title: Gaps in the evidence for well-child care: a challenge to our profession.
abstract: BACKGROUND
  Up to one third of visits to pediatricians involve health supervision (well-child care), and recommendations for office-based preventive interventions have dramatically expanded. We reviewed the evidence for the effectiveness of these interventions.
  
  
  METHODS
  The well-child care recommendations of 7 major North American organizations were tabulated. Three types of health supervision interventions were recommended, ie, behavioral counseling, screening, and prophylaxis. For recommendations common to at least 2 of the 7 organizations, evidence of effectiveness was sought from systematic reviews and clinical trials. Immunizations were not considered for this review, because they have been reviewed elsewhere.
  
  
  RESULTS
  Forty-two preventive interventions were recommended by > or =2 of the organizations. Limited clinical trials show that counseling can change some health risk behaviors; repeated intensive counseling is most likely to be effective. Harmful effects were shown for a few behavioral counseling interventions. Trials have been conducted for only 2 of the recommended screening interventions; therefore, rigorous evidence supporting screening is very limited. Trials support the use of folate to prevent neural tube defects, trials of iron supplementation do not address developmental outcomes, and trials were not found for the other recommended prophylactic interventions.
  
  
  CONCLUSIONS
  Limited direct evidence was found to support the recommended interventions. Because a large number of interventions are routinely recommended and often mandated and because the implementation of any recommendation may cause harm (including the displacement of other beneficial activities), these recommendations should be based on the strongest possible evidence. When recommendations are made, supporting evidence should be clearly stated.
authors.affiliation: University of Texas-Houston Health Science Center, Houston, Texas, USA. virginia.a.moyer@uth.tmc.edu
authors.forename: Virginia A
authors.initials: VA
authors.lastname: Moyer
authors.forename: Margaret
authors.initials: M
authors.lastname: Butler
mesh_terms: D000293:Adolescent; D002648:Child; D002662:Child Health Services / Q000592:standards*; D019317:Evidence-Based Medicine; D006801:Humans; D008403:Mass Screening / Q000592:standards*; D009656:North America; D017410:Practice Guidelines as Topic / Q000592:standards*; D011314:Preventive Health Services / Q000592:standards*; D011322:Primary Prevention / Q000592:standards