It’s Not What You Say, Its How You Say It: Improving

the Effectiveness of Anticipatory GuidanceRobert Sege, MD, PhD

From the Boston Medical Center, Boston, MassAddress correspondence to Robert Sege, MD, PhD, 850 Harrison Avenue,Yawkey Ambulatory Care Center 5N-02, Boston,Massachusetts 02118 (e-mail: robert.sege@bmc.org).

ACADEMIC PEDIATRICS 2011;11:3–4

THERE IS VERY good news in primary care pediatrics.The Affordable Care Act of 2010 helps ensure that everyAmerican child will continue to receive routine healthcaremaintenance. Furthermore, the compendiumof routinehealth care maintenance that is enshrined in Bright Futuresforms the core of covered routine health care maintenancefor children. This represents a social consensus that routinehealth care is valuable for children and their families. Thenext step for us as a profession is to use this endorsementto make a real difference for children’s health.

For those of us in the trenches, it is easy to underestimatethe importance of anticipatory guidance. After all, howmuch impact can a 15- or 20-minute visit have? It turnsout that even marginally effective interventions may havea large impact. In simple terms, the public health impactof an intervention can be thought of as the product of theeffectiveness of the intervention and the proportion thepopulation reached. The near universal reach of routinehealth care maintenance for American children meansthat even interventions of relatively low individual effec-tiveness will have a large public health impact.

The importance of these visits is magnified by theconfluence of 2 other circumstances, one social and theother biological. For the years of a child’s life before schoolentry, health care providers are often among the mosttrusted sources of information regarding parenting prac-tices. This is the same period of time when extraordinarybrain growth occurs, suggesting a lifelong influence ofearly childhood environmental factors on the brain andnervous system.

How can we best leverage this extraordinary access tochildren and their families to improve health outcomes?There has been a fair amount written, often in the formof consensus reports and policy statements regarding thecontent of such visits. Bright Futures,1 after remindingus to first attend to parent and child concerns, suggests 5top priority topics for each routine health care mainte-nance visit. Examination of these priorities clearly estab-lishes that 21st-century pediatrics includes the social,psychological, and behavioral factors that influence ofchild health.

Although the content of the routine visit has changed,pediatricians have been slow to adapt strategies to improve

ACADEMIC PEDIATRICSCopyright ª 2011 by Academic Pediatric Association 3

the effectiveness of the guidance we offer. Previousexamples of successful efforts to augment anticipatoryguidance include Reach Out and Read, which promotesliteracy simply by giving children’s books to families,2,3

and Safety Check, a research study that demonstrated theeffectiveness of providing kitchen timers to encouragefamilies to use time-outs as an alternative to corporalpunishment.4

In that context, 2 articles that appear in this issue ofAcademic Pediatrics illustrate important concepts inimproving the effectiveness of anticipatory guidance.Both reports describe programs that augment the wordsof the physician in conversation with the family withmore tangible products.In the article by Reich and colleagues,5 parents were

given children’s books with embedded information aboutchild safety practices. The investigators found that motherswho received the books with safety information were morelikely to implement some safety practices.The second article, by Paradis and colleagues at Roches-

ter, examined the use of a short video played in the office todemonstrate infant-related anticipatory guidance.6 Thevideo was played in the examination room before thedoctor’s arrival, then given to the family to take home.As in the first study, parents exposed to the interventionhad better knowledge; strikingly, they made fewer phonecalls and visits to the pediatrician for routine infant issues.These 2 studies use appropriate experimental and statis-

tical techniques to critically examine the process ofprimary health care maintenance. The studies reportedobjective assessments of the effectiveness of interventionsin the primary targets. Reich found that fewer safetyhazards were seen during home visits. In the report by Para-dis and colleagues,6 parents who had seen the videomanaged their infants themselves, with less need forprofessional guidance for common issues.Strictly speaking, noneof the outcomes reportedare health

outcomes. Studying the actual health outcomes from antici-patory guidance is fraught with difficulty.7 First, the actualhealthoutcomesmaymanifest quite far in the future. Second,much of the child-rearing advice that we offer parentscompetes with other cultural social and personal norms andexperiences, thus complicating the general application of

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knowledge from small trials. Although the technical difficul-ties involved in assessing the effectiveness of anticipatoryoutcomes on changing health outcomes may seem daunting,these 2 studies demonstrate the usefulness of more easilymeasured proxy outcomes.

Proxy outcomes in small samples limit the overall confi-dence that interventions of the sorts studied here are effec-tive. However, the costs and risks are extraordinarily low.In fact, the low marginal cost and risk of improving ourguidance allows us to reexamine how we use the occasionof a routine health care maintenance visit to improve childhealth outcomes. Perhaps, as these studies suggest, theeffectiveness of these visits can be greatly increased byproviding additional materials that leverage the time spentin the office.

Having begun the transformation of pediatric practiceinto one that addresses the new morbidities,8 the challengeover the next decade will be to develop, evaluate, anddisseminate methods for making these office visits liveup to their potential to improve child health.

REFERENCES

1. Hagan J, Shaw J, Duncan PE. Bright Futures: Guidelines for Health

Supervision of Infants, Children, and Adolescents: Pocket Guide. Elk

Grove Village, Ill: American Academy of Pediatrics; 2008.

2. Weitzman CC, Roy L, Walls T, Tomlin R. More evidence for reach out

and read: a home-based study. Pediatrics. 2004;113:1248–1253.

3. Zuckerman B, Augustyn M. Books and reading: evidence-based stan-

dard of care whose time has come. Acad Pediatr. 2011;11:11–17.

4. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about

media use, timeouts, and firearm storage effective? Results from

a cluster-randomized, controlled trial. Pediatrics. 2008;122:e15–e25.

5. Reich SM, Penner EK, Duncan GJ. Using baby books to increase new

mothers’ safety practices. Acad Pediatr. 2011;11:34–43.

6. Paradis HA, ConnKM,Gerwirtz JR, Halterman JS. Innovative delivery

of newborn anticipatory guidance: a randomized, controlled trial incor-

porating media-based learning into primary care. Acad Pediatr. 2011;

11:27–33.

7. Sege RD, De Vos E. Evidence-Based Health Care for Children: What

Are We Missing?. New York, NY: The Commonwealth Fund; April 30,

2010.

8. Kelleher KJ, McInerny TK, Gardner WP, et al. Increasing identification

of psychosocial problems: 1979–1996.Pediatrics. 2000;105:1313–1321.