Well Child Care: Components, Benefits, History, and Future Need

William B. Pittard III, MD, PhD, MPH

Introduction

Well child care is designed to promote optimal physical, social, and cognitive development for children birth through twenty years. A broadly accepted manifestation of success for this preventive care in the preschool years is increased time without illness and readiness for first grade learning. Increased wellness time should promote greater opportunity for playing and interacting with other children and adults, facilitating socialization, school readiness, and more long-term life success. Specifically, well child visits in the preschool years include an assessment of physical growth, anticipatory guidance for parents or caregivers, immunizations, and screening procedures for illness and abnormal vision, hearing, and cognitive development.

This chapter presents an overview of well child care, describing its components and anticipated benefits for children. The history of governmental recognition of need for well child care and its funding for low-income children includes the Children's Bureau; the Sheppard-Towner Act; the American Academy of Pediatrics (AAP); Medicaid and the confrontations and controversies surrounding its early and periodic screening, diagnosis, and treatment (EPSDT) benefit for children; and the establishment of the State Children's Health Insurance Program (SCHIP). The chapter concludes with a look at future needs for maternal and child preventive care.

Components and Benefits

Well child visits offer clinicians an opportunity to identify and address problems that might impede optimal growth and development. The AAP recommends frequent well child/EPSDT visits in the preschool years, including six visits in year one, three visits in year two, two in year three, and one visit annually thereafter. An initial visit during the prenatal period provides child health education and anticipatory guidance for soon-to-be parents, and post-delivery visits offer age appropriate immunizations, developmental and sensory evaluations, assessment of nutrition status and oral health, and age-specific parenting education. Parents of children with the recommended number of visits in infancy should receive more information than parents of children with fewer visits about cognitive stimulation for their children and about avoiding risks to cognitive health such as lead exposure, accidents, and under-nutrition. Recommended topics for parental anticipatory guidance include advice regarding physical activity, appropriate use of health care services, parent-child reading, and avoidance of household toxins. Developmental screening includes assessment of height and weight, vision, hearing, language skills, and behavior; the screening is designed to facilitate the early implementation of corrective measures for any abnormality detected with improved health outcomes.

Despite the benefits of well child care, it is not always utilized. Due to cost and lack of information confirming well child care effectiveness, privately insured children have been reported to under-use well child care particularly in the preschool years. In contrast, despite government funding, the Medicaid EPSDT/well child benefit is more likely to be underutilized by low-income children than well child care by privately insured children.

Although providing well child care involves cost, not using well child visits often results in still greater medical cost. Low-income children also more frequently use emergency department and in-hospital, non-primary care provider services for non-urgent ambulatory care sensitive condition (ACSC) diagnoses than higher income children. ACSC diagnoses include asthma; seizure; cellulitis; ear, nose, and throat infections; bacterial pneumonia; kidney and urinary tract infections; and gastrointestinal infections and are illnesses routinely treated in a primary care provider (PCP) office setting. Increased use of ACSC ED visits has been directly associated with both inadequate EPSDT/well child care utilization by Medicaid-insured children and by lack of a regular medical home by low-income children. These characteristics may reflect lack of awareness by low-income parents of the availability of EPSDT and its beneficial effects on the physical, social, and cognitive development of children.

History

The Children's Bureau

The history of well child care in America began with publicly recognizing the need to identify the causes for and methods to prevent maternal and child mortality. With this issue in mind, President Theodore Roosevelt called a conference in Washington DC in 1909, subsequently referred to as the first White House Conference on Children. A significant recommendation from this conference was for the establishment of a federal Children's Bureau. After much debate in Congress, President William Howard Taft approved and signed the Children's Bureau into law on April 9, 1912.

The mission for this bureau was "to investigate and report on all matters pertaining to the welfare of children and child life among all classes of our people". Bureau staff initiated studies to identify the social and economic factors contributing to maternal and child morbidity and mortality in both rural and urban settings. The bureau also initiated the routine registration of all births nationwide and the publication of guidelines regarding appropriate prenatal and infant care; these guidelines were presented at professional meetings and were made available to the public.

The Sheppard-Towner Act and the Academy of Pediatrics

Early Children's Bureau findings led to yet another pivotal Congressional action strongly endorsed by the newly established contingency of women voters. This action was known as the first Maternity and Infancy Act (or the Sheppard-Towner Act) of 1921. The act provided maternal and child health services such as maternal outreach education and support through pregnancy and postpartum, as well as instruction regarding parenting and child health needs. These activities were funded through federal grants-in-aid and matching state funds. With these monies, so-called Sheppard-Towner clinics were established in all but three states (Connecticut, Illinois, and Massachusetts), where opposition was strongest to government-sponsored support for the health of mothers and children. During the Congressional debates preceding approval of the Sheppard-Towner Act, many...