Evidence for well-child-care advice is scanty

Recommendations for office-based preventive interventions have expanded greatly, requiring far more time than a health-care provider has to perform them. But how many interventions are supported by evidence of effectiveness?

To find out, investigators searched the literature for high-quality systematic reviews and both randomized and controlled nonrandomized trials of 42 preventive interventions (not including immunizations, the effectiveness of which has been amply demonstrated). The studied interventions were recommended by at least two of seven major organizations, including the American Academy of Pediatrics, the Bright Futures project, and the US Preventive Services Task Force. The literature review showed that no trials or reviews have been conducted on the effectiveness of making many of these office-based recommendations-particularly for screening activities-and that even fewer (discussed below) are supported by direct evidence.

In regard to behavioral counseling interventions, some studies found modest benefit from counseling for seat belt and car seat use, bicycle helmet use, safe road-crossing behavior, smoke alarm use, and safe tap-water temperature. No effect was found for brief counseling on seat belt use, childproofing, poison prevention, and firearm safety. Exposure to passive smoking was unaffected by brief counseling, with more intensive efforts showing modest effects. Recent reviews and trials of counseling for prevention of sexually transmitted disease and pregnancy had mixed results. One-on-one health education may contribute to initiation of breastfeeding among low-income women, studies showed.

Commentary: This study makes clear the need for evidence to support our well-child-care practices. Our time and resources are limited, so we should spend both on efforts that have been shown to work. But what do we do while waiting for careful studies of these practices? Don't throw in the towel! Instead, continue to do what seems best, relying on the guidance of the American Academy of Pediatrics and other professional groups. Choose a reasonable course but be open to change as better evidence makes the best way clear.