Ditch the Well-Child Visit?

The care of children has always been a part of the human experience. So it may come as a surprise to learn that the birth of the pediatric discipline emerged less then a century ago. 

In the early 1900’s, medical licensing codes were introduced and the large influx of new medical professionals began to create specialization within the field of medicine. Pediatrics is one example of a broader trend seen in institutional medicine emerging at that time: specialization.

****

Although the average parent might not be aware of it, the current approach to well child visits in the US has been under scrutiny by the medical community for over a decade – and a push to reform the content and structure surrounding children’s care is gaining momentum. 

What are the current limitations to the messiah of pediatric preventative care we know as ‘well child visits’ ….and what does this mean to parents?

Read on…

What is a Well-Child Visit?

A well-child visit is an appointment made with a primary pediatrician while a child is not sick in which the objective is to assess development, administer scheduled vaccines, perform age-appropriate screenings and provide advice about nutrition and various preventive measures parents can incorporate into their daily lives.

International Comparison

For me, I always like to start with good ol’ comparison to the rest of the world.

Yep, that’s right, we’re not the only kids on the block.

Here in the states, we are among a very small number (if not the only) of countries on the globe to place all well-child care under the responsibility of a single primary care provider. We expect in-office visits by one pediatrician to effectively complete developmental screenings, psychosocial assessments, and to lend guidance about preventative measures and nutrition.[*][*]



Current US Schedule of Well-Child Care



Is there a superior way of pediatric care and assessment being currently utilized in other parts of the world?

Well, when you look at Sweden, Australia and the UK (for example) they use “health visitors” (nurses with public training) to make home visits to assess children’s development and to take time to discuss concerns parents might have(how awesome is this). In other European countries, public clinics offer developmental services in conjunction with home visits.[*]

One country that seems to be getting it right is Sweden – Swedish parents understand that they go to a general practitioner if their child is sick, a public health nurse for various developmental services, and a pediatrician for complex medical problems. This unique system provides comprehensive, continuous care, without coordinating services in a pediatric practice.[*] 

The Evidence in Screening/Prevention

One of the principal reasons for parents to attend well-child care visits regularly is the early surveillance of childhood developmental issues.

Surprisingly, experts have been questioning the evidence supporting regular developmental screening, behavioral screening, and psychosocial assessments for years simply due to the lack of research backing it up.[*][*][*][*]

Social and psychological assessments, for example, are effective with an assessment in an in-home environment and particular parent-child evaluations. However, in an office setting, the validity of these assessments is absent.[*] 

As for child behavioral problems during the first 3 years of life, the published literature confirms the absence of a universal diagnostic classification. The diversity among check-lists and questionnaires provided to parents and used by pediatricians for review have never been examined in terms of effectiveness.[*] 

If you are using well-child care as a preventative measure in developmental and behavioral issues, then it would be wise to re-examine this impression. Problems of this type in children are increasing and occurring at younger ages. The large majority of pediatricians are NOT addressing developmental and psychosocial issue adequately.[*] 

The current system in place in the US for preventative care in children in not very scientific, nor is supported by evidence of effectiveness. [*][*]   

Trying harder will not work – changing systems of care will. Parents need to act as a catalyst, requiring more from doctors and educating themselves about what is proven by research to be effective care.[*]

There is a very strong need for better, more rational, scientific guidance regarding preventive care for children – especially as it affects their development.

Well Vaccine-Child Visits & The Time Crunch

Instead of a schedule based on key transition points in development, the U.S. pediatric well-child schedule is driven by the current immunization recommendations.   

If you thought pediatric well-child office visits lack in developmental/psychosocial assessment, then it is revoltingly deficient in communicating information about vaccines.

In one study published in JAMA Pediatrics, researchers studied the information exchange regarding vaccination during well child visits. Only 5% of families actually read the materials provided by practitioners with pediatricians prompting questions regarding vaccination 16% of the time.[*]

The median time spent on the discussion of vaccines being administered during a well-child visit was about 2 minutes (with a cumulative discussion of vaccination within the first 2 years of life estimated to be less then 10 minutes). [*] 




Check out NVIC’s Ask 8 –

 Questions to ask before you vaccinate

  

Well-child visits are touted as key times for communication between parents and their care provider but this dialogue among parents and care providers is not occurring.

The study mentioned above gathered information from 7 pediatric practices and presented the following timetable during a well-child visit[*]:

(time listed in minutes)

4.9 = physical exam

1.9 = vaccine discussion

9.5 = discussed other health concerns

0 = vaccine administration (performed by a nurse 1.6 minutes)

16 minutes = Total median time spent with primary doctor during well-child visits

The time allotted during a well-child visit is not enough to effectively address what the actual visit is intended to do. 

Is it simply too much for one primary physician to accomplish? Certainly.

Are parents relying significantly on the pediatrician to prompt dialogue, questions and concerns? Maybe.

All or Nothing?

With my oldest daughter, we went to every well-child visit.

With my youngest, we attended none.

After my experience with both extremes – I do believe there should be some happy medium between the two.

Obviously, if you are planning to vaccinate on schedule according to the ACIP/CDC national immunization program, then attending all well-child visits would be logical because you have to go to the doctor anyway to administer the intended vaccines.

However, if you are planning on delaying or altering the vaccine schedule in an exclusive approach then attending only a few would be reasonable as well since the research and evidence supporting the excessive amount of visits early in life is lacking.  

When we rejected all well-child visits, I believe we missed out on the ability to build a relationship between our pediatrician that could have been beneficial.  Although we did not need her services or advice, there is something to be said about the possibility of the relationship between doctors and parents.

My past experience (aka being “fired”) with pediatricians most likely played a role in my refusing all well-child care – and looking back, I think that was unfortunate.  

I hope this post helps you to re-examine the confidence we hold in the ability of a primary pediatrician to solely assess behavioral/social/psychological development, lend nutritional advice, and provide evidence-based information.

I hope this also motivates parents to be more diligent in learning/researching more about health outside of the doctor’s office.

In my experience, I’ve learned 3 critical details in a successful well-child visit :

(1) When you do attend a well-child visit, go with your partner (if there is absolutely no way to schedule this, then have someone attend that is supportive) and never go without a written list of questions, concerns, topics to discuss.

(2) Don’t be anxious to leave a practice if you are not a good fit with their policies or their position on certain practices. The doctor/patient(guardian) relationship is just that: a relationship – NOT a dictatorship.

(3) If you unsure about a particular medical procedure (vaccines, screening, testing, etc)- NEVER decide in-office at a well-child care visit. Always give yourself time to review the information provided by the doctor, to do your own research, and time resolve what is the best choice for your child. Simply state you are there to collect information and you will schedule another appointment it you decide that is necessary.

To overhaul what has been preset for decades is not going to happen in our life time, but that doesn’t mean that we should give up – or worse, accept the current state as is.

The methods for pediatric care are changing, slowly. Pediatricians may see interdisciplinary care (ex. the care model seen in Europe nations with many care providers imparting assessment and care to children) as a threat, but new models suggested by researchers (such as home care, vaccine clinics, group education, etc) is the next level of children’s health care which would improve quality and efficiency to the field of pediatric medicine.[*]

Other posts you might find informative:

5 Useless Medical Practices Used on Children

How Your Doctor is Taught to Deal with Questions About Vaccines

2012 Changes to the Immunization Schedule

Linear Thinking in Modern Medicine