Anticipatory guidance is information conveyed to parents verbally, in written materials, or even directing parents to certain Internet websites to assist them in facilitating optimal growth and development for their children. Anticipatory guidance that is age relevant is another part of the Bright Futures guidelines. Bright Futures has a “toolkit” that includes the topics and one-page handouts for families (and for older children) about the highest yield issues for the specific age. Table 9-5 summarizes representative issues that might be discussed. It is important to review briefly the safety topics previously discussed at other visits for reinforcement. Age-appropriate discussions should occur at each visit.
The most common cause of death for infants 1 month to 1 year of age is motor vehicle crashes. No newborn should be discharged from a nursery unless the parents have a functioning and properly installed car seat. Many automobile dealerships offer services to parents to ensure that safety seats are installed properly in their specific model. Most states have laws that mandate use of safety seats until the child reaches 4 years of age or at least 40 pounds in weight. The following are age-appropriate recommendations for car safety:
Infants and toddlers should ride in a rear-facing safety seat until they are 2 years of age, or until they reach the highest weight or height allowed by the safety seat manufacturer.
Toddlers and preschoolers over age 2 or who have outgrown the rear-facing car seat should use a forward-facing car seat with harness for as long as possible, up to the highest weight or height recommended by the manufacturer.
School-age children, whose weight or height is above the forward-facing limit for their car seat, should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 ft 9 in. in height and are between 8 and 12 years of age.
Older children should always use lap and shoulder seat belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. This is specifically to protect them from airbags, which may cause more injury than the crash in young children.
The Back to Sleep initiative has reduced the incidence of sudden infant death syndrome (SIDS). Before the initiative, infantsroutinely were placed prone to sleep. Since 1992 when the AAPrecommended this program, the annual SIDS rate has decreasedby more than 50%. Another initiative is aimed at day care providers, because 20% of SIDS deaths occur in day care settings.
See Table 9-5 as well as the Bright Futures’ recommendations (found at http://brightfutures.aap.org/clinical_practice.html )for presentation of age-appropriate activities that the pediatrician may advocate for families.
Discipline means to teach, not merely to punish. The ultimate goal is the child’s self-control. Overbearing punishment to control a child’s behavior interferes with the learning process and focuses on external control at the expense of the development of self-control. Parents who set too few reasonable limits may be frustrated by children who cannot control their own behavior. Discipline should teach a child exactly what is expected by supporting and reinforcing positive behaviors and responding appropriately to negative behaviors with proper limits. It is more important and effective to reinforce good behavior than to punish bad behavior.
Commonly used techniques to control undesirable behaviors in children include scolding, physical punishment, and threats. These techniques have potential adverse effects on children’s sense of security and self-esteem. The effectiveness of scolding diminishes the more it is used. Scolding should not be allowed to expand from an expression of displeasure about a specific event to derogatory statements about the child. Scolding also may escalate to the level of psychological abuse. It is important to educate parents that they have a good child who does bad things from time to time, so parents do not think and tell the child that he or she is “bad.”