Clinical guidelines for postpartum women and infants in primary care: a systematic review.

BMC Pregnancy Childbirth. 2014 Jan 29;14:51.doi: 10.1186/1471-2393-14-51.

Haran C, van Driel M, Mitchell BL, Brodribb WE(1).

BACKGROUND: While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.

METHODS: PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.

RESULTS: Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.

CONCLUSIONS: Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.

Preventive services for children and adolescents

Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Preventive services for children and adolescents. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Sep. 96 p. [229 references] Describe por niveles de evidencia todas las actividades preventivas. Actualizado en septiembre 2013.

Study of Well-Child Visits Analyzes Content and Satisfaction

September 19, 2011 — Although most well-child visits for children under 3 years of age are of "short duration," parent satisfaction is generally high, according to the results of a cross-sectional national survey in the October 2011 issue of Pediatrics (published onlineSeptember 19).

Among a subset of 1428 parents who participated in the 2000 National Survey of Early Childhood Health (NSECH), one third reported spending 10 minutes or less with the clinician during their well-child visit, 47% reported visits lasting 11 to 20 minutes, and 20% reported visits of 21 minutes or more, reported Neal Halfon, MD, from the Center for Healthier Children, Families and Communities at the University of California, Los Angeles, and colleagues.

"Longer visits are associated with more developmental screening, discussions of more psychosocial risks, and greater parent satisfaction," they write. However, "even with the shortest visits parent-reported satisfaction generally was high."

The NSECH included 2068 parents of children aged 4 to 35 months, of whom 1428 provided details about their well-child visit within the past year.

Participants were asked about the length of the visit, their satisfaction with the visit, and the content of care in terms of anticipatory guidance, psychosocial assessment of risks, developmental assessment, and family-centered care.

Regardless of the length of visit, more than 80% of parents reported receiving anticipatory guidance on immunizations and breastfeeding, with more issues such as sleeping position, feeding issues, and car seats being included in longer visits.

"The pattern indicated that traditional topics that have been part of anticipatory guidance for decades are most likely to be addressed, whereas topics added more recently are less likely to get mentioned when time is short," the authors write.

"Overall, many anticipatory guidance topics were provided more frequently than a developmental assessment (which ranged between 50% and 68% depending on the visit length)," they note.

Ninety-nine percent of parents reported having adequate time with their doctors when the visit was 21 minutes or longer, compared with 76% of parents whose visits lasted 10 minutes or less.

Parental satisfaction remained higher with longer visits even after adjustment for the content of the visit, supporting the notion that "a trusting relationship and good communication between parents and their child’s pediatrician is a key component of optimal well-child care," they suggest.

The authors note that demands on pediatricians performing well-child visits continue to expand as new directives clash with time constraints and lack of reimbursement.

"Efforts to improve preventive services will require strategies that address the time devoted to well-child care," they note.

A focus on parent-identified concerns, the integration of previsit questionnaires, tiered systems that allot more time to higher-risk children, and the division of some care with nonphysician clinicians are among suggested strategies that might enhance care, they write.

"Ultimately, greater reimbursement for preventive and developmental services may best encourage the devotion of time and attention to their provision," they conclude.

The study was supported by the Commonwealth Fund and the Gerber Foundation. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 19, 2011.

Preventive services for children and adolescents.

Preventive services for children and adolescents.
Institute for Clinical Systems Improvement (ICSI). Preventive services for children and adolescents. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Sep. 84 p. [193 references]

Las recomendaciones 2010 sobre actividades preventivas en niños y adolescentes

Guide to Clinical Preventive Services, 2009 Recommendations of the U.S. Preventive Services Task Force

Guide to Clinical Preventive Services, 2009
Recommendations of the U.S. Preventive Services Task Force

Resumen de las recomendaciones de la USPSTF con fecha del 2009. En http://www.ahrq.gov/clinic/pocketgd09/pocketgd09.pdf se puede bajar las recomedaciones.
Interesante también el manual de procedimientos de la institución descargable en http://www.ahrq.gov/clinic/uspstf08/methods/procmanual.htm
Por último su escala de grado de la recomendación se puede bajar en http://www.ahrq.gov/clinic/uspstf/grades.htm

Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model

Howard Dubowitz, MD, MS, Susan Feigelman, MD, Wendy Lane, MD and Jeongeun Kim, PhD.
CONTEXT. Effective strategies for preventing child maltreatment are needed. Few primary care–based programs have been developed, and most have not been well evaluated.
OBJECTIVE. Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment.
METHODS. A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0–5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale.
RESULTS. Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis.
CONCLUSIONS. The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.