Bright Futures update focuses on health promotion, social determinants

When it comes to setting the tone for wellness, health promotion, and disease prevention, Bright Futures is a valuable resource for both clinicians and families.

Joseph F Hagan, Jr, MD, FAAP, of Hagan, Rinehart and Connolly Pediatricians, clinical professor in Pediatrics at the Robert Larner, MD, College of Medicine at the University of Vermont, Burlington, and co-editor of the Bright Futures Guidelines, 3rd and 4th editions, provided an overview of the revisions and updates to the Bright Futures recommendations, as well as strategies for weaving these recommendations into well-child visits, during his presentation “Bright Futures update: What has changed and why” at the American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition on Saturday, September 16.

Bright Futures is an evidence-based and theory-based set of tools, strategies, and principles that promotes the health and well-being of children. Geared toward offering guidance to clinicians, families, communities, the health system, and policymakers, the program focuses on the health promotion and disease prevention aspect of the medical home.

“Health supervision done well is essential in pediatric care,” says Hagan, adding the Bright Futures Guidelines, 4th edition, helps clinicians apply the recommendations from the overall program. “The AAP Periodicity Schedule tells us what to do, the Bright Futures Guidelines tells us how to do it well. I think that is why the lecture room for the Bright Futures Guidelines talks is typically full. We pediatricians are proud of our impact on children and families, and we want to do our best possible job,” he says.

The session provided an overview of the clinical content found in the updated 4th edition of the Bright Futures Guidelines, as well information to restructure developmental surveillance and screening, enhance adolescent practice, and understand the social determinants of health and how to promote lifelong health.
Health promotion in the updated guidelines focuses on lifelong health for both families and communities; family support; health considerations for children with special healthcare needs; healthy development; mental health; healthy weight and nutrition; physical activity; oral health; adolescent development; safe social media use with screen-time recommendations; and safety and injury prevention.

New universal screening recommendations in the guidelines include bilirubin screening at every newborn visit; maternal depression screenings at both the 1-month and 6-month visits; and fluoride varnish at the 6-month visit or at first tooth eruption, and repeated as needed through age 5 years with additional fluoride supplementation at the 6-, 12-, and 18-month visits through age 16 years. The guidelines also recommend dyslipidemia screening once between ages 9 and 11 years in addition to the one-time dyslipidemia screening between ages 17 and 21 years that was first introduced in the 3rd edition of the Bright Futures Guidelines.

Other screenings include depression screening for all adolescents beginning annually after their 12-year visit and one-time human immunodeficiency virus (HIV) screening between ages 15 and 18 years.

Changes from the 3rd to the 4th edition include universal audiometry once during early, middle, and late adolescent visits instead of selective audiometry based on risk assessment at all adolescent visits; tobacco, alcohol, and drug screening at every adolescent visit instead of selective screenings based on risk assessments; and universal cervical dysplasia screening beginning at the 21-year visit instead of selective risk-based screening at every adolescent visit.
 

The presentation also covered updates to the Periodicity Schedule. Infant visits should prioritize addressing parental concerns, but should also cover social determinants of health; infant behavior and development; oral health; nutrition and feeding; and safety. Selective screenings based on risk may be performed for blood pressure, hearing, lead, oral health, tuberculosis, and vision.

Additionally, clinical recommendations include maternal depression screenings at the 1-, 2-, 4-, and 6-month visits; safe sleep education including advising parents to keep infants in their room for at least 6 months with no couch-, chair-, or bed-sharing, and to avoid swaddling and the use of bumpers or loose blankets; and the use of iron supplements in breastfed infants aged 4 months and older until iron-rich foods can be introduced.

In terms of developmental screening, the new guidelines suggest performing developmental surveillance at every well-child visit, plus screening with a standardized tool at the 9-, 18-, and 30-month visits or when concerns arise. When screening results indicate a possible problem, referrals for both developmental and medical evaluations and early intervention are recommended. Pediatricians in the medical home should follow up on referrals and track the child’s progress.

Hagan’s session also included an overview of new adolescent guidelines, with the addition of major depressive disorder screenings for teenagers aged 12 to 18 years and all adults. Screenings should include a plan for effective treatment and appropriate follow-up, Hagan says. Other recommendations for adolescents include prepubertal cholesterol screening; universal hearing screenings in early, middle, and late adolescence; HIV screening once between ages 15 and 18 years and as needed additionally based on risk; chlamydia and gonorrhea screening in all sexually active, nonpregnant women aged younger than 24 years; sexually transmitted infection screening; syphilis screening in at-risk patients; and regular drug, tobacco, and alcohol use screening.

The new guidelines have a heavy focus on health promotion and social health determinants. According to Hagan’s presentation, evidence has proven that frontal lobe volume is less in children raised in adverse conditions, and childhood maltreatment is highly associated with problems with health and well-being later in life.

Bright Futures also offers an online tool and resource kit with previsit and supplemental questionnaires; assessment tools; delegation and practice change management advice; coding information; and more.