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Anticipatory guidance

Not just for patients

Maurer, Brian T. PA-C

Journal of the American Academy of PAs: June 2016 - Volume 29 - Issue 6 - p 66
doi: 10.1097/01.JAA.0000483109.79649.90
The Art of Medicine
Free

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

Figure

Figure

A PA student accompanies me to see a 6-month-old for his well-child check. His mother looks up at both of us and smiles. I introduce the student and start the interview with an open-ended question: “How are things going with Bobby?”

“Just fine,” the mother says. “He rolls over both ways, and he can sit up now. He's very vocal—talks all the time, don't you Bobby?” As though on cue, the infant laughs from his mother's lap.

“How are the feedings going?” I ask. “What does he eat over the course of the day?”

The mother launches a detailed litany of the boy's daily intake: five breastfeedings interspersed with three feedings of beikost: cereal, pureed fruits, and vegetables. “I put him to breast once more before bed, and he sleeps through the night,” she beams.

“He's certainly getting plenty of calories,” I say, demonstrating his robust percentile rankings on the growth chart. “Let's look at him.”

I examine Bobby as he sits in his mother's lap. He appears to be a healthy, cherubic infant—the classic Gerber baby.

“Bobby's growth and development are right on target,” I say. “We ought to see him back in 3 months for his 9-month well-child check.”

“Meantime, remember that he'll become a bit more mobile over the next month or two. If you haven't already done so, now would be a good time to do a home safety survey and baby-proof your house.” Briefly, I discuss locks on cabinet doors, covers for electrical outlets, gates for stairs. “Questions? No? Good—the nurse will be in shortly to give him his shots.”

“So that's a typical 6-month well-child check,” I explain to the PA student as we amble down the hallway. “It's important to document any interim illness, growth and development, feeding, elimination, sleep—and also anticipatory guidance. First-time parents don't know exactly what to expect. You have to keep in mind the sorts of things the child will be doing before you see him back again at the next checkup. That will determine the guidance you give the parent.”

Later that afternoon, the student and I see a 12-month-old girl for well care. This visit does not go as smoothly as the other one. The child's weight has plateaued over the past 3 months. “How are the feedings going?” I ask the mother.

“Terribly,” she says, almost in tears. “She wants to feed off me all the time. She won't take solids from a spoon. She just spits them out and reaches for my breast. I'm exhausted. She's up at least 3 times every night. The only way I can get her back down is to put her to breast. I'm at my wit's end. What should I do?”

“Will she drink from a cup?”

“She doesn't like the sippy; but if I help her, she'll drink from a regular cup.”

“That's great! If she can drink from a regular cup, offer her whole milk—but try to feed solids first. That way she'll be hungry, and we should be able to get some additional calories into her. I'm afraid that breast milk alone is no longer adequate for her.”

“What can she eat besides baby food?” the mother asks. “I'm so afraid she'll choke.”

“She can have food from the table,” I say. “Just don't give her anything that doesn't break up easily in the mouth. Avoid nuts, peanuts, whole grapes. Be careful with meat. It should be well cooked and cut up into small bits. She can finger feed herself.”

“I can let her feed herself?” the mother says. “I didn't know. Nobody told me that before. Now, how can I get her to sleep through the night?”

I counsel the mother on proper infant sleep hygiene, finish the examination, and explain the vaccines her daughter will get today. “Let's see her back in a month for a weight check,” I say.

“Thanks so much,” the mother says as the student and I step out of the room.

“There you had the opportunity to see what sometimes happens when we fail to provide proper anticipatory guidance to parents. Things devolve into disasters, and they're much harder to fix.”

“I'm so green at this,” the student says. “How will I ever learn everything I have to know to be a good PA?”

“Little by little,” I say. “The more you engage with patients, the easier it will become. Learn to cultivate your approach to the patient. Always think about the next step, and you'll do fine.”

Anticipatory guidance: it is not only good for parents; it also is helpful for student clinicians at the outset of their careers in medical practice.

Copyright © 2016 American Academy of Physician Assistants