Anticipatory Guidance and Safety

This section provides background on anticipatory guidance, addresses some common topics, offers commentary on the guidance (often gained from preceptors and leading experts), and supplies links to resources and informative videos. A full review of anticipatory guidance in pediatrics could fill volumes. The Bright Futures website contains a research-based list of guidelines compiled by the American Academy of Pediatrics (AAP).

In this section, we address the following topics:

• Principles of Anticipatory Guidance

• Feeding, Nutrition, and Oral Health

• Sleep

• Illness and Injury Prevention and Safety

• Childproofing and Safety Proofing

• Activities

• School and Education

• Emotional Well-Being

• Behavior and Habits

• Anticipatory Guidance During Adolescence

Principles of Anticipatory Guidance

Anticipatory guidance is a cornerstone of pediatrics and one of the key features of a well child visit, yet there is no consensus about the topics that should be covered and very little evidence about the effectiveness of anticipatory guidance. One study found that parental recall dwindled when more than eight topics were covered.

Approaches for tailoring guidance include:

• age based: tackling the developmental considerations at a given age (e.g., childproofing for toddlers, use of helmets in school-age children)

• public health based: centered in epidemiology and evidence of common sources of harm and illness (e.g., water safety for children living in coastal areas, lead safety for children living in older homes)

• parental priority based: addressing issues that parents identify as most important (e.g., adjusting to a life change such as divorce, death, or moving)

Social determinants of health: Social determinants of health were recently incorporated into the Bright Futures guidelines and are discussed in the Community and Societal Pediatrics section of this rotation guide.

Development: Anticipatory guidance regarding development often revolves around helping families understand what milestones to expect between the current visit and the next. These achievements inform many of the other topics covered in anticipatory guidance (e.g., self-feeding follows attainment of key motor skills). See the Growth and Development section in this rotation guide for more on developmental milestones.

Feeding, Nutrition, and Oral Health

Breastfeeding: Breast milk is the ideal food for infants. When promoting breastfeeding, it is critical to address the particular needs and goals of each family and try to provide guidance directed at the challenges each dyad is experiencing. Find informative videos on breastfeeding at Global Health Media.

• Pain with breastfeeding is a common challenge that often can be improved by adjusting the latch.

• Maternal fatigue is also common. Supportive resources include friends, family, local community resources, and lactation consultation.

• Struggling parents who are ready to switch to formula sometimes benefit from reassurance that any breast milk is better than none and a combination is OK. It is important to support families in their choices around whether or not to feed infants formula.

• All breastfed infants should receive supplementation with 400 international units (IUs) of vitamin D daily. Although breast is best, that doesn’t mean it contains absolutely everything a baby needs. Even a mother who is vitamin D sufficient does not pass enough in breast milk to prevent rickets.

Formula feeding: Families who choose to feed their infants with formula should be supported. Often families have questions about formula choice, because standing at a wall of formula in a store can be daunting.

• Recommend choosing a basic iron-fortified milk-based formula and then sticking with it. No need for nonstandard variations (e.g., lactose-free, soy, gentle).

Starting solid foods: Not all that long ago, pediatricians provided strict guidance on what foods to start and when. However, little evidence exists to support a strict order for starting solids. Here’s what we know:

• Infants should be exclusively breast- or formula-fed for 4 to 6 months and should receive no solids before the age of 4 months.

• A baby is ready to start solids when they demonstrate interest, have good head control, can swallow safely, and are demonstrating adequate weight gain.

• Solids should provide a source of iron (iron-fortified cereal, leafy greens, or blended meat), because by age 4 to 6 months infants start to exhaust their iron stores.

• The choice of first solids is highly influenced by culture.

• Research does not support avoiding typically allergenic foods. In fact, evidence is growing that early introduction actually prevents the development of food allergies.

• The National Institute of Allergy and Infectious Diseases expert panel suggests that age-appropriate peanut-containing foods should be freely introduced into the diet of infants without eczema or any food allergy, together with other solid foods and in accordance with family preferences and cultural practices.

Transitioning to cow’s milk: The introduction of cow’s milk usually starts at about 12 months. Before that, the only fluids infants should receive are breast milk, formula, or water. Some families choose to breastfeed longer than 12 months, but most choose to wean to whole milk.

• Cow’s milk should not replace breast milk or formula before age 12 months. Cow’s milk is not as nutrient dense as breast milk or formula.

• Families often need reassurance that milk intake often drops during weaning and more calories and nutrition should come from solids. However, vitamin D supplementation is indicated. Water is a good choice for fluid intake other than milk. Juice is not necessary and should be discouraged, along with all other sugared beverages, such as soda.

• Excessive cow’s milk intake has been linked with iron-deficiency anemia.

Oral Health

Early oral health is important for lifelong dental and medical health. A good start to oral health can begin even before babies have teeth.

• Certain bacteria in a parent’s or caregiver’s mouth may cause a child to develop tooth decay if saliva is exchanged and the caregiver has a history of caries. The recommendation is that caregivers avoid cleaning pacifiers with their saliva and avoid sharing utensils.

• When babies’ teeth erupt (between ages 6 and 12 months), caregivers should begin to clean the child’s teeth regularly. Teeth can be cleaned with a toothbrush and a small amount (the size of a grain of rice) of fluoridated toothpaste.

• Parents should avoid the use of bottles in the bed and should clean the teeth after the last feeding of the evening.

Fluoride: In many urban areas, water is fluoridated by the city. However, if children only drink bottled water, they may not receive adequate fluoride. In rural areas, many sources of well water or small municipalities are not fluoridated.

• Fluoride supplements are indicated to help prevent caries if the primary water source is not fluoridated.

• All children can have fluoride varnishes as often as every 3 months in either a dental or medical home.

Sleep

Safe sleep: Sudden infant death syndrome (SIDS) is the leading cause of death in infants ages one month to one year. A safe sleep environment reduces the risk of SIDS and other sleep-related causes of infant death. Good resources for safe sleep include Safety in Seconds and the NIH Safe to Sleep Campaign.

Key elements of a safe sleep environment include:

• Place infants on their backs every time they are put down to sleep.

• Use a firm sleep surface (not a bouncer).

• Use a crib, bassinette, or other sleep environment free of pillows, blankets, bumpers, stuffed animals, and other loose objects.

• Provide a smoke-free environment.

• Do not allow infants to sleep in an adult bed, chair, or couch alone or with anyone else.

Sleep training: Advice on sleep training is as varied as the providers giving advice. It is important to identify the family’s sleep goals and engage in shared decision-making. Sleep training can start when a baby no longer needs to be fed overnight and starts to have self-soothing skills, typically around 4 months. Some families are comfortable with the “cry it out” method, but many are not.

• One approach is to gradually transition parental support from holding the child to sitting beside the bed, by the door, and eventually outside the room. Although every child will have to learn to go to sleep on their own, every family will feel differently about when that should be.

• Guidelines on sleep can be found at HealthyChildren.org.

Bedtime routines: Bedtime routines may differ by age. For example, young babies often feed and young children often brush their teeth, have a bath, and read a book. Older children and adolescents may have varied routines that include listening to soothing music, reading, drawing, or journaling. At all ages, a routine helps train the brain to expect sleep. An important part of a bedtime routine is to avoid high-energy activities and screen time for at least an hour beforehand because the light and stimulation disrupt sleep.

Sleep hygiene: Sleep needs vary by age (as shown here) and by the individual. Newborns can sleep anywhere from 11 to 19 hours per day. Over time, the required sleep time decreases to an average of 8 to 11 hours per day for teens.

Some elements of sleep hygiene include:

• a bedtime routine

• no screen time at least one hour before bed (and none in bed or in the bedroom)

• a consistent bedtime and waking time

• little or no caffeine in the diet or avoid caffeine in the afternoon and evening

• minimizing all liquids 1-2 hours before bedtime

• making daytime light and bedtime dark: get up and be exposed to light; exercise during the day; eliminate extra lights at night, and use blinds if bedtime occurs before sundown

Illness and Injury Prevention and Safety

This topic is amenable to a public health approach to anticipatory guidance. The following table shows the leading causes of injury deaths by age:

(Source: 10 Leading Causes of Injury Death by Age Group 2020. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control 2020.)

Fires and burns: Fire safety and burn prevention is more than “stop, drop, and roll.” The following websites provide useful resources and recommendations:

• Start Safe Fire: How to Prevent Fires and Burns at Home

• HealthyChildren.org (Fire Safety: Protecting Your Family from a Home Fire)

• AAP Patient Education (Keep Your Family Safe: Fire Safety and Burn Prevention at Home)

Water safety: Water can be a great source of fun but also a source of risk for children. Close supervision is important to prevent drowning. The following are some prevention strategies:

• “Touch supervision” (an adult stays within touching distance of a child in the water) is recommended for children younger than 5 years and for inexperienced swimmers.

• A “water watcher” is an adult designated to watch older and more experienced children who are playing in the water.

• Avoid “diffusion of responsibility” wherein no one is responsible for the children despite adults being present.

• Gates or fences around pools can dramatically reduce the risk of drowning.

• See Safety in Seconds: Water Safety and Gary on the Street: Water Safety for more guidance on water safety.

Car seats: Familiarize yourself with resources for car seat selection and installation. Families often have questions about whether their car seat is installed correctly. You can search for local organizations that perform car seat safety checks at the National Highway Traffic Safety Administration.

(Source: Child Passenger Safety. Centers for Disease Control and Prevention 2024.)

Childproofing and Safety Proofing

Childproof before a child starts exploring and continue to monitor over time. The following websites provide childproofing guidance for parents:

• Childproofing Your Home for Poisons

• TV and Furniture Tip-Overs

Medications and poisoning: All medications, including over-the-counter medications, as well as household cleaning items and other poisonous products should be stored out of reach or in locked or otherwise childproof cabinets. Every household should have the Poison Help Center number readily available.

• Poison Control (1-800-222-1222)

• Simple Steps to Safe Medicine Storage

Firearm safety: Firearm injuries are now the leading cause of death among children and adolescents. About 30% of homes with children also contain guns. Precautions are necessary when children are in an environment where guns are present. It is important to ask if guns are in the home or other homes where children spend time.

Families should be counseled on taking the following precautions:

• Lock all guns and ammunition separately and use child-resistant gun locks on all of them.

• Temporarily remove guns from the home if a child or other family member is depressed: the leading cause of death by guns is suicide.

• Ask about the presence of guns in homes of friends and relatives and confirm they are locked before leaving children for visits.

(Source: Current Causes of Death in Children and Adolescents in the United States. N Engl J Med 2022.)

Activities

Tummy time: Physical activity starts in infancy. Supervised tummy time while an infant is awake provides an opportunity for them to safely spend time in a prone position to develop needed motor skills involving the neck and back and to help prevent the development or worsening of positional plagiocephaly or head flattening. Keep it simple for families.

• Advise caregivers to spread a blanket on the floor and lay the baby down on the tummy. Some infants may not like this position at first. Adults can encourage tummy time by joining the infant on the blanket while talking and smiling and starting with a few minutes several times a day and increasing the amount of time until tummy time becomes a regular routine as the baby grows and has more interest in playing with toys.

Promoting physical activity: Young children often get physical activity just from routine play. If TV and screen time is limited and they are offered opportunities to go outside, most children get the activity they need. For older children, organized sports help to plan active time into busy schedules. Recommendations for physical activity can be found here.

Families should be encouraged to find local activities that are free or low-cost. Clinicians should be aware of what activities are offered by their community and be sensitive to families’ concerns about safety.

Helmets: Talking with children and their parents about bike helmet safety is another important part of anticipatory guidance. Research indicates that use of a properly fitted helmet significantly reduces risk of injury from a fall while bicycling, snowboarding, or participating in another recreational sport. Safety in Seconds: Bike Helmets provides a video of how to properly fit a bike helmet on a child, and the AAP has published guidelines on helmet use.

Media, TV, and the internet: Family rules should establish limitations on screen time and safe internet use. All families should be encouraged to discuss internet safety with their children. The AAP has a dedicated webpage on Media and Children with guidelines and recommendations. Their specific guidance on screen time for various age groups can be found here. See a video on modeling anticipatory guidance for patients and parents about media-related health concerns.

School and Education

Literacy and reading promotion: Encourage families to read with their children from early infancy. Reading together helps build language and promotes bonding. A book before bed is a good place to start for most families. See the Reach Out and Read Resource Center for information on encouraging healthy growth and early literacy for children.

School success: Emphasize the importance of school early in life. Rewarding effort over perfection encourages children to develop a growth mindset. Liking school and enjoying the learning process helps them engage. When problems arise, collaboration with the teacher and school is critical. If children or parents get frustrated and blame the teacher, remind parents that teachers have the child’s best interests in mind and encourage them to have an open conversation about the best way to support the child. Both parents and teachers can usually learn from each other. Pediatricians can often advocate for their patients’ needs at school.

Emotional Well-Being

Mood, anxiety, and mental health: Children as young as age 4 to 5 years can share what makes them angry, sad, or worried. Talking about emotions helps children know they can discuss these topics at their visits. Young children usually still need parents’ help in regulating their emotions. Start talking about coping mechanisms in school-age children by asking questions (e.g., What do you do to help yourself feel better when you are angry, sad, or worried?). You can normalize these emotions by stating that everyone feels angry, sad, or worried sometimes and that an important part of growing up is learning how to manage your feelings. If children have difficulty sharing their feelings, parents may then be invited to share concerns. Encourage parents to talk with their children about how they manage their feelings. Role modeling emotional regulation helps children learn how to do it themselves. Pediatric providers can help older children and parents communicate about more-difficult topics. See the Pediatric Mental Health rotation guide for more on this topic.

Bullying: Bullying is not new but has become more recognized and pervasive. Many providers bring this up in the context of talking about school (e.g., That’s great that you have friends at school. Does anyone at school or anywhere else make you feel unsafe? Do you have any concerns about bullies?). When discussing internet safety, ask children if anything has made them feel uncomfortable or unsafe on the internet and suggest that they always let their parents know when that happens.

Strength and protective factors: Asking children about their strengths and parents about what makes them proud of their child is a good way to start conversations and even encourage parents to praise their children. Strengths can also serve as tools to address challenges or weaknesses.

Social supports provide some of the most important protective factors that enable children and families to manage the challenges in their lives. For a child, one of the most important factors for developing resiliency is having an adult they can trust and who supports them. Find out about the supports children and families have and about relationships in the family. Do they have friends that they trust and who support them? What about community connections (e.g., community groups, religious groups, community agencies)? Help families who lack those connections consider sources of support.

Behavior and Habits

Discipline and behavior: Two important aspects of discipline are clear rules/boundaries and consistency. Although children will always try to test boundaries, they need to know the rules to follow them. Explain to parents the need to clearly express the rules and consequences and to follow through with consistent application of consequences, especially when children have different rules in different households. After infancy, children are able to learn that different rules apply in different settings. Therefore, consistency within each setting and with a given caregiver is helpful. In general, positive reinforcement works better than negative reinforcement. Sometimes, natural consequences help children realize the impact of their actions (e.g., being required to take time to clean up a mess that they made or having less time for a fun activity if they don’t get ready on time). Provide anticipatory guidance that corporal punishment teaches children to solve their problems with violence.

Toilet training: The age at which most children are considered toilet trained varies by time, culture, and definition of the endpoint of toilet training. In the United States, 26% of children achieve daytime continence by the age of 24 months, 85% by 30 months, and 98% by 36 months. In contrast, the Digo people in East Africa begin toilet training their infants during the first weeks of life, relying on nearly continuous contact with the caregiver and dependence on the caregiver to recognize subtle cues given by the infant prior to elimination. These infants achieve stooling and urination on command by the time are 4 to 5 months old. The AAP recommends that the process of toilet training begin only when the child is developmentally ready or shows signs of readiness, which is consistent with Brazelton’s child-oriented approach. Some children show interest in the toilet as early as 18 months but cannot control their bowel and bladder functions until closer to age 2 years. Parents can look out for signs of interest and celebrate them. Praise goes a long way with toddlers. If a child does not show any interest, a good time to start encouragement is between 2 to 3 years: Have them sit on a toilet with the lid down and clothes on just to get used to the experience. To help alleviate fears of “losing” part of themselves down the toilet, have the child dump the stool from their diaper into the toilet and flush it. Recognize when the child typically voids or stools, such as after mealtimes, and use that as a time to read a book on the toilet. It is important to address constipation before trying to toilet train.

Picky eating: Regardless of age — 12 months, 5 years, or 12 years — children should be included in family meals and eat the same food that the rest of the family eats. Young children regulate their intake and eat to satiety if they are offered healthy options. However, given the opportunity, we all often choose salty, fatty, or sweet foods.

• Leading expert Ellyn Satter recommends the division of responsibility in feeding: It is the parent’s job to decide the what, when, and where of feeding, and it is the child’s job to determine how much and whether to eat what the parent provides.

Anticipatory Guidance During Adolescence

The following topics specific to adolescence are addressed in the Adolescent Care rotation guide:

• Puberty

• Sex/Sexuality

• Contraception

• Sexually Transmitted Infections

• Eating Disorders

• Substance Use Screening