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.

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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 –
  
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.[*]



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11 comments:

  1. I love this. We stopped all vaccines before the 6 month check up but we have gone as a family me my husband n lil boy to every regularly schelduled well visit. We have a good relationship with pediatrician and use well visit to moniror his development. Recently he was dragging a foot when he walked so with the help of our family chiropractor AND pediatrician we were able to catch and correct issue. I think the doctor you choose is as important choice as any in parenting.

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  2. Whether you vaccinate or not you should still take your child to well visits for growth and development monitoring. Doctors recognize issues an untrained parent would not, such as heart problems or developmental delays.

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  3. Great article. Something to think about: we are not/have not vaccinated either of our girls. We have a great family practice (no pediatrician) that is integrative and supportive. I have debated whether or not I should do the "well child visits" - and I decided I should because there's no way to know if someday the laws will change on vaccinations, or if I might someday be found legally negligent for not having them done. We are also charged a higher premium for our health care because our girls aren't "up to date on their immunizations." (Never mind that they've never been sick...) So I decided to keep the visits going to establish a record of my attentiveness to their health, to "cover my butt", as they say. Pardon the expression.

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  4. excellent points!!! having had my first child in Europe and the subsequent ones here in the USA I was appalled at the sick healthcare system here!
    be informed is really the main point! some times medical information is outdated (just because this is how we do it, is not reason enough); if what we do here is "gospel", children in Africa should not even be alive! (yes the infant mortality rate is high there, but a lot is nutrition and hygiene related, not well baby visit related)

    be informed about every thing! then make your decision - and after 25 years you might still question if you made the right decision :)

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  5. Thank you for this. We stopped shots after 6 months with our oldest two and our youngest two haven't ever had any and it made me wonder why we still go. But my mom encouraged us to continue going, even if it seems pointless because someone might catch something if we didn't and also, it could never come back on us that we were negligent in not going. So when I first started reading your post, I thought, "Oh, so we don't need to go!", but by the end I realized you are right, it is a great chance to build a relationship. I'm always floored by my Dr.'s lack of communication. They never address diet, sleep habits, television, reading, outside play time, I'm generally in and out in 5 minutes. And they just assume I'm going to vaccinate (it hasn't come up yet that we don't- that's how little interested they are). I will make sure to have a list of my own questions and try to build something next time :)

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  6. While I understand why it is suggested that well checks be done away with, I disagree. I find them to be very valuable. We did refer our younger son to Early Intervention because our pediatrician took too much of a wait and see approach for our taste on developmental concerns. Past one year of age, we have never had a well check last less than 30 minutes. We see the pediatrician frequently for sick visits and he always asks about the chronic stuff. (Our previous pediatrician did as well, though the one before was less thorough.) Still, taking that closer look during well-checks has helped us identify issues that likely would have otherwise been overlooked or caught later.

    The aspect of well checks that I think is most important is the relationship building between the pediatrician and patient/parents. Well-checks allow kids to get to know their pediatrician when they are not experiencing the stressor of illness. Physicians can make observations about the child's personality & preferences that can be jotted down to help them reestablish rapport during sick visits. Also, if a parent is unhappy with a pediatrician's demeanor during a well-check then that is a good sign that they will not like how sick visits will be handled. Better to figure that out up front than when there is a problem!

    I would like to see the option of replacing some of the infant well-checks with home visits. I also think that the 3 suggestions for well-checks are good. I would expand that to sick and specialty visits, as well.

    We no longer handle appointments with the pediatrician and most specialists as a team, but that is because I have established good working relationships with them. (If that can't happen, then the physician in question gets replaced!) Initial appointments are still joint ventures whenever possible.

    The written list of questions/concerns is an absolute. I try to type my list of questions so I can print two copies. One copy goes to the physician. The other stays with me so that I can write down the answers. Most doctors are happy to have the list so they can modify patient/family education to include answers to those questions. It is rare that I have to insist that all questions be answered.

    Deferring on decision making is also important for all. I will make decisions in the office only if the options presented are what I would have expected. When new medications are recommended when I have not anticipated them, I will accept the prescription. But I also say that I will look into the medication when I get home. If I have concerns, then I will call. If I do not call within 24 hours, then the doctor will know that I was comfortable proceeding.

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    1. I think we actually agree...as I said in the post:

      "When we rejected all well-child visits, I believe we may have 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."

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  7. Thanks for the great post Amanda! I posted the link on my 'Vaccination Information Network' Facebook page and got a number of responses from my subscribers including this one from a mother who appears to have quite strong views on the subject I thought I would share:

    "Heck Yes u better ditch it unless u want to be trapped in a small room with a bunch of deranged brainwashed drug-pushing robotic spineless creepsters in white coats wanting to profit off of making your child sick through toxic painful filthy disgusting evil shots :(.

    Dont forget all the wonderful sick children(that they made sick to ensure their job security)waiting in the lobby :(

    My boys see a chiro, holistic chinese herbalist, never ever sick.. never been poisoned and over my dead body will they ever be... we weight at home, they are stealthy healthy, thank you God for YOUR natural amazing ways!

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  8. A mother just posted this on my Facebook page "My child's vaccine reaction":

    https://www.facebook.com/photo.php?fbid=440829995995449&set=a.422465491165233.93891.372638272814622&type=1&theater

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  9. You don't need a well child visit to take not of whether your child is growing. You need a scale and a tape measure, or some eyes.

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  10. You do not need well child visits to see if your child is gaining weight and growing. A scale, eyes, and a tape measure should do the trick.

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Please be respectful. If you are about to say something that you would not let your child hear, then please refrain from saying it.