COMMENTARY

Pediatrics by the Numbers: Putting Our Time Where It Works Best

L. Gregory Lawton, MD

Disclosures

June 04, 2018

It's a morning of (mostly) well-child check visits. I move between rooms. I caution the parents of a newborn about sudden unexpected infant death (SUID, which includes sudden infant death syndrome) in one. I recommend seatbelts to a 14-year-old in another. I advise safe storage of medications and cleaning products to the mom of a 2-year-old in a third.

There is a seasonal variation to this anticipatory guidance. During the summer months, I will mention sunscreen. Beginning in October and through the holidays, caution about lights and fragile decorations find their way into my daily spiel.

Anticipatory guidance is the medical version of Ben Franklin's aphorism, "an ounce of prevention is worth a pound of cure." Essentially, the name of the game is to decrease morbidity (pain, injuries, and trips to the office for nonfatal accidents or issues) and mortality (death). General pediatricians and other clinicians who care for children spend time at each well child checkup asking about things that can lead to bad outcomes and recommending certain courses of action to decrease the likelihood of that event.

Primary care involves relationships. One family at a time. It is the equivalent of retail politics, knocking on one door, making that one connection. At the end of a day of seeing patients, that is between 25 and 32 connections.

Over time, those connections evolve into trust. The goal and the joy of pediatrics are to see those individual relationships flourish over the course of a child's life as we watch the parental process of raising a child to be a happy, healthy, and successful adult. We encourage and promote the process by sharing bits of developmentally appropriate advice. It is anticipatory guidance, delivered to one family at a time.

The list of required and recommended things to do and ask at a given well child visit greatly exceeds the time allotted to cover such topics. And that's if there are no questions from the family or clinically complicated issues. Couple this time crunch with the fact that the recall by patients of what was discussed by clinicians during a visit is rarely better than 20%, and we have a situation that places our anticipatory time and topics at a clear premium.

Question: When it comes to pediatric anticipatory guidance, what's the biggest return on investment? What is the relationship between what we ask and what actually harms or kills children? Are we asking the right questions?

Do we even know what the leading causes of childhood mortality are?

Pop quiz:

Excluding congenital conditions, and just among the conditions listed below, can you order, from most to least, these annual causes of death in children aged 1-20 years in the United States?*

  • Motor vehicle accidents

  • Cancer

  • Firearms

  • Poisonings

  • Drug overdose

*Because this quiz references children over the age of 1 year, sleep-related deaths, including SUID, were not included.

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