Early prevention of parent-infant problems: Anticipatory guidance
- Pre-empt common infant problems like excessive crying and poor sleep patterns
- Promote greater understanding by parents, of individual infants’ temperament and needs
Anticipatory guidance consists of the provision of brief preventive advice by physicians and other healthcare workers in healthcare settings.
Temperament-based anticipatory guidance involves discussion by physicians, about the child's temperament in order to increase parents’ understanding of the child’s individuality and promote better parent-child interaction.
Summary of Evidence:
Anticipatory guidance and written instructions by healthcare professionals in healthcare settings can be effective on a range of outcomes including reduction of parental stress, increasing parents' confidence during the first two months of life, and promotion of alternatives to physical punishment.
One review (Regalado 2000) evaluated the effect of anticipatory guidance for parents during the perinatal period and early infancy. 9 papers (10 trials) met inclusion criteria for the DataPrev review. Two papers (one of which reported on two trials) involved anticipatory guidance to parents based on assessment of the infant’s temperament; three studies evaluated the effect of anticipatory guidance on promoting infant sleep; one study on promoting ‘time out’ as an alternative to physical disciplinary practices; three studies on the effect of anticipatory guidance on promoting more sensitive mother-infant interactions.
Twostudies examined the clinical use of temperament assessments in paediatric primary care. One paper (Cameron 1986) reported two trials of temperament-based anticipatory guidance materials designed to help parents understand and manage caregiving challenges from their infants. The first trial was a large scale RCT. Expected temperament profiles were developed for six clinical issues occurring between the ages of five and twelve months. Parents completed temperament questionnaires for infants when these were 4 months old. A computer programme selected two clinical issues per month for the expected temperament profile that most closely resembled the study infant. Parents received written anticipatory guidance by post about the clinical issues tailored to their infants’ temperament profile. Temperament measured at four months demonstrated significant predictability. More than 80% of parents perceived the guidance materials useful in helping them understand clinical issues and 70% of the sample found anticipatory guidance advice helpful. In a second RCT of the same procedure (contained in the same paper), parents followed the same procedures and were assessed over a two-year period following the birth of healthy newborns. The intervention was of particular value to parents of challenging ("high-energy") infants.
A second cross sectional survey of temperament anticipatory guidance, (Little, 1983) evaluated parents’ perceptions of anticipatory guidance addressing infant temperament. This intervention took place when infants were approximately 6 months old and evaluated at 8 months. 90% of respondents felt they had gained a better understanding of their children and 57% that discussion of infant temperament had changed their approach to parenting.
Three studies found that anticipatory guidance was effective in reducing night waking in infancy. One RCT (Wolfson, 1992) reported that the combination of anticipatory guidance and written material was effective in promoting better infant sleep patterns, reducing stress and increasing parents' confidence during the first two months of life. One further RCT (Pinilla, 1993) and one CCT (Adair, 1992) combined anticipatory guidance with provision of written material. In both cases, experimental group infants experienced significantly less night waking than controls. Efficacy was demonstrated for different behavioural approaches to mild sleep problems. However, behavioural modification techniques were not always effective for children with severe sleep problems.
One study (Sege 1997) was not related to the perinatal period. It evaluated the short-term effectiveness of anticipatory guidance on parents’ use of discipline with children aged 15 – 24 months. The intervention group received discussion about the topic from providers, in conjunction with written materials that promoted the use of “time-out” in place of corporal punishment. There were no significant differences between intervention and control groups in the use of non-violent disciplinary techniques (“time-out”) before or after the well-child visit. However, intervention parents who had not used “time-out” in the past were more likely to report using “time-out” for the first time than parents in the control group.
Three studies examined the effect of anticipatory guidance on parent-infant interaction. One CCT involved prenatal coaching for enhancing parent-infant interaction. Individualised training was provided for new parents on days 1, 2 and 7 of life designed to inform them of newborn capabilities and how to achieve optimal mother-infant interaction. Mothers receiving the intervention showed more effective vocal interactions and were more social during feeding interactions. A further RCT evaluated the effectiveness of providing adolescent mothers with a videotape modelling feeding interactions of mothers and infants. Experimental group mothers reported more favourable interactions and communication with children. In a third study, also an RCT, the intervention group mothers of infants aged 0 – 6 received guidance aimed at enhancing mother-infant interaction, cooperation and play during. Experimental group mothers rated significantly higher on sensitivity, cooperation, and appropriateness of interaction and appropriateness of play.
Anticipatory guidance is the key to achieving two of the primary goals of paediatric care: (1) promoting health and (2) preventing disease.
Anticipatory guidance can be provided by healthcare practitioners in a range of settings. In the US, where it has been most rigorously studied, it is provided by paediatricians. In Europe, it may be provided by health visitors and midwives.
The principles of anticipatory guidance involve three types of tasks: (1) gathering information, (2) establishing a therapeutic alliance, and (3) providing education and guidance. In practice, the first two stages are sometimes neglected. The AAP Handbook on Pediatric Care stresses that without education and the creation of an alliance, the third stage – education – can be ineffective or misguided.
Providing anticipatory guidance in primary care is challenging because of the range and complexity of appropriate issues, the enormous individual differences among normal children and their families, and the limited time in health supervision visits. Despite the time constraints, these challenges can be the greatest source of interesting variety and rewarding physician-patient interactions in the practice of primary paediatric care.
Named programmes in Europe
Other relevant links
- Adair R, Zuckerman B, Bauchner H, Philipp B, Levenson S. Reducing night waking in infancy: A primary care intervention. Pediatrics. 1992;89:585-588.
- Pinilla T, Birch L. Help me make it through the night: Behavioral entrainment of breast-fed infants’ sleep patterns. Pediatrics. 1993;91:436–444.
- Regalado M, Halfon N. Primary care services promoting optimal child development from birth to age 3 years: review of the literature. Arch. Pediatr. Adolesc Med. 2001;155(12):1294-1295.
- Sege RD, Perry C, Stigol L, Cohen L, Griffith J, Cohn M, Spivak H. Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence. Arch Pediatr Adolesc Med.1997;151:392–97.