Child-health supervision for children under 2 years of age: a review of its content and effectiveness

The Indicators of Psychosocial Development in Thailand

A battery of 119 items for psychosocial development screening testing of preschool children in Thailand was assembled. Appropriateness to Thai culture and suitability for use in the home and community by parents and primary health care workers were the chief criteria in selecting the test items. The battery consisted of 22 items for testing gross motor development; 17 items for fine motor development; 30 items for hearing, language, and concept development; 29 items for self-help skill development; and 21 items for social skill development. Between April 1987 and January 1988, the battery was administered to a sample of 5, 424 children up to the age of six years in rural and urban areas in the four geographical regions of Thailand. At the same time, information on the children and their families was recorded. The development data were processed with the Grandstat package program to obtain curves showing the percentages of the children not passing the items at different ages. The development curves and bar charts showing the ages at which certain percentiles of the children were unable to pass each developmental test item are presented together with information on the children and their families incorporating the findings of this study.

Preventive Healthcare of Infants in a Region of Lebanon: Parental Beliefs, Attitudes and Behaviors

OBJECTIVES

This study aimed to investigate healthcare seeking behaviors of mothers for themselves and their infants in the Bekaa Valley, Lebanon, to identify attitudes and beliefs towards the preventive healthcare of infants and to assess whether a healthcare-based intervention program would be accepted by the population.

METHODS

Ninety-two interviews were conducted with women who had delivered a live birth in two hospitals in the Bekaa. The hospitals selected attracted women from different socioeconomic classes.

RESULTS

Differences were found in adequacy of healthcare utilization based on household size, number of children and prenatal care utilization. There was a higher perception of barriers to healthcare by parents who did not seek adequate preventive care for their infants. Mothers of infants who had inadequate care had a lower perception of severity of illness and of physicians' ability to prevent illness. The population believes strongly that medical professionals are reliable sources of health information and guidance. Infants' mothers and grandmothers are important sources of healthcare-related information.

CONCLUSIONS

Rates of preventive infant healthcare in the Bekaa need improvement. Any intervention must target mothers and grandmothers, as they appear to influence the medical care of infants. Other targets include parents of larger families. Dissemination of information regarding the seriousness of illness and the ability to prevent illness is required. The medical profession may influence health choices made by this population. However, further investigation of healthcare barriers, especially economic and geographic barriers, is needed. In preparing to improve healthcare utilization for infants in the Bekaa, local, regional and international organizations should refer to the population's beliefs, attitudes and behaviors described in this study, as these findings may aid in planning interventions that are likely to positively impact mothers and infants.

Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries

OBJECTIVE

Because research has not confirmed a relationship between compliance with health supervision in infancy and improved health outcomes, we examined the association between adherence to prevailing guidelines for periodic health supervision and adverse health outcome indicated by incidence of avoidable hospitalizations.

METHODS

This was a historic cohort study of 308 131 children enrolled in Medicaid at birth in California, Georgia, and Michigan in 1990 using Medicaid records linked across 3 years. We used avoidable hospitalizations as indicators of health in a survival analysis. The analysis used variables that represented completeness and timeliness of well-child visits and immunizations using AAP guidelines for health supervision as the gold standard.

RESULTS

When the children in this cohort were up-to-date for age on their schedule of well-child visits, they were less likely to have an avoidable hospitalization (race, illness, and level of poverty adjusted hazard ratios 0.52 [95% confidence interval (CI): 0.50-0.55] in California, 0.54 [95% CI: 0.50-0.55] in Georgia, and 0.7 [95% CI: 0.69-0.79] in Michigan). Among children who were not up-to-date with well-child visits, a sporadic preventive care visit conferred a mild benefit. Immunizations and race/ethnicity had no consistent relationship with incidence of avoidable hospitalizations.

CONCLUSIONS

A series of well-child visits maintained during the first 2 years of life has a positive effect on health outcomes as indicated by a decrease in avoidable hospitalizations among poor and near-poor children, regardless of race, level of poverty, or health status. National efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children in addition to improving immunization levels.

Methodologic issues in pediatric outcomes research

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

An analysis of group versus individual child health supervision

This study compares the effectiveness of group health supervision (three or four families counseled simultaneously) with traditional visits in conveying knowledge of child health and development, increasing perceived maternal support, and mitigating maternal depression. Subjects were recruited from a predominantly white, middle-class, suburban/rural pediatric practice. Twenty-five families were allocated to group health supervision and 25 to individual visits. A questionnaire covering knowledge of child health and development (CHDQ), the Maternal Social Support Index (MSSI), and the Center for Epidemiologic Studies Depression Scale (CESD) were administered to both groups before their 2-month and after their 10-month visits. A subset of these charts was reviewed for problem visits between 2 and 6 months. As compared with families having traditional visits, families who received the group intervention did at least as well in acquiring knowledge of child care and development and, although not statistically significant, tended to recover from postpartum depression faster and deal better with minor illnesses. The investigators found group child health supervision to be a pleasant and effective method of health care delivery.

The organisation of a national survey for evaluating child psychomotor development in Argentina

A total of 211 selected paediatricians were invited to participate in a national survey designed to evaluate the age of attainment of developmental milestones in children aged 0-5 years. Following a pilot study and a cascade training design, 61.1% of the paediatricians successfully completed the data collection on 139 developmental items. In the pilot study, there were more missing (not performed) items in children over one year of age, thus confirming the impression that paediatricians are more familiar with evaluating development in infants. However, in the age range 1-5 years, there were significantly fewer missing items in the gross motor area than in the other areas. Following a training programme and data editing and cleaning, a final sample of 3573 healthy, normal children was obtained. The impact of the training process was significant, in the sense that 3.5% of the items in children older than one year were not performed by the paediatricians before training, but this percentage was reduced to 1.9% after training (P < 0.01). The sample formed 0.11% of the national population less than 6 years of age and included a sex ratio of 1.01 compared with a national ratio of 1.02. There were no significant differences in the geographical distribution of the sample in comparison with that of the national population. The social composition, assessed by maternal education level, was biased towards a better education level than the national population. Mean Z-scores for height and weight were not significantly different from zero, when calculated on the basis of the national growth standards. In addition to successfully obtaining a representative sample for the analysis of the age of attainment of developmental milestones in Argentinian children, the survey also accomplished an educational objective in the training of paediatricians in developmental paediatrics.

Inappropriately timed immunizations: types, causes, and their relationship to record keeping

OBJECTIVES

This study examined inappropriately timed immunizations and their relationship to record keeping practices in Los Angeles public health centers.

METHODS

Records of children's visits were reviewed at four public health centers maintaining separate records.

RESULTS

One third of all children seen at both immunization-only and well child clinics were given inappropriately timed immunizations. Almost half of the immunizations were not transferred between sets of records. Children seen in both clinics were more than twice as likely to receive at least one inappropriately timed immunization as those seen only at the well child clinic.

CONCLUSIONS

Keeping separate immunization records at separate clinics leads to inappropriately timed immunizations.

Assessing mothers' attitudes about the physician's role in child health promotion

OBJECTIVE

This study assessed maternal attitudes about the physician's role in child health promotion.

METHODS

Home interviews were conducted with 200 Massachusetts mothers (with one child age 2 to 3 years) enrolled in a health maintenance organization.

RESULTS

Mothers chose growth and nutrition, physical development, and illness as the most important topics and felt that providers have the ability to prevent problems and to help. Psychosocial and safety issues were less important, although mothers felt susceptible to these issues and believed they greatly affected children's health.

CONCLUSIONS

On all issues, mothers believed physicians were more effective in helping families after, not before, problems arose. The Health Belief Model provided insight into attitudes and possible interventions.

Expectations, goals, and perceived effectiveness of child health supervision: a study of mothers in a pediatric practice

The purpose of the study was to assess parent expectations and goals in child health supervision and variability by socioeconomic status (SES), family size, social support, and pediatrician. Home interviews were conducted with mothers and their pediatricians were surveyed. Two hundred mothers with at least one child age 2-3 years who see one of five pediatricians in a staff model health maintenance organization were asked to participate. Mothers' and pediatricians' goals in the following seven areas of health supervision were assessed: biomedical, development, behavior, family functioning, safety education, and interpersonal and system interaction. Mothers stated physicians were their main source of parenting information. Assurance of physical health and normal development were more important than discussion of behavioral, family, or safety issues. Mothers of low SES were more likely to feel that physical aspects of health should be the focus and were less interested in psychosocial issues. Physicians stressed interpersonal, safety, and behavioral goals more than mothers. Individual physician responses did not predict the responses of mothers in their practice. Our data suggest either that mothers do not feel that psychosocial and safety issues are the highest priorities in health supervision or that physicians are not effectively reaching mothers on these issues.

Preventing common feeding problems in infants and young children

Feeding is one of many important ways that parents nurture their infants and children. When parents are overly concerned about feeding, they can exacerbate temporary feeding difficulties and misbehaviors by their inappropriate responses to the child's behavior. Child health supervision visits provide opportunities for the early detection of feeding problems, for education about early feeding experiences and typical child behavior at mealtimes, and for suggestions about the prevention of feeding problems. Handouts and printed materials can provide useful guidelines for introducing solid foods and for managing children's mealtime behavior. Early detection might reduce the likelihood that minor feeding disturbances will develop into severe feeding problems. Behavior management strategies and a pleasant social context for mealtimes can improve children's eating and mealtime behavior. Impairments in the parent-infant relationship may lead to serious feeding problems and referrals to appropriate support services are necessary. Prevention and early treatment of feeding problems can be facilitated by health education about early food experiences and the common developmental behaviors that occur as children grow and develop.

Developmental intervention: a pediatric clinical review

We have attempted to review developmental intervention for pediatricians in a way that is of clinical relevance to primary care pediatricians. In so doing, we chose not to evaluate certain topics such as therapeutic intervention for handicapped children or center-based educational programs because these have been adequately addressed elsewhere. It is clear that pediatricians have a unique and important role to play in developmental intervention for the following reasons: pediatricians have easy and routinely accepted access to infants and families in the prenatal, perinatal, and preschool periods: pediatricians possess a socially accepted role of authority; and pediatricians can integrate understanding of the child's health and developmental status within the context of the family and social environment to make clinical interpretation regarding the child's developmental status and prognosis. Pediatricians are thus in the best position to convince parents of their impact on their child's development. The following general roles have been identified for pediatricians. First, pediatricians should be aware of the child's biologic status and family environmental situation and the relative degree of risk for developmental problems. This clinical awareness, in combination with the use of appropriate screening instruments of the child's development and family environment, will allow clinical judgment regarding the frequency and type of child health supervision, the need for further diagnostic evaluation, and the need for referral to intervention programs and other resources. Second, the pediatrician should develop an approach for developmental intervention for all children, whatever their degree of biological risk. This review of medical, educational, and psychological literature demonstrate the following recurring important themes as goals for primary intervention: Improve parental understanding of normal child development and developmental expectations. Assist parent's understanding of the individual developmental characteristics and temperamental style of their child. Promote parental sensitivity to the social nature of infant behaviors. Encourage parent responsiveness to the social behaviors. Improve parental feelings of confidence and competence to affect their child's development. Pediatricians can be influential in supporting structural changes that can have beneficial effects on children's development. Support of humanization of obstetric and nursery practices, and the increased use of child health supervision to parents in groups are examples of such efforts.(ABSTRACT TRUNCATED AT 400 WORDS)

Developmentally disabled infants can be hard to trace

The purpose of this study was to determine how well the existing medical care system in a large geographic region communicates about and keeps track of the developmental problems of infants receiving tertiary inpatient care. Two hundred thirty-seven infants hospitalized in the first months of life were tracked, using a postal questionnaire at a mean age of 20 months. A discharge summary was present in 98 percent of charts, and a follow-up physician was identified in 95%. Questionnaires were returned by 116 physicians about 182 infants (77%). Seventy-one physicians had received a discharge summary. Current developmental information was obtained for 111 infants: 44 normal, 52 with known disabilities, and 15 with developmental delays. One hundred twenty-six infants could not be located at the time of the study. We conclude that many infants likely to have major disabilities are hard to track using simple retrospective techniques.

An analysis of physician-parent communication in pediatric prenatal interviews

Thirty-three prenatal interviews done in the offices of four practicing pediatricians were audio-recorded, transcribed, and analyzed for content by two separate methods. Interviews with the individual pediatricians varied markedly in length and were significantly longer if the father was present. Pediatricians took charge of the interviews by asking more questions than parents and by talking twice as much as parents. A relatively small number of topics (medical care of the infant, infant feeding, business aspects of the pediatrician's practice, and history of the current pregnancy) occupied a majority of the interview time. Although interviews with individual pediatricians tended to include a standard set of topics, any given visit was individualized to address parents' issues. Follow-up interviews with mothers showed that they were highly satisfied with the visits and perceived the doctors as having been warm and friendly. Mothers' highly favorable reactions were achieved in spite of the fact that interview style was generally doctor-active/parent-passive, indicating that, in some medical settings, this approach may be quite appropriate.

Teaching well child care

Despite recommendations that the emphasis of the well child visit be on behavior and development, some studies indicate that pediatricians continue to spend a relatively small percentage of each well baby visit on these subjects. One factor contributing to the discrepancy between current recommendations and practice may be the way we teach residents to perform this task. In this study, we investigated and evaluated current methods for teaching well child care. Our data indicate that the content of well child care is being taught, but that problems with teaching setting, methods and frequency of supervision, and lack of formal evaluation may be among the factors which contribute to our continued inability to change the focus of well child visits.