Which statement should the nurse include when providing anticipatory guidance to the parents of a 3

Tasks of Well-Child Care

The well-child encounter aims to promote the physical and emotional well-being of children and youth. Child health professionals, including pediatricians, family medicine physicians, nurse practitioners, and physician assistants, take advantage of the opportunity well-child visits provide to elicit parental questions and concerns, gather relevant family and individual health information, perform a physical examination, and initiate screening tests. The tasks of each well-child visit include the following:

Disease detection

Disease prevention

Health promotion

Anticipatory guidance

To achieve these outcomes, healthcare professionals employ techniques to screen for disease—or for the risk of disease—and provide advice about healthy behaviors. These activities lead to the formulation of appropriate anticipatory guidance and health advice.

Clinical detection of disease in the well-child encounter is accomplished by a careful physical examination and both surveillance and screening. In well-child care,surveillance occurs in every health encounter and is enhanced by repeated visits and observations with advancing developmental stages. It relies on the experience of a skilled clinician performing intentional observation over time.Screening is a more formal process using some form of validated assessment tool and has known sensitivity and specificity. For example, anemiasurveillance is accomplished through taking a dietary history and seeking signs of anemia in the physical examination. Anemiascreening is done by hematocrit or hemoglobin tests. Developmentalsurveillance relies on the observations of parents and the assessment of clinicians in pediatric healthcare who are experienced in child development. Developmentalscreening uses a structured developmental screening tool by personnel trained in its use or in the scoring and interpretation of parent report questionnaires.

The 2nd essential action of the well-child encounter,disease prevention, may include bothprimary prevention activities applied to a whole population andsecondary prevention activities aimed at patients with specific factors of risk. For example, counseling about reducing fat intake is appropriate for all children and families. However, counseling is intensified for overweight and obese youth or in the presence of a family history of hyperlipidemia and its sequelae. The child and adolescent healthcare professional needs to individualize disease prevention strategies to the specific patient, family, and community.

Health promotion andanticipatory guidance activities distinguish the well-child health supervision visit from all other encounters with the healthcare system. Disease detection and disease prevention activities are germane to all interactions of children with physicians and other healthcare clinicians, but health promotion and anticipatory guidance shift the focus to wellness and to the strengths of the family (e.g., what is being done well and how this might be improved). This approach is an opportunity to help the family address relationship issues, broach important safety topics, access needed services, and engage with extended family, school, neighborhood, and community and spiritual organizations.

Sharing relevant information

Anticipatory guidance in pediatric palliative care is challenging for many reasons: the complexity of the issues encountered and their sensitive natures, the uniqueness of each patient's and family's experience, the limited time available for relevant conversations, and the natural resistance that some families have in confronting such difficult and threatening issues. To facilitate communication with patients and families, one must take into consideration their physical, emotional, social, and spiritual needs, their need for support in the process of making difficult decisions, and anticipatory guidance. As discussed in previous sections, two important components of anticipatory guidance in pediatric palliative care are learning about the child and the illness experience from his or her perspective and establishing a therapeutic alliance. The third component of anticipatory guidance is sharing relevant information, which may include information learned from other families in similar circumstances. This process helps patients and families to feel a sense of control and comfort in the knowledge that they have made the best decisions possible throughout the illness trajectory.

Anticipatory Guidance, Counseling, and Preventive Care

Preventive healthcare through health education, anticipatory guidance, and participation in screening and immunization schedules is the mainstay of pediatric public health programs (seeChapter 28).Bright Futures, developed by the American Academy of Pediatrics and their collaborators and supported by the Maternal and Child Health Bureau, Health Resources and Services Administration, provides a knowledge base for pediatric healthcare providers and the public about anticipatory guidance, health promotion, and prevention for children and adolescents, but it has few references to disability. Anticipatory guidance refers to general information related to growth/development and healthy practices. Counseling refers to advice given regarding specific conditions, which could include discussions of applications of general guidance to children with disabilities. For the general population, 25% of parents receive no information and <50% receive all recommended guidance. Although parents of children with special healthcare needs (the broad inclusive definition of disabilities) report similar or better receipt of general preventive information, it is not clear whether those with higher severity of functional limitations receive this guidance or counseling, and whether it is provided in the context of disability and other circumstances.

Children with special healthcare needs require typical prevention, as well as more specific counseling related to their disability. Some of this more specific counseling can be managed by specialty care providers, although children with special healthcare needs have difficulty obtaining appropriate specialty outpatient services. Additional barriers to care, especially with increasing age of the child, are the lack of accessible medical equipment and facilities. Although discussions of health risks with adolescents about smoking, drinking, and protected sexual activity should be undertaken, the discussions may require a different focus for adolescents with disabilities. Higher violence and abuse rates toward children with disabilities are reported, for which providers must be vigilant.

The recommendation is to recognize the need for modifications to typical guidance, to be alert for any signs of violence, and to broaden counseling to include questions and discussions about conditions associated with the specific disabilities (e.g., epilepsy or cognitive impairments often seen with cerebral palsy, or neurogenic bladder and bowel in spinal cord dysfunction) or secondary conditions, such as pain, osteoporosis/fractures, or fatigue seen in many children and adolescents with disabilities.

Anticipatory Guidance

Anticipatory guidance is defined as proactive counseling that addresses the significant physical, emotional, psychological, and developmental changes that will occur in children during the interval between health supervision visits. Anticipatory guidance is the complement to a risk assessment. It addresses protective factors aimed at preventing oral health problems. An example of anticipatory guidance would be a discussion on ambulation of an infant with a warning about possible tooth trauma that often occurs as the infant learns to stand and walk. Topics to address in this age group include oral development, fluoride adequacy, nonnutritive habits, diet and nutrition, oral hygiene, and injury prevention.29 These six areas capture the major concerns related to the oral conditions of dental caries, periodontal disease, trauma, and malocclusion.

Communication, Advance Care Planning, and Anticipatory Guidance

Although accurate prognostication is a particular challenge in pediatrics, the medical team often recognizes a terminal prognosis before the prognosis is understood by parents or the child. This delay may impede informed decision-making about how the child lives at the end of life. Given the inherent prognostic uncertainty of a life-threatening diagnosis, discussions concerning resuscitation, symptom control, and end-of-life care planning should be initiated when the physician recognizes that a significant possibility of patient mortality exists. Having these conversations in the midst of a crisis is not ideal. Whenever possible, they should occur well in advance of the crisis or when the patient has recovered from a crisis but is at high risk for others.

Patients and families are most comfortable being cared for by physicians and other care providers with whom they have an established relationship. Even in the face of long-standing and highly connected relationships,clinicians often hold assumptions about parent prognostic awareness, as well as parent readiness and willingness to have such discussions. In an attempt to protect families, clinicians may avoid conversations that they perceive as promoting distress or hopelessness. However, parents greatly value honesty, and in fact such conversations can promote parent hopefulness, as well as trust and connection with the care team. At times, therefore, aconsultative palliative care team provides the family with an opportunity to engage in sensitive conversations that do not as readily occur with the primary team, at least initially.

The population of individuals who die before reaching adulthood includes a disproportionate number of nonverbal and preverbal children and adolescents who are developmentally unable to make autonomous care decisions. Although parents are usually the primary decision-makers, these youth should be as fully involved in discussions and decisions about their care as appropriate for their developmental status. Using communication experts, child life therapists, chaplains, social workers, psychologists, or psychiatrists to allow children to express themselves through art, play, music, talk, and writing will enhance the provider's knowledge of the child's understanding and hopes. Tools such asFive Wishes (for adults),Voicing My Choices (for adolescents), andMy Wishes (for school-age children), have in practice been useful in helping to introduce advance care planning to children, adolescents, and their families (www.agingwithdignity.org/index.php).

Counseling and Anticipatory Guidance

Anticipatory guidance appropriately targeted to a child’s developmental stage is a critical component of preventive care. Also, although good-quality evidence supporting the efficacy of most anticipatory guidance is limited, the standard of care is to provide such advice and counseling for parents (Moyer and Butler, 2004). Anticipatory guidance involves counseling caregivers to prepare for future normal child growth and development and to prepare caregivers for how these changes may need to be accommodated to promote development and to prevent injury or harm. Examples of anticipatory guidance include providing counseling to caregivers about various safety issues (e.g., use of infant and child car seats, bicycle helmets, water safety, poisoning prevention, childproofing the home), nutrition, appropriate dental care, and physical activity. Injury prevention is particularly important because unintentional injury is the leading cause of death for children and adolescents. In children 1 to 14 years old, the three leading causes of injury-related death are motor vehicle crashes, drowning, and fire.

Bright Futures (http://brightfutures.aap.org/web) is a well-known, frequently implemented example of a program that includes health supervision and anticipatory guidance dedicated to well-child care and prevention. The Bright Futures program was begun by the Maternal and Child Health Bureau (MCHB) of the federal government and is endorsed by the AAFP and AAP.

Preventive care of adolescents emphasizes anticipatory guidance and counseling. Important topics to discuss include sexual activity; alcohol, tobacco, and drug use; healthy eating and physical activity; injury prevention; and mental health. The evidence of the benefits of screening and counseling for these conditions in adolescence is not clear. The clinician must also ensure that immunizations are delivered to the adolescent according to the recommended schedule. Vaccination against hepatitis B should be administered if it was not given during infancy, and boosters for varicella; measles, mumps, rubella (MMR); tetanus, diphtheria, and pertussis are given as determined by the schedule. Adolescents, especially college students, are at increased risk for meningococcal meningitis. The risks of disease and the risks and benefits of immunization should be discussed with prospective college students.

Screening tests for infants and children are discussed online at www.expertconsult.com.

Anticipatory Guidance

Anticipatory guidance (or preventive counseling) is the advice pediatricians provide to avoid problems that could occur in the future. Topics such as nutrition, injury prevention, behavior management, developmental stimulation, sex education, and general health education all may be covered during every visit. Most expectant parents have many questions that can be discussed with their pediatrician several weeks before delivery. The most frequent concerns include arguments for and against breastfeeding and circumcision, hospital policies about rooming-in and the father's presence in the delivery room, ways of decreasing sibling rivalry, and essential infant equipment.

Anticipatory guidance

Anticipatory guidance prepares families for what to expect next in their child’s development. As the list of topics that could be addressed at each visit grows, the pediatrician faces a dilemma in determining which topics to discuss. Guidance is most effective when personalized to individual circumstances, and delivered in the context of a relationship with a known and trusted physician. Topics include healthy habits, prevention of injury and illness, nutrition, social development, and family relationships. As time during office visits is limited, guidance can be supplemented with educational videos and written materials that can be studied at home, with parent educational classes, and with general health promotion messaging through the media.

Anticipatory Guidance

Anticipatory guidance is a crucial part of pediatric care and has been shown to reduce caregiver anxiety and utilization of emergency services, improve satisfaction with care and adherence, and reduce morbidity.198 All children and caregivers should be offered ability- and developmental stage-appropriate counseling regarding safety issues for children with epilepsy, such as bathing, injury prevention, and plan of action for each seizure type. In addition, counsel should be given regarding seizure prevention strategies, such as medication adherence, maintaining adequate sleep, and avoidance of alcohol. Young women (ages 12 and up) with epilepsy are at high risk of unplanned pregnancy due to psychosocial factors, poor adherence to hormonal contraceptive regimens, and contraceptive failure related to drug interactions. They should be counseled regarding the effect of epilepsy and antiseizure medicines on reproductive function and management.199,200

Related Conditions

Anticipatory guidance, prevention of infectious diseases through immunization, and evaluations of vision and hearing are other important functions of the family physician. Preterm infants should receive immunizations according to AAP and CDC recommendations, including guidelines for the administration of palivizumab, a monoclonal immunoglobulin G given intramuscularly that reduces the severity of respiratory syncytial virus (RSV) infections (Sherman, 2005). Preterm infants are particularly susceptible to RSV infections in their first year of life.

The preterm infant should also be monitored for anemia. Premature infants have a more rapid and severe decrease in hemoglobin after birth, and the hematocrit and reticulocyte count should be followed closely. The hematocrit usually begins to rise at 3 to 6 months of age.

When premature infants are discharged with cardiorespiratory monitors, parents often ask when these monitoring devices can be discontinued. Criteria used for stopping home monitoring often include a 1- to 2-month period in which there is no clinical apnea, no cyanotic episodes, and no history of the alarm being triggered for apnea or bradycardia (Sherman, 2005). An algorithm is available for judging when to cease home monitoring (Spitzer and Gibson, 1992).

If an infant is sent home receiving oxygen therapy, oxygen saturation should be monitored with pulse oximetry. The parameters for increasing or decreasing the amount of oxygen being delivered to the infant should be communicated from the NICU team and managed by the primary care provider. The decision to stop the oxygen therapy is generally made by a pediatric subspecialist who is also following the infant.

Gastroesophageal reflux (GER) is a common problem in the preterm infant. Symptoms of GER include regurgitation or emesis after feedings, apnea after feedings, fussiness during or after feedings, and arching of the head and neck during or after feedings. Little consensus exists regarding the optimum method for testing or for treatment of GER (Sherman, 2005). Consultation with a pediatric gastroenterologist may be appropriate for these infants.

The most common and serious central nervous system (CNS) disorders that may be present in premature infants at discharge are posthemorrhagic hydrocephalus, postmeningitic hydrocephalus, periventricular leukomalacia, and seizures. Other conditions affecting the CNS of NICU graduates include developmental defects in the brain or spinal cord. Infants with these problems should be referred to the NICU follow-up clinic or to a pediatric neurologist. These infants should also be referred to community services that provide early intervention and rehabilitation.

Visual defects, including retinopathy of prematurity (ROP), should be closely monitored after NICU discharge because ROP can lead to permanent blindness. A retina specialist should have screened for ROP before the infant was discharged from the NICU, and the results should be reported to the family physician. Preterm infants who have had evidence of ROP also should be screened for refractive disorders at 2 to 3 years of age, before school entry, during grade school, and during adolescence, when rapid growth is occurring (Sherman, 2005).

Physical and mental disabilities of the patient significantly affect parents and the family unit. The infant should be referred to community- and education-based services appropriate for the individual disabilities of the infant. Family support groups or counseling may also be helpful to the parents of a developmentally challenged infant. Technology-dependent infants, such as those with chronic ventilatory support, can require supplies and home health services. The family physician should be certain that office systems are set up to ensure that a continuous supply of necessary supplies is available to the infant (Sherman, 2005).