denver II has relatively high sensitivity for detecting possible developmental delays, the specificity is poorer, and this may lead to the over referral of normal children for further developmental testing.
In addition to general developmental screening, autism-specific screens (such as the Modified Checklist for Autism in Toddlers [MCHAT]) should be administered at the 18- and 24-month health supervision visits.
Regardless of the approach taken to developmental screening, there are a number of important considerations: (1) The range of normal childhood development is broad, and therefore a child with a single missing skill in a single developmental area is less likely to have a significant developmental problem than a child showing multiple delays in several developmental areas (eg, gross motor and language delays); (2) continuity of care is important, because development is best assessed over time; (3) it is beneficial to routinely use formal screening tests to assess development; (4) if developmental delays are detected in primary care, these patients need referral and close follow-up to insure evaluation completion for further testing and likely will benefit from receiving developmentally focused therapies and strategies; and (5) parents appreciate when attention is paid to their child’s development and generally react positively to referrals for appropriate developmental therapies.
Several developmental charts with age-based expectations for normal development are presented in Chapter 3 (see Tables 3–1, 3–2, 3–3), as well as a discussion of the recommended medical and neurodevelopmental evaluation of a child with a suspected developmental disorder.
In addition to developmental issues, pediatric providers are an important source of information and counseling for parents regarding a broad range of behavioral issues. The nature of the behavioral problems, of course, varies with the child’s age. Some common issues raised by parents, discussed in detail in Chapter 3, include colic, feeding disorders, sleep problems, temper tantrums, breath-holding spells, and noncompliance. Behavioral issues in adolescents are discussed in Chapter 4.
American Academy of Pediatrics Council on Children With Disabilities: Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics 2006;118:1808
. Note: This policy was reaffirmed by the American Academy of Pediatrics in 2014 (Pediatrics 2014;134:e1520).
AS: Identifying and addressing mental health risks and problems in primary care pediatric settings: a model to promote developmental and cultural competence. Am J Orthopsychiatry 2013 Jan;83(1):7388. doi: 10.1111/ajop.12005
et al: Improving developmental screening documentation and referral completion. Pediatrics 2014 Oct;134(4):e1181–e1188. doi: 10.1542/peds.2012-1151 [Epub 2014 Sep 1]
Monitoring appropriate growth is pivotal in ambulatory pediatric practice.
Height, weight, and head circumference are carefully measured at each well-child examination and plotted on age- and sex-specific growth charts. The Centers for Disease Control and Prevention (CDC) recently recommended use of the World Health Organization (WHO) growth standards to monitor growth for infants and children ages 0–2 in the United States, in lieu of its own growth charts. The WHO standards are based on a sample of 8500 babies (from Brazil, Ghana, India, Norway, Oman, and the United States) who were predominantly breast-fed for at least 4 months, still nursing at 1 year and living in nonsmoking households. The methods used to create the CDC growth charts and the WHO growth charts are similar for children aged 2 years and older.
To ensure accurate weight measurements for longitudinal comparisons, infants should be undressed completely and young children should be wearing underpants only. Recumbent length is plotted on the chart until approximately 2 years of age. When the child is old enough to be measured upright, height should be plotted on the charts for ages 2–20 years. Routine measurements of head circumference may cease if circumferential head growth has been steady for the first 2 years of life. However, if a central nervous system (CNS) problem exists or develops, or if the child has growth deficiency, this measurement continues to be useful. Tracking the growth velocity for each of these parameters allows early recognition of deviations from normal.
It is useful to note that in the first year of life, it is common for height and weight measurements to cross over a percentile line. After approximately 18 months, most healthy children tend to follow the curve within one growth channel.
Determination of whether or not a child’s weight falls within a healthy range also relies on growth charts. For children younger than 2 years, the weight-for-length chart is used. For children 2–18 years, a BMI chart is used, which is a measure that correlates well with adiposity- and obesity-related comorbidities. The BMI is calculated as the weight (in kilograms) divided by the squared height (in meters). The BMI is useful for determining obesity (BMI ≥ 95th percentile for age) and overweight (BMI between 85th and 95th percentiles), as well as underweight status (BMI ≤ 5th percentile for age). It must be emphasized that “eyeballing” overweight or underweight is frequently inaccurate and should not substitute for careful evaluation of the data on growth charts.
et al: Use of World Health Organization and CDC growth charts for children aged 0–59 months in the United States. MMWR Recomm Rep 2010;59(RR-9):115
US Preventive Services Task Force: Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics 2010;125(2):361–367.
Blood pressure screening at well-child visits starts at age 3 years. There are some conditions that warrant blood pressure monitoring at an earlier age:
History of prematurity, very low birth weight, or other neonatal complication requiring intensive care
Congenital heart disease (repaired or nonrepaired)
Recurrent urinary tract infections, hematuria, or proteinuria
Known renal disease or urologic malformations
Family history of congenital renal disease
Solid organ transplant
Malignancy or bone marrow transplant
Treatment with drugs known to raise blood pressure (steroids, oral contraceptives)
Other conditions associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)
Evidence of elevated intracranial pressure
Accurate determination of blood pressure requires proper equipment (stethoscope, manometer and inflation cuff, or an automated system) and a cooperative, seated subject in a quiet room. Although automated blood pressure instruments are widely available and easy to use, blood pressure readings from these devices are typically 5 mm Hg higher for diastolic and 10 mm Hg higher for systolic blood pressure compared with auscultatory techniques. Therefore, the diagnosis of hypertension should not be made on the basis of automated readings alone. Additionally, blood pressure varies by the height and weight of the individual. Consequently, hypertension is diagnosed as a systolic or diastolic blood pressure greater than the 95th percentile based on the age and height percentile of the patient using charts from the AAP Clinical Practice Guidelines (see references).
The width of the inflatable portion of the cuff should be 40%–50% of the circumference of the limb. Overweight children need a larger cuff size to avoid a falsely elevated blood pressure reading. Cuffs that are too narrow will overestimate and those that are too wide will underestimate the true blood pressure. Hypertension should not be diagnosed based on readings at one visit, but rather three separate occasions of documented hypertension are required. Repeated measurements at different visits over time should be tracked using flowcharts in an electronic medical record or equivalent in a paper chart. Children with repeated blood pressure readings from the 90th to the 95th percentile may be classified as having elevated blood pressure. Those with greater than between the 95th and 99th percentile plus 12 mm of Hg are classified as Stage 1 hypertension, and those greater than the 99th percentile plus 12 mm of Hg are termed Stage 2 hypertension. National High Blood Pressure Education Program recommends that all children with blood pressure of greater than or equal to 95% should have a complete blood count (CBC), serum nitrogen, creatinine, electrolytes, lipid panel, glucose, urinalysis, and a renal ultrasound in those with abnormal urinalysis or renal function. Nonpharmacologic interventions include diet, exercise, and weight management. Indications for pharmacologic therapy may include the following:
Stage 2 hypertension without a clearly modifiable factor (eg, obesity)
Chronic kidney disease
Diabetes (types 1 and 2)
Persistent hypertension despite nonpharmacologic measures
Based on a recent systematic review for US Preventive Services Task Force, it is unclear whether screening for hypertension in children and teens reduces adverse outcomes in adults.
National High Blood Pressure Education Program Working Group in High Blood Pressure in Children and Adolescents: The fourth report on diagnosis, evaluation and treatment of high blood pressure in children and adolescents. Pediatrics 2004 Aug;114(2 Suppl 4th Report):555–576
et al: Evaluation of pediatric patients with mild to moderate hypertension: yield of diagnostic testing. Pediatrics 2008;122:e988–e993
VISION & HEARING SCREENING
Examination of the eyes and an assessment of vision should be performed at every health supervision visit. Eye problems are relatively common in children: refractive errors (including myopia, hyperopia, and astigmatism), amblyopia (loss of visual acuity from cortical suppression of the vision of the eye), and/or strabismus (misalignment of the eyes) occur in 5%–10% of preschoolers. Assessment of vision should include visual inspection of the eyes and eyelids, alignment of eyes, and visual acuity.
Starting at birth, the movement and alignment of the eyes should be assessed and the pupils and red reflexes examined. The red reflex, performed on each pupil individually and then on both eyes simultaneously, is used to detect eye opacities (eg, cataracts or corneal clouding) and retinal abnormalities (eg, retinal detachment or retinoblastoma). By 3 months of age, an infant should be able to track or visually follow a moving object, with both eyes.
Starting after age 3, formal testing of visual acuity should be done if possible. This can be performed in the office with a variety of tests, including the tumbling E chart or picture tests such as Allen cards. In these tests, each eye is tested separately, with the nontested eye completely covered. Credit is given for any line on which the child gets more than 50% correct. Children who are unable to cooperate should be retested, ideally within 6 months, and those who cannot cooperate with repeated attempts should be referred to an ophthalmologist. Because visual acuity improves with age, results of the test are interpreted using the cutoff values in Table 9–2. However, any two-line discrepancy between the two eyes, even within the passing range (eg, 20/20 in one eye, 20/30 in the other in a child aged ≥ 6 years) should be referred to an ophthalmologist.
Table 9–2.Age-appropriate visual acuity.a ||Download (.pdf) Table 9–2. Age-appropriate visual acuity.a
|Age (y) ||Minimal Acceptable Acuity |
|3–5 ||20/40 |
|≥ 6 ||20/30 |
Throughout childhood, clinicians should screen for undetected strabismus (ocular misalignment). The corneal light reflex test can be used starting at 3 months and the cover test can be used beginning at 6 months to assess for strabismus. The corneal light reflex test, the cover test, and visual acuity test are described further in Chapter 16.
Recommendations for vision screening and indications for referral are listed in Table 9–3. Referral to an ophthalmologist is also recommended for preterm infants for evaluation of retinopathy of prematurity (ROP), as well as children with a family history of amblyopia, strabismus, retinoblastoma, or retinal degeneration. Children with Down syndrome should be referred to an ophthalmologist at 6 months of age given their increased risk for refractive error, strabismus, and cataracts.
Table 9–3.Recommended vision screening in the primary care office. ||Download (.pdf) Table 9–3. Recommended vision screening in the primary care office.
|Test ||Age for Screening ||Indication(s) for Referral |
|Inspection of eyes and lids ||All || |
|Red reflex ||Birth until child can read eye chart ||Abnormal red reflex, asymmetry of the red reflexes, or partially obscured red reflex |
|Assessment of fixation and following ||Starting at 2 mo ||Poor fixation/following by 3 mo |
|Corneal light reflex for assessing strabismus ||3 mo to 5 y ||Asymmetry of light reflex (in relation to iris and pupil) |
|Cover testing for assessing strabismus ||6 mo to 5 y ||Presence of refixation movement |
|Fundoscopic examination ||Starting at 3 y || |
|Preliterate eye chart testing ||Starting at 3–4 y ||Unable to pass 20/40 for ages 3–5 or 20/30 for 6 and older. Also refer if there is a difference of two or more lines between the eyes. |
Hearing loss, if undetected, can lead to substantial impairments in speech, language, and cognitive development. Because significant bilateral hearing loss is one of the more common major anomalies found at birth, and early detection and intervention of hearing loss leads to better outcomes for children, universal hearing screening is provided to newborns in most parts of the United States. Hearing in infants is assessed using either evoked otoacoustic emissions or auditory brainstem-evoked responses. Because universal newborn hearing screening is sometimes associated with false-positive test results, confirmatory audiology testing is required for abnormal tests.
Informal behavioral testing of hearing, such as observing an infant’s response to a shaken rattle, may be unreliable. In fact, parental concerns about hearing are of greater predictive value than the results of informal tests, and such concerns should be taken seriously. Prior to age 4, infants should be referred to an audiologist for testing if a concern arises. Conventional screening audiometry, in which a child raises her hand when a sound is heard, can be performed starting at age 4. Each ear should be tested at 500, 1000, 2000, and 4000 Hz and referred at threshold levels of greater than 20 dB at any of these frequencies. Any evidence of hearing loss should be substantiated by repeated testing, and if still abnormal, a referral for a formal hearing evaluation should be made.
The AAP periodicity schedule recommends routine hearing screening at 4, 5, 6, 8, and 10 years of age and several times during adolescence. Children with any risk factors for hearing loss should be closely followed and receive more frequent screening. A number of inherited or acquired conditions increase the risk of hearing loss. Sometimes hearing loss can be mistaken for inattention, and so hearing screening should be part of workup for attention problems. Additional details regarding hearing assessment are provided in Chapter 18.
American Academy of Pediatrics et al: Red reflex examination in neonates, infants, and children. Pediatrics 2008;122:1401
C; American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section of Otolaryngology: Hearing assessment in infants and children: recommendations beyond neonatal screening. Pediatrics 2009;124(4):1252–1263
DR: Hearing impairment in children. Pediatr Clin North Am 2008;55:1175
MF: Pediatric vision screening. Pediatr Rev 2018 May;225–234
Newborn screening involves population-wide testing for metabolic and genetic diseases. It has become an essential component in a public health program that screens over 4 million newborns every year. Blood samples are collected by heel stick from newborns before hospital discharge, and results are usually available within 1 week. Some states routinely repeat blood testing between 7 and 14 days of life, while others recommend it if the child is discharged in less than 24 hours. The state-to-state variation seen in newborn screen panels has begun to diminish as a result of national recommendations. In 2010, the Secretary Advisory Committee on Heritable Disorders in Newborns and Children recommended screening for 32 core conditions with another 26 detectable through differential diagnosis. Most states have adopted these guidelines.
Infants with a positive screening result should receive close follow-up, with additional confirmatory studies performed at a center with experience in doing these tests. Screening tests are usually accurate, but the sensitivity and specificity of a particular screening test must be carefully considered. If symptoms of a disease are present despite a negative result on a screening test, the infant should be tested further. Newborn screening has benefited thousands of infants and their families, preventing and diminishing the morbidity of many diseases. At the same time, the emotional cost of false-positive screening is a continuing challenge. Parents report high levels of stress during the evaluation process. Recommendations for useful resources, given the variability of information on the Internet, and prompt clinical services can help reduce this distress.
et al; Advisory Committee on Heritable Disorders in Newborns and Children: Committee report: method for evaluating conditions nominated for population-based screening of newborns and children. Genet Med 2010 Mar;12(3):153–159
The developing infant and child are at risk of lead poisoning or toxicity because of their propensity to place objects in the mouth and their efficient absorption of this metal. Children with lead toxicity are typically asymptomatic. High blood levels (> 70 mcg/dL) can cause severe health problems such as seizures and coma. Numerous neuropsychological deficits have been associated with increased lead levels. Blood lead levels less than 10 mcg/dL have been correlated with lower intelligence quotients. The primary source of lead exposure in this country remains lead-based paint, even though most of its uses have been banned since 1977. Lead levels have declined nationally from a mean of 16 mcg/dL in 1976 to less than 2 mcg/dL in 2008. However, considerable variation in lead levels exists in different regions of the United States, and a majority of children at risk of lead toxicity are not currently screened. Despite the wide variation in the prevalence of lead toxicity, the CDC recommends universal lead screening for children at ages 1 and 2 and targeted screening for older children living in communities with a high percentage of old housing (> 27% of houses built before 1950) or a high percentage of children with elevated blood lead levels (> 12% of children with levels > 10 mcg/dL). Children enrolled in Medicaid are required to be screened at 12 and 24 months.
Communities with inadequate data regarding local blood lead levels should also undergo universal screening. Caregivers of children between 6 months and 6 years of age may be interviewed by questionnaire about environmental risk factors for lead exposure (Table 9–4), although the data to support the use of this screening are inconclusive. If risk factors are present, a blood lead level should be obtained. A venous blood sample is preferred over a capillary specimen. An elevated capillary (fingerstick) blood sample should always be confirmed by a venous sample. There is no safe level of lead in a child’s blood, but the CDC reference level of 5 mcg/dL should be used to identify children at risk in order to initiate public health actions. The recommended actions can be viewed on the CDC website (see references).
Table 9–4.Elements of a lead-risk questionnaire. ||Download (.pdf) Table 9–4. Elements of a lead-risk questionnaire.
Does your child live in or regularly visit a house built before 1950? This could include a day care center, preschool, the home of a baby sitter or relative.
Does your child live in or regularly visit a house built before 1978 with recent, ongoing, or planned renovation or remodeling?
Does your child have a sister or brother, housemate, or playmate being followed for an elevated lead level?
Questions that may be considered by region or locality
Does your child live with an adult whose job (eg, at a brass/copper foundry, firing range, automotive or boat repair shop, or furniture refinishing shop) or hobby (eg, electronics, fishing, stained-glass making, pottery making) involves exposure to lead?
Does your child live near a work or industrial site (eg, smelter, battery recycling plant) that involves the use of lead?
Does your child use pottery or ingest medications that are suspected of having a high lead content?
Does your child have exposure to old, nonbrand-type toys or burning lead-painted wood?
Does your child play on an athletic field with artificial turf?
The cognitive development of children with confirmed high blood levels should be evaluated and attempts made to identify the environmental source. Iron deficiency should be treated if present. Chelation of lead is indicated for levels of 45 mcg/dL and higher and is urgently required for levels above 70 mcg/dL. All families should receive education to decrease the risk of lead exposure. With any elevated lead level (> 5 mcg/dL), rescreening should be performed at recommended intervals.
American Academy of Pediatrics Committee on Environmental Health: Lead exposure in children: prevention, detection, and management. Pediatrics 2005;116(4):1036–1046
Iron deficiency is the most common nutritional deficiency in the United States. Severe iron deficiency causes anemia, behavioral problems, and cognitive effects, but recent evidence suggests that even iron deficiency without anemia may cause behavioral and cognitive difficulties. Some effects, such as the development of abnormal sleep cycles, may persist even if iron deficiency is corrected in infancy.
Risk factors for iron deficiency include preterm or low-birth-weight births, multiple pregnancy, iron deficiency in the mother, use of nonfortified formula or cow’s milk before age 12 months, and an infant diet that is low in iron-containing foods. Infants and children with chronic illness, restricted diet, or extensive blood loss (such as gastrointestinal bleeding or injury) are at risk for iron deficiency.
Primary prevention of iron deficiency should be achieved through dietary means, including feeding ground up meats and iron-containing cereals by age 6 months, avoiding low-iron formula during infancy, and limiting cow’s milk to 24 oz per day in children aged 1–5 years.
Universal screening for anemia should occur at approximately 12 months of age by obtaining often by obtaining a hemoglobin or hematocrit. Premature and low-birth-weight infants may need testing before 6 months of age.
A full CBC to look at mean corpuscular volume (MCV) can aid in the evaluation. Serum ferritin is a useful test to evaluate iron-deficiency anemia, as it can also pick up iron deficiency in the absence of anemia, and provides more specificity in detecting iron deficiency. Serum ferritin is recommended by the WHO for iron screening. Because ferritin is an acute-phase reactant and can be falsely reassuring in the presence of inflammation, infection, or malignancy, some experts recommend obtaining a concurrent C-reactive protein (CRP) for accurate interpretation of the ferritin level. Elevated lead levels can cause iron-deficiency anemia and should be explored as a cause for at-risk infants and children.
Management of iron deficiency with or without anemia includes treatment doses of 3–6 mg/kg body weight of elemental iron.
et al; American Academy of Pediatrics; Committee on Nutrition: Diagnosis and prevention and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics 2010;126:1040
et al: Screening for iron deficiency in early childhood using serum ferritin in the primary care setting. Pediatrics 2018 Dec;142(6)
Hypercholesterolemia & Hyperlipidemia
Cardiovascular disease is the leading cause of death in the United States, and research has documented that the atherosclerotic process begins in childhood. Genetic factors, diet, and physical activity all play a role in the disease process. Nonfasting lipid screening is recommended universally for children between the ages of 9 and 11. Fasting lipid screening is recommended between the ages of 2 and 8, and ages 12 and 16 if risk factors are present. Diet and weight management strategies are the primary interventions. However, for severe dyslipidemia (LDL ≥ 190 mg/dL), pharmacologic therapy should be considered. However, consideration of pharmacotherapy should be made for severe dyslipidemia (LDL ≥ 190 mg/dL), or at greater than 160 mg/dL if there is a family history of heart disease, and in all patients at greater than 130 mg/dL depending on their level and amount of risk factors.
FR; Committee on Nutrition: Lipid screening and cardiovascular health in childhood. Pediatrics 2008 Jul;122(1):198–208
et al: Usefulness of non-fasting lipid parameters in children. J Pediatr Endocrinol Metab 2017;30(1):77–83.
According to the CDC, 9272 cases of tuberculosis (TB) were reported in the United States in 2016. Risk of TB should be assessed at well-child visits, and screening should be based on high-risk status. High risk is defined as contact with a person with known or suspected TB; having symptoms or radiographic findings suggesting TB; birth, residence, or travel to a region with high TB prevalence (Asia, Middle East, Africa, Latin America); contact with a person with AIDS or human immunodeficiency virus (HIV); or contact with a prisoner, migrant farm worker, illicit drug user, or a person who is or has been recently homeless. TB testing can be performed by a skin test or a blood test. The Mantoux test (five tuberculin units of purified protein derivative) is the only recommended skin test. The interferon-gamma release assays (IGRAs) are blood tests that can be useful for patients who have been immunized with bacille Calmette-Guerin (BCG) or for patients who may have difficulty returning for a second appointment to look for skin reaction.
Targeted screening for latent TB for high-risk individuals is the recommended approach based on available evidence. The following screening questions have been validated to determine high-risk status:
Was your child born outside the United States? If yes, this question would be followed by: Where was your child born? If the child was born in Africa, Asia, Latin America, or Eastern Europe, a TB testing should be performed.
Has your child traveled outside the United States? If yes, this question would be followed by: Where did the child travel, with whom did the child stay, and how long did the child travel? If the child stayed with friends or family members in Africa, Asia, Latin America, or Eastern Europe for more than 1 week cumulatively, TB testing should be performed.
Has your child been exposed to anyone with TB disease? If yes, this question should be followed by questions to determine if the person had TB disease or latent TB infection (LTBI), when the exposure occurred, and what the nature of the contact was. If confirmed that the child has been exposed to someone with suspected or known TB disease, TB testing should be performed. If it is determined that a child had contact with a person with TB disease, notify the local health department per local reporting guidelines.
Does your child have close contact with a person who has a positive TB test? If yes, go to question 3.
American Academy of Pediatrics: Tuberculosis. In: Pickering LK (ed): 2015 Red Book: Report of the Committee on Infectious Diseases. 31st ed. American Academy of Pediatrics; 2018.
Pediatric Tuberculosis Collaborative Group: Targeted tuberculin skin testing and treatment of latent tuberculosis infection in children and adolescents. Pediatrics 2004 Oct;114(Suppl 4):1175–1201
Screening of Adolescent Patients
Adolescents may present with chief complaints that are not the true concern for the visit. Repeating the question “Is there anything else you would like to discuss?” should be considered. Since suicide is a leading cause of morbidity and mortality in this age group, screening with the Pediatric Symptom Checklist for Youth is recommended (https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf).
Testing adolescents for blood cholesterol, TB, and HIV should be offered based on high-risk criteria outlined in this chapter and in Chapter 41. Females should have a screening hematocrit once after the onset of menses. During routine visits, adolescents should be questioned sensitively about risk factors (eg, multiple partners; early onset of sexual activity, including child sexual abuse) and symptoms (eg, genital discharge, infectious lesions, pelvic pain) of sexually transmitted infections (STIs). An annual dipstick urinalysis for leukocytes is recommended for sexually active adolescents. Because STIs are often not symptomatic, urine polymerase chain reaction (PCR) for gonorrhea and chlamydia and screening tests for trichomoniasis should be considered. Current guidelines recommend that the first Papanicolaou (Pap) test should be performed at age 21 years, regardless of onset of sexual activity. A complete pelvic examination should be performed when evaluating lower abdominal pain in an adolescent.
Please see Chapter 4 for additional details on adolescent preventive services.
Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention: Tuberculosis Surveillance Reports. http://www.cdc.gov/nchhstp/default.htm
. Accessed June 29, 2019.
An essential part of the health supervision visit is anticipatory guidance. During this counseling, the clinician directs the parent’s or the older child’s attention to issues that may arise in the future. Guidance must be appropriate to age, focus on concerns expressed by the parent and patient, and address issues in depth rather than run through a number of issues superficially. Both oral and printed materials are used. When selecting written materials, providers should be sensitive to issues of literacy and primary language spoken by the family members. Areas of concern include diet, injury prevention, developmental and behavioral issues, and health promotion.
Deleterious effects of secondhand smoke (SHS) on children’s health are well documented and the AAP has highlighted the importance of tobacco screening and counseling at each pediatric visit. One-third of children live in a home with an adult smoker. The Ask, Advise, and Refer methodology has been shown to be a feasible approach to smoking cessation. Ask families if there is a smoker at home, advise the family about the benefit of cessation for the child, and refer to a formal cessation program if the family member is ready to quit.
For children and adolescents aged 1–19 years, unintentional injuries are the number one cause of death. In every age category, males are at higher risk than females for unintentional injury.
Injury prevention counseling is an important component of each health supervision visit and can be reinforced during all visits. Counseling should focus on problems that are frequent and age appropriate. Passive strategies of prevention should be emphasized, because these are more effective than active strategies; for example, placing chemicals out of reach in high, locked cupboards to prevent poisoning will be more effective than instructing parents to watch their children closely.
Informational handouts about home safety, such as The Injury Prevention Program (TIPP; available from the AAP), can be provided in the waiting room. Advice can then be tailored to the specific needs of each family, with reinforcement from age-specific TIPP handouts.
A. Motor Vehicle Injuries
The primary cause of death of children in the United States is motor vehicle injuries. Although the rate of death from this cause is improving, still in 2015, about 35% of children aged 12 years or younger who were killed in motor vehicle accidents were unrestrained.
The type and positioning of safety seats can be confusing. While car seat and booster seat laws differ by state, a recent AAP policy statement describes the best practice recommendations. All infants and toddlers should ride in a rear-facing car safety seat until 2 years of age or until they reach the weight and height limits for convertible car safety seats (usually 35–40 pounds). Infants may ride in infant-only seats (which often have a carrying handle and snap into a base that is secured in the car) until they reach the height and weight limit for that seat, and then transition to a convertible car seat. Once a child reaches 2 years of age (or younger than 2 if outgrown the weight and height limit of a convertible car seat), he or she can be in a forward-facing car safety seat with a harness. The safest scenario is for a child to remain in a car safety seat with a harness as long as possible. Once a child reaches the weight or height limits of a forward-facing seat, he or she may be transitioned to a belt-positioning booster until the vehicle’s lap-and-shoulder belt fits properly (child can sit with his back against the vehicle seat, bend his knees at the edge of the seat, have the belt positioned in the center of the shoulder and across the chest, and have the lap belt touching the thighs). These criteria are generally met once a child reaches height of 4 ft 9 in and is between the ages of 8 and 12 years. All children younger than 13 years should be restrained in the rear seats of the vehicle.
Unfortunately, restraint use shows a decreasing trend with advancing age: children from 1 to 8 years of age use restraints over 90% of the time, but those 8–12 years of age use restraints less than 85% of the time. African-American and Hispanic children use child safety seats less often than white children.
A final motor vehicle risk for health involves the use of portable electronic devices. Using a cell phone while driving is associated with a threefold increase in motor vehicle accidents. Texting while driving poses an even greater danger. All should avoid these risks and adults should model safe practices.
Each year, an average of nearly 400 children die from bicycle crashes, and over 450,000 are treated for bicycle-riding injuries. Over 150,000 children are treated annually in emergency departments for head injuries sustained while riding a bicycle. Many observational studies have shown a decreased risk of head injury with the use of bicycle helmets. Community-based interventions, especially those that provide free helmets, have been shown to increase observed bike helmet wearing. Counseling by physicians in various settings has also been shown to increase bike helmet use. While there is no federal law mandating bicycle helmets, some states have passed legislation requiring bicycle helmets.
C. Skiing and Snowboarding Injuries
Recent studies have suggested that the burden of skiing injuries is high among children, and that children have the highest rate of injury of any age group: approximately 3 injuries per 1000 skier days. Traumatic brain injuries are the leading cause of death for pediatric age skiers. Case-control studies have shown a decrease in head injuries associated with helmet use.
D. Firearm Injuries and Violence Prevention
The United States has a higher rate of firearm-related death than any other industrialized country. For children younger than 15, the death rate from firearm-related injuries is nearly 12 times greater than that of 25 other industrialized nations. Some gun deaths may be accidental, but most are the result of homicide or suicide. A gun in the home doubles the likelihood of a lethal suicide attempt. Although handguns are often kept in homes for protection, a gun is more likely to kill a family member or a friend than an intruder. Adolescents with a history of depression or violence are at higher risk with a gun in the home. The most effective way to prevent firearm injuries is to remove guns from the home. Families who keep firearms at home should lock them in a cabinet or drawer and store ammunition in a separate locked location.
E. Drowning and Near Drowning
Drowning is the leading cause of injury-related death in children ages 1–4 years and the third leading cause of injury-related death in children ages 5–19 years. An estimated 8700 children younger than 20 years old were taken to a hospital emergency department for a drowning event in 2017. Children younger than 1 year are most likely to drown in the bathtub. Buckets filled with water also present a risk of drowning to the older infant or toddler. For children aged 1–4 years, drowning or near drowning occurs most often in swimming pools; and for school-aged children and teens, drowning occurs most often in large bodies of water (eg, swimming pools or open water). Parents should be cautioned that inflatable swimming devices are not a substitution for approved live vests or close supervision and can give a false sense of security. All children should be taught to swim, and recreational swimming should always be supervised. Home pools must be fenced securely, and parents should know how to perform cardiopulmonary resuscitation. A phone should be available near the swimming area. Because drowning is a leading cause of death by injury in children, the AAP has produced a Drowning Prevention “toolkit” for pediatric providers and families (see references).
F. Fire and Burn Injuries
Fires and burns are the leading cause of injury-related deaths in the home. Categories of burn injury include smoke inhalation; flame contact; scalding; and electrical, chemical, and ultraviolet burns. Scalding is the most common type of burn in children. Most scalds involve foods and beverages, but nearly one-fourth of scalds are with tap water, and for that reason it is recommended that hot water heaters be set to a maximum of 120°F. Most fire-related deaths result from smoke inhalation. Smoke detectors can prevent 85% of the injuries and deaths caused by fires in the home. Families should discuss a fire plan with children and practice emergency evacuation from the home.
Sunburn is a common thermal injury and often is not recognized because symptoms of excessive sun exposure usually do not begin until after the skin has been damaged. Repeated sunburn and excessive sun exposure are associated with skin cancers. Prevention of sunburn is best achieved by sun avoidance, particularly during the midday hours of 10 AM to 4 PM. A sunscreen with a minimum sun protection factor (SPF) of 30 that protects against both UVA and UVB rays should be used on sunny and cloudy days to help protect against sunburn. Hats, sunglasses, and long-sleeved swim shirts are also important aspects of safe sun exposure. The safety of sunscreen is not established for infants younger than 6 months; thus, sun avoidance, appropriate clothing, and hats are recommended for this age group. In extreme circumstances in which shade is not available, a minimal amount of sunscreen can be applied to small areas, including the face and back of the hands.
Choking is a leading cause of injury and death in young children. Choking hazards include food and small objects. Children younger than 3 are particularly at risk because they do not have fully coordinated chewing and swallowing, and they are more apt to put small objects in their mouths. Foods that are commonly associated with choking include hot dogs, hard candy, nuts, popcorn, raw vegetables, and chunks of meat, fruit, or cheese. Common nonfood items that pose a risk for choking include coins, latex balloons, button batteries, marbles, small toys, and small toy parts. While being mindful of choking hazards is important, accidents can still occur. Again, parents and caregivers should be trained in CPR and choking first aid.
American Academy of Pediatrics, Committee on Injury and Poison Prevention: Bicycle helmets. Pediatrics 2001;108:1030
(reaffirmed Pediatrics 2012;129).
American Academy of Pediatrics, Committee on Injury and Poison Prevention: Firearm-related injuries affecting the pediatric population. Pediatrics 2012;130:5
American Academy of Pediatrics, Committee on Injury and Poison Prevention: Reducing the number of deaths and injuries from residential fires. Pediatrics 2000;105:1355
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention: Prevention of choking among children. Pediatrics 2010;125:601
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention: Child passenger safety. Pediatrics 2011;127:788
et al: The ONE step initiative: quality improvement in a pediatric clinic for secondhand smoke reduction. Pediatrics 2013 Aug;132(2):e502–e511
SA; American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention: Prevention of drowning. Pediatrics 2019:143e20190850.
HG; American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention: Office-based counseling for unintentional injury prevention. Pediatrics 2007 Jan;119(1):202–206
Screening for nutritional problems and guidance for age-appropriate dietary choices should be part of every health supervision visit. Overnutrition, undernutrition, and eating disorders can be detected by a careful analysis of dietary and activity patterns interpreted in the context of a child’s growth pattern.
Human milk feeding is species specific and is the preferred method for infant feeding for the first year of life. Pediatricians should assist mother-infant dyads with latch and help manage breast-feeding difficulties in the early newborn period. For exclusively and partially breast-fed infants, vitamin D supplementation should be given. Iron-fortified formula should be used in situations when breast-feeding is contraindicated such as HIV, active untreated TB, galactosemia, and certain medications. As noted in Chapter 11 (Normal Childhood Nutrition & Its Disorders), the positive benefits of continued breast-feeding and breast milk by mothers who have used illicit drugs should be balanced in individual cases against the risk of transmission of such drugs to the infant via the milk. After the first year, breast-feeding may continue or whole cow’s milk can be given because of continued rapid growth and high-energy needs. After 2 years of life, milk with 2% fat or lower may be offered. Baby foods and appropriately prepared table foods should be introduced between 4 and 6 months of age and self-feeding with finger foods encouraged by 7–8 months of age.
When obtaining a dietary history, it is helpful to assess the following: who purchases and prepares food, who feeds the child, whether meals and snacks occur at consistent times and in a consistent setting, whether children are allowed to snack or “graze” between meals, the types and portion sizes of food and drinks provided, the frequency of eating meals in restaurants or eating take-out food, and whether the child eats while watching television.
For children 2 years of age and older, a prudent diet consists of diverse food sources, encourages high-fiber foods (eg, fruits, vegetables, grain products), and limits sodium and fat intake. Since obesity is becoming increasingly prevalent, foods to be avoided or limited include processed foods, sugar-sweetened drinks or soda, and candy. Parents should be gently reminded that they are modeling for a lifetime of eating behaviors in their children, both in terms of the types of foods they provide and the structure of meals (eg, the importance of the family eating together). For additional information on nutritional guidelines, undernutrition, and obesity, see Chapter 11; for eating disorders, see Chapter 6; for adolescent obesity, see Chapter 4.
As of 2009, the Women, Infants, and Children (WIC) food packages reflect the recommendations above and include provision of more fruits and vegetables, whole grains, yogurt and soy products, low-fat milk, and limitations on juice. Breast-feeding mothers receive more food as part of their package, less formula supplementation, and breast-fed infants receive baby food meats as a first food (because of more iron and zinc).
American Academy of Pediatrics, Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 2007;120:s164
American Academy of Pediatrics Section on Breastfeeding Policy Statement: Breastfeeding and the use of human milk. Pediatrics 2012;129:e841
COUNSELING ABOUT TELEVISION & OTHER MEDIA
Screen time and social media have a significant influence on children and adolescents. The average child in the United States watches approximately 3–5 hours of television per day, and this does not include time spent watching movies, playing video games, playing on computers or tablets, accessing the Internet, or using cell phones. Taking into account these other forms of media, current estimates are around 7.5 hours of media exposure per day for average 8- to 18-year-olds. Figure 9–2 shows a breakdown of media exposure by age group.
Breakdown of media exposure by age showing a significant increase in media use between ages 11 and 14. (Reproduced with permission from Rideout VJ, Foehr UG, Roberts DF; Kaiser Family Foundation Study: Generation M2: Media in the Lives of 8- to 18-Year-Olds; January 2010.)
Having a television set in the bedroom increases daily media exposure and is also associated with sleep disturbances. According to the Kaiser Family Foundation, over 70% of 8- to 19-year-olds have a television in their bedrooms.
Watching television may have both positive and negative effects. Programs directed toward early childhood may increase knowledge and imaginativeness, and may also teach empathy and acceptance of diversity. However, excessive television viewing of programs with inappropriate content has been shown to have negative effects with respect to violence, sexuality, substance abuse, nutrition, social skills, and body self-image. More recent data suggest that excessive viewing in childhood may have a long-lasting negative effect on cognitive development and academic achievement. Clinicians should assess media exposure in their patients and offer parents concrete advice. Screen time for all media, including television, movies, DVDs, video games, computer activities, computers, tablets, the Internet, and cell phones, should be limited. The AAP recommends that 18- to 24-month-old children should not have any screen time (unless it is video chatting), and that children 2–5 years be limited to 1 hour total screen time each day. The television should not be on during mealtimes, night, or naptimes. Parents should themselves watch sensibly, monitor the program content to which their children are exposed, watch programs and discuss interesting content with children, remove television sets from all bedrooms, and encourage alternative activities. Parents should be advised that research consistently shows that exposure to media violence correlates with childhood aggression.
Social networking sites are becoming increasingly popular, and clinicians need to encourage parents to monitor participation and be aware of potential problems with cyberbullying, “Facebook depression,” sexting, and exposure to inappropriate content on sites such as YouTube. Free family media use plans are available through the AAP (www.HealthyChildren.org/MediaUsePlan).
C: Children and adolescents and digital media. Pediatrics 2016;138(5):e20162593. doi: 10.1542/peds.2016-2593.27940795.
D: Increased screen time: implications for early childhood development and behavior. Pediatr Clin North Am 2016;63(5):827–839.
A child’s immunization status should be assessed at every visit and every opportunity should be taken to vaccinate. Even though parents may keep an immunization record, it is critical that providers also keep an accurate record of a child’s immunizations. This information should be written in a prominent location in the paper or electronic chart or kept in an immunization registry.
Despite high overall national immunization coverage levels, areas of under immunization continue to exist in the United States. An understanding of true contraindications (vs “false contraindications”) and a “no missed opportunities” approach to immunization delivery has been shown to successfully increase immunization levels. Therefore, it is important that clinicians screen records and administer required immunizations at all types of visits, not just well child visits, and administer all needed vaccinations simultaneously. Additionally, clinicians should operate reminder or recall systems, in which parents of underimmunized children are prompted by mail, telephone, and text messages (particularly with adolescents) to visit the clinic for immunization. The assessment of clinic-wide immunization levels and feedback of these data to providers have also been shown to increase immunization rates.
Parent refusal of immunizations is an issue in some communities. Because a plethora of incorrect information about vaccine safety and efficacy is on the Internet, it is useful for the provider to direct parents toward reliable sources to help them make an informed decision. A wealth of information for parents and providers about immunizations is available at the National Immunization Program’s Web site (www.cdc.gov/vaccines).
W; General Recommendations on Immunization: Recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2011;60(RR02):1–60.
MG: Finding reliable information about vaccines. Pediatrics 2011;127:s134–s137
Other Types of General Pediatric Service
Acute-care visits account for 30% or more of the general pediatrician’s office visits. Office personnel should determine the reason for the visit and whether it is an emergent situation, obtain a brief synopsis of the child’s symptoms, carefully document vital signs, and list known drug allergies. The clinician should document the events related to the presenting problem and carefully describe them in the medical record. The record should include supporting physical examination data and a diagnosis. Treatments and follow-up instructions must be recorded, including when to return to the office if the problem is not ameliorated. Immunization status should be screened, as previously discussed. Depending on the severity of illness, this may also be an opportunity for age-appropriate health maintenance screenings and anticipatory guidance. This may be particularly true with older school-aged children or adolescents who may be seen more rarely for routine health maintenance visits.
Ideally, a couple’s first trip to a physician’s office should take place before the birth of their baby. A prenatal visit goes a long way toward establishing trust and enables a pediatric provider to learn about a family’s expectations, concerns, and fears regarding the anticipated birth. If the infant develops a problem during the newborn period, a provider who has already met the family is in a better position to maintain rapport and communication with the new parents.
In addition to helping establish a relationship between parents and pediatric providers, the prenatal visit can be used to gather information about the parents and the pregnancy, provide information and advice, and identify high-risk situations. A range of information can be provided to parents regarding feeding choices and the benefits of breast-feeding; injury prevention, including sleeping position and the appropriate use of car seats; and techniques for managing colic. Potential high-risk situations that may be identified include mental health issues in the parents, a history of domestic violence, or maternal medical problems that may affect the infant.
A preparticipation physical examination (PPE) evaluation is a recommended part of every routine well-child and adolescent care visit. Physicians should be recommending exercise and activity to every child, not just those participating in organized sports.
The goal of the sports physical is to identify medical conditions that would make sports participation unsafe, screen for underlying illness through a traditional history and physical, and recognize preexisting injuries or medical problems that have affected previous sports seasons. As part of the history, the particular sport being played or specific exercise activity should be discussed. Different sports have different potentials for injury, and prevention methods will differ. All patients should be asked about previous cardiac, respiratory, musculoskeletal, or neurologic problems associated with activity. Particular attention should be drawn to any suspicion of cardiac syncope, asthma symptoms, past concussions, or history of unilateral organs, such as kidneys or testicles. Anabolic steroid and nutritional supplement discussion should be explored. Any relevant family history of cardiac death younger than age 50 should be documented.
The physical examination starts with vital signs, including accurate blood pressure screening and examination for obesity. Highlights of the examination include a careful respiratory and cardiac examination, looking for evidence of exercise-induced bronchospasm or anatomic heart disease. Electrocardiogram (ECG) or pulmonary function tests can be considered for suspected abnormalities. The skin examination should look for evidence of potentially contagious skin infections like impetigo or molluscum. The musculoskeletal examination should include all major muscle groups, as well as range of motion and stability testing of the neck, back, shoulder, hips, knees, and ankles. Any pain or limitation should prompt consideration of further investigation or therapy.
A few specific conditions bear mentioning during the counseling phase of the sports participation, including the risks and danger of concussions and performance-enhancing drugs. A list of medical conditions that may affect sports participation can be found in the references. Appropriate protective equipment should be encouraged.
CK: The preparticipation physical examination: an update. Clin Sports Med 2011 Jul;30(3):491–501. doi: 10.1016/j.csm.2011.03.008
CHRONIC DISEASE MANAGEMENT
Chronic disease in pediatrics is defined as illness that has been present for more than 3 months. Around 25% children and 35% adolescents have illnesses that meet the definition of a chronic illness. The most common chronic conditions in pediatric practice include asthma, obesity or overweight, attention-deficit/hyperactivity disorder (ADHD), and allergic diseases, but also include congenital anomalies and other conditions. Many patients with chronic conditions are cared for only by a primary care provider. However, when subspecialist care is required, the primary care provider plays an integral part of the care to deal with the complexity of these conditions, which also includes understanding the child’s growth and development, routine health promotion and anticipatory guidance, evaluating for social issues, advocating for children and their families, and care coordination.
The goal of chronic disease management is to optimize quality of life while minimizing the side effects of treatment interventions. Problem lists should be used to document chronic diagnoses and monitor associated medications. The child and family’s emotional responses to chronic illness should be addressed, and referrals to counselors should be offered if needed. Nutrition and the management of medical devices (eg, catheters, gastrostomy tubes) may need to be addressed, and care coordinated with appropriate specialists.
American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians, Transitions Clinic Report Authoring Group: Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics 2011;128:183
JA: Primary Care of the Child with a Chronic Condition. 5th ed. Mosby-Year Book; 2010.
The medical home is a concept in which children and their families have an identified, easily accessible primary care provider or group of primary care providers within an office. The AAP has identified seven characteristics of a medical home. The medical home must be (1) accessible, meaning that it must be within the child’s community, physically accessible, and all insurances accepted; (2) family centered, with mutual responsibility and decision-making between the patient or family and medical provider, and the family is recognized as an expert of the child; (3) continuous, in that the same medical professionals provide the continuity of care; (4) comprehensive, with provisions made such that ambulatory and inpatient care are available 24 hours per day, 7 days a week, for 52 weeks of the year; (5) coordinated, with a plan of care developed by the physician and family that is communicated to other providers and agencies as needed; (6) compassionate, meaning that concern is expressed and efforts are made to understand the patient’s and family’s perspective; and (7) culturally effective, in that the cultural background of the patient and family is respected and incorporated into care, and services are provided in the family’s primary language or through a trained medical interpreter.
All children should have a medical home, but it is particularly crucial for children with special health care needs or those with one or more chronic health condition expected to last more than a year. A primary care provider through a medical home should be available for children to assist families with the coordination of consultant recommendations and development of a care plan to implement recommendations.
American Academy of Pediatrics: The medical home. Pediatrics 2002;110:184