What instruction would the nurse include when planning anticipatory guidance for parents of a toddler?

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.

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.

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 (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.

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).

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

Patient/Family Education

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Anticipatory guidance should be age‐ and syndrome‐appropriate.

Topics for discussion and reinforcement include:

Need to seek medical attention for fever or ill appearance

Regular penicillin administration

Appropriate hydration

Thermometer use

Spleen palpation

Recognition of signs of sequestration, aplastic crises, stroke, priapism, aseptic necrosis, and chest crises

Genetic counseling and diagnostic testing should be made available to all families of children with sickle cell disease.

Emphasis should be on preventing complications.

Support groups: Sickle Cell Disease Association of America, Inc.; local chapters in many cities

TRAVEL AND THE CHILD WITH HEART DISEASE

Good anticipatory guidance will often allow children with heart disease to enjoy traveling for vacation. Several issues need to be addressed. First is the mode of travel. With the exception of children with significant cyanosis, air travel does not pose particular problems. For children with residual cyanosis, it needs to be recognized that the cabin pressure aboard most planes is equal to that at 10,000 feet and can result in a lower oxygen saturation in the patient. As such, the infant with cyanosis may benefit from the addition of oxygen on a plane trip. This can be done successfully but requires significant planning on the part of the family. Some smaller planes are not equipped or are restricted from having pressurized oxygen on board. Children with pacemakers should show the airport secuity personnel their pacemaker identification card and be allowed to bypass metal detectors or electromagnetic devices.

It is important that families carry sufficient medications for the duration of the trip, since obtaining medication away from home, out of state, or out of country can be difficult. In addition, the family should carry a medical history, including current condition and medications, in the case of emergency care. The medical history should provide information for the possible adjustment of medication dosage, if appropriate, related to time zone changes. Finally, consideration should be given to the type of activity that the family and child will experience. Some limitations may be advised regarding the amount or type of exercise required to participate in the planned activities.

A common question is that of participation on different amusement park rides. Many rides stipulate that persons with a cardiac condition are restricted. This may or may not apply to the child with heart disease. Children with significant arrhythmias or those at risk for loss of consciousness with sudden changes in position should be restricted from some rides that could produce significant physical and emotional stress. This is especially true of children with arrhythmias triggered by increased catecholamine activity and children with moderate to severe pulmonary hypertension.

OPPORTUNITIES FOR PREVENTING FEEDING PROBLEMS

Primary prevention through anticipatory guidance can limit or eliminate many common feeding problems. Education about early infant feeding begins at the prenatal visit and newborn examination. Plans for feeding should be explored, and breastfeeding should be encouraged by emphasizing nutritional, immunologic, and psychological benefits. Realistic expectation for nursing and instructions to ensure proper latching on and effective sucking by the infant should be reviewed before mother and infant are discharged home. A follow-up office visit within 1 week should be encouraged for first-time nursing mothers. Lactation counseling by the infant's clinician or another person assists many mothers and prevents early discontinuation of breastfeeding (Powers and Slusser, 1997).

Clinicians can assist parents to prepare for each stage in feeding by reviewing anticipated milestones that change a feeding pattern (see Table 58-1). Temperament variations and cultural differences should be evaluated and incorporated into recommendations.

When talking directly to school-age children and adolescents, nutritional counselors should take into consideration cognitive stages of development in terms of the child's ability to understand cause and effect (concrete operations) and to hypothesize an outcome (formal operations) (see Chapters 5 and 6Chapter 5Chapter 6).