WASHINGTON – A new edition of the Bright Futures guidelines is scheduled for release in 2016, and among the expected changes are a recommendation for developmental screening at 4 years and an increased emphasis on the “social determinants of health.”
Revisions planned for the 4th edition of the Bright Futures Health Supervision Guidelines for Infants, Children, and Adolescents, including the American Academy of Pediatrics Periodicity Schedule, are notable not only because they reflect new evidence, but because the services recommended in the guidelines are required by the Affordable Care Act to be covered by insurers without any cost sharing, Dr. Joseph F. Hagan Jr., a pediatrician in Burlington, Vt., and coeditor of Bright Futures, said at the annual meeting of the American Academy of Pediatrics.
Dr. Joseph F. Hagan Jr.
The current Recommendations for Preventive Pediatric Health Care – Periodicity Schedule – which represents a consensus of the Bright Futures advisory committee and the AAP – recommends standardized developmental screening at ages 9, 18, and 30 months, and autism screening at ages 18 and 24 months.
The expected addition of developmental screening to the 4-year health supervision visit will be in keeping with the tools most often utilized in pediatric practices, such as the Ages & Stages Questionnaires, which are validated for screening in children up to 5 years of age. “A lot can happen in 18 months [since the 30-month visit],” Dr. Hagan said.
In 2015 the U.S. Preventive Services Task Force assigned a “I” evidence rating to screening for speech and language delays and disorders in children aged 5 and younger, which means it found insufficient evidence to recommend for or against screening. Still, developmental screening meets a minimum standard for Bright Futures of being “evidence informed” in its recommendations for services and screening, Dr. Hagan said.
“We have tried to provide at least evidence-informed recommendations for the content each of the 31 visits you provide from birth to age 21,” he emphasized. Evidence was “important in the 3rd edition and it’s essential in the 4th. We must have a strong evidence base when we make a recommendation for something new that insurance companies will need to pay for.”
Outside of the Periodicity Schedule, Bright Futures offers recommendations for health promotion and anticipatory guidance, and some of these recommendations are consensus based rather than evidence based or evidence informed. However, a lack of evidence “doesn’t necessarily mean lack of efficacy,” he said at the meeting. “It usually reflects a lack of study in children.”
The updated guidelines – which, like previous versions, have been funded by the U.S. Department of Health and Human Services and will be published by the AAP – will include an expanded chapter on rationale and evidence for each recommendation so that “you can see transparently what we chose and why,” Dr. Hagan told this newspaper.
The social components of health have been a core component of the Bright Futures guidelines since their inception in 1994, but the upcoming 4th edition will more specifically incorporate social determinants of health as a visit priority for most of the recommended health supervision visits, he said.
Some of the other expected changes to Bright Futures address the following areas:
• Motor screening. Recommended developmental surveillance in the updated Bright Futures guidelines will for the first time include evaluation for motor delays, the importance of which was described in a 2013 AAP clinical report (Pediatrics. 2013 Jun;131[6]:e2016-27).
• Maternal depression screening. This was included in the 3rd edition as a selective screen, and was recommended by the AAP in a 2010 clinical report on recognition and management of perinatal and postpartum depression (Pediatrics. 2010 Nov;126[5]:1032-9). Finalization of a draft USPSTF statement recommending depression screening in mothers will give Bright Futures and the AAP the evidence it needs to incorporate this screening into the periodicity schedule.
• Safe sleep. Sleep in the parents’ room “for at least 6 months” will be recommended, as well as a move away from swaddling by 2 months of age. The latter is based on consensus opinion. “There’s no evidence, but there’s concern about safety [of swaddling],” Dr. Hagan said. “By the 1-month visit, we should be encouraging parents not to swaddle for sleep.”
• Iron supplementation. The AAP recommended in 2011 that exclusively breastfed infants should receive an iron supplement starting at 4 months, and the 4th edition of Bright Futures will highlight this. And as a reflection of “current best thinking,” the new edition will recommend advising parents that meat is a better source of iron than iron-fortified cereal. “We want to move it earlier in the nutritional schema,” Dr. Hagan said.