Evidence based well child care
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7317.846 (Published 13 October 2001) Cite this as: BMJ 2001;323:846
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With great interest I read the article about evidence based well
child care. What specially caught my attention me was the authors'
suggestion that there was a serious lack of evidence regarding the
effectiveness of well child examination, in particular the routine checks
on healthy children.1 If, however, the situation in The Netherlands is
anything to go by, this perceived lack of evidence is due to a severe
publication bias.
In October 1999, my thesis 'Long-term effects of preventive
activities of youth health care (YHC) for schoolchildren in The
Netherlands' was published.2 In this thesis, an assessment was made of the
long-term health effects of a selection of YHC activities at primary and
secondary schools: screening, well-care visits, and open consultation
hours at secondary schools. In a nutshell, the results almost invariably
showed no positive influence of any of the activities studied. If any
influence could be demonstrated, it invariably was detrimental to the
health outcome targeted. Needless to say, this study gained me no lasting
friendships among my fellow YHC physicians.
From the thesis, several articles were published in various international
journals. However, the interested researcher will not find any references
in the official review of Dutch literature on YHC,3 or a (customary)
review of the thesis in a Dutch YHC journal. A comparable fate befell two
earlier theses, published in 1983 and 1985, in which YHC activities were
also criticised. The official standpoint of the Dutch YHC Association, as
taken during one of their scientific conferences in 2000, is literally:
'the less said about it, the better' (official conference report). In this
setting it is no wonder, literature searches regarding effectiveness of
these preventive measures yield little or no results, let alone that
critical research is encouraged.
An explanation can be sought in the fact that in The Netherlands
curative medicine (and thus, treatment) and preventive medicine are
strictly separated, often much to the chagrin of the latter, as they are
regarded by some as physicians of a somewhat 'lesser order'. Therefore,
the YHC physicians have trouble relinquishing the curative 'doctor-
patient' setting, they were trained in for so many years. As well child
examinations – in most cases taking up more than 75% of the available time
– come very close to this setting, it is no wonder, that any criticism on
these activities is directly translated into an attack on a cherished and,
dare I say it, rather comfortable way of life.
1. Dinkevich E, Hupert J, Moyer VA. Evidence based paediatrics –
Evidence based well child care. BMJ 2001;323:846-9.
2. Wiegersma PA. Long term effects of preventive activities of youth
health care for schoolchildren in The Netherlands [thesis]. University of
Nijmegen, Nijmegen 1999.
3. Ouwehand LM, Bergink AH, de Moel M, Hirasing RA. Bibliografie
Jeugdgezondheidszorg 1998-1999 (Review of available literature on youth
health care 1998-1999). TNO Prevention and Health, Leiden 2000.
There are no competing interests.
Competing interests: No competing interests
Editor - We read with interest a review of the effectiveness of US
childhood checks in the first 2 years of life1. We in the UK have
received the 4th edition of Health For All Children with new guidance
which is yet to be evaluated in RCTs. It is reassuring that we no longer
need to do numerous screening tests on children who have no cause for
concern. The report, described at 2 national seminars, promotes a
universal programme that delivers a service based on need. That is, after
4 months of age “the health visitors should negotiate the nature of any
further reviews with the parents”. However, it is not clear how at 4
months of age, one would judge the likelihood of future health needs of a
baby. Many factors that place a child at risk are not manifest in
infancy. These include the vulnerable children listed in the
documentation about the report 2, e.g. disability, special educational
need, abuse, or homelessness. Other examples are less extreme, e.g.
failure to thrive, speech and language delay, and behaviour problems.
Although, screening does not detect these difficulties, contact of high-
risk families with health visitors can lead to detection of problems and
opportunities for health promotion.
Furthermore, the report will legitimise and encourage health
promotion by health visitors, but the suggested methodology will not be
practical with some families in need. It is suggested that written health
promotion information should be provided while “all families can request
and negotiate additional help” 2. This reactive approach is at risk of
increasing the inequalities gap since evidence suggests that those in
greatest need least access health-care for a range of reasons including
the lack of confidence. The notes circulated recognise that “children
living on the edge of poverty would have limited access to health care,
(and) providing appropriate services for these children is a major
challenge” 2. However, there is no indication as to what to do with these
children. Could it be that during negotiations with parents, they will be
‘signed-off’ because of no obvious risk, forgetting that the very nature
of their socio-economic status puts them at high-risk? The guidance will
be a lot more pragmatic if softer family/environment risk factors that are
known to put a child at high-risk were spelt out. Such risk factors have
been used in government initiatives to define geographical areas of high
need which have received Sure Start or Children’s Fund – they include
poverty indicators. Since using individual level risk factors are
stigmatising, Health For All Children could suggest ways of identifying
geographical areas in which no child should be ‘signed-off’. Thus, in
these vulnerable families, as well as screening, a regular contact with
health visitors could engage families in health promotion activities and
problem detection.
References
1. Dinkevich E, Hupert J, Moyer VA. Evidence based well child care. BMJ
2001;323:846-9.
2. Health for all children: HFAC4 and the Core Programme - notes by David
Hall. Health For all Children - 4th edition launch seminar; 2001; London
and Manchester. Harlow Printing Ltd.
Competing interests: No competing interests
Reading the haedlines of the BMJ I was pleasently supprised with the
announcement of 5 planned articles on primary health care. So I download
number one and I will come back to you with comments, but at the moment I
only want to draw your attention to a quite similar proces in the
Netherlands Maybe you are already aware of it. As a result of an order of
the dutch gouvernement all activities of our primary health care system
for children 0-19 years were evaluated on effectiviness, being evidence
based, cost effectiviness and so on. A top 10 list of activities came out
where there was no need for further investigations because the activities
were proven to be effective on all aspects. Ohter activities were divided
in group to be investigated further and also a group where there isn't
kwown any research at all.
May be it's interesting for you to hear more about this results?
Best
regards
Thea Strieder, MD
Competing interests: No competing interests
Well child care - the UK view
Editor
It was good to read the review from the USA on “evidence based well
child care” by Dinkevich and colleagues (1) , but one has to ask “ why has
it taken our USA colleagues so long to question their practice?”. In the
UK, the purpose and value of routine checks on apparently well children
were first questioned at least fifteen years ago (2). Since then we have
reviewed the subject three times (3) and as a result have drastically
reduced the standard UK programme, shifting the balance to a more targeted
approach and placing more emphasis on primary prevention. We are
currently preparing a fourth edition of our report (4).
Proponents of well child care claim a number of benefits in addition
to those examined by these authors. We do not wish to open up that
debate here but suggest that to ignore evidence from other disciplines and
methodologies, and the experience of practitioners and parents, is not
good science.
David Hall,
President, Royal College of Paediatrics and Child
Health, London:
Professor of community paediatrics, University of
Sheffield.
(d.hall@sheffield.ac.uk)
David Elliman,
consultant community paediatrician,
St George’s
Hospital, London:
chair, children’s sub-group, UK National Screening
Committee.
(DavidElliman@compuserve.com)
1 Dinkevich E, Hupert J, Moyer VA. Evidence based well child care.
BMJ 2001:323: 846-9.
2 Baird G, Hall DMB Developmental paediatrics in primary care -
what should we teach? BMJ 1985; 291: 583-6
3 Hall DMB (Ed.). Health for all children. Oxford: OUP. 1st
edition 1989; 2nd edition 1992; 3rd edition 1996.
4 www.health-for-all-children.co.uk
Competing interests: No competing interests