Bright Futures: 4th edition includes focus on social determinants of health
AlysonSulaski Wyckoff, Associate Editor
A new edition of the AAP Bright Futures Guidelines, the resource on health supervision visits for primary care professionals, was released
today in conjunction with an updated Periodicity Schedule of recommended screenings.
Both guide the preventive care of pediatric patients through age 21 years.
Taking a positive approach to health advice, Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
outlines guidelines for 31 health supervision visits, plus the prenatal visit. It
complements the AAP policy statement 2017Recommendations for Preventive Pediatric Health Care, or Periodicity Schedule, from the AAP Committee on Practice and Ambulatory Medicine
and the Bright Futures Periodicity Schedule Workgroup (see resources).
“The Periodicity Schedule tells us what should be done in a well visit,” said Joseph
F. Hagan Jr., M.D., FAAP, one of the Bright Futures co-editors. “I believe Bright Futures tells us how to do it well.”
The updated edition builds on more than 20 years of experience with an aim to advance
understanding of key health promotion themes and health supervision recommendations,
to improve clinical practice and address children’s health care needs within the context
of the family and community. Driven by evidence, the guidelines have evolved as a
common framework and language used by many practitioners in their interactions with
children and families.
The first half of the book provides background and recommendations on 12 themes, including
three new themes. The second half offers developmental information, health supervision
recommendations and anticipatory guidance.
There is a new focus on assessing for social determinants of health. For most visits,
pediatricians are encouraged to ask about topics such as food insecurity, domestic
violence, substance use, housing situations and other issues that may affect a family’s
“We have always known that children who are in healthy environments do better than
children who are in less healthy environments. ...That’s what’s great about pediatrics.
We always believed this made a difference. Now we have the science,” Dr. Hagan said.
3 new health promotion themes
Besides a new theme called “promoting lifelong health for families and communities”
(linked to social determinants of health), other new health promotion themes are “promoting
health for children and youth with special health care needs” and “promoting the healthy
and safe use of social media.”
Dr. Hagan said the previous edition integrated information on caring for children
with special needs throughout the book, emphasizing they are children first, who also
need immunizations, various guidance, etc., and not just “lose them in their diagnosis.
“I think the times have changed and people get that,” he said. “And the cost of doing
that is we didn’t have an area in the book where we could talk specifically about
new trends in care planning, case management, decision-making in palliative care,
Similarly, more data on social media allow for expanded coverage, such as the guidance
in recent AAP statements on media use in children and adolescents, and the new family
media use plan.
Taking a positive approach
Overall, Bright Futures emphasizes a strength-based approach to health supervision visits championed by co-Editor
Paula M. Duncan, M.D., FAAP. The approach encourages safe, stable, nurturing environments,
according to co-Editor Judith S. Shaw, Ed.D., M.P.H., R.N., FAAP (hon.). Dr. Shaw
calls the health visits a roadmap.
“It’s the visits that come alive in the practice. It’s really what a clinician and
family should experience during a well-child care visit,” Dr. Shaw said. “I always
say, if you’re a really good clinician and you’ve been doing this, you just kind of
have to look at the Periodicity Schedule and maybe some of the anticipatory guidance
priorities of the visit, and you go in and know what to do.”
Dr. Hagan routinely asks his residents and students to read the introductions to the
visits in Bright Futures to fully understand “what we’re trying to do.”
“The intro really is a helpful piece — it lays out not just how the visit is done
but why you do it that way,” Dr. Hagan said. “I want people to see why it’s really
important to go into that (exam) room and find that family’s strengths and support
Bright Futures zeroes in on “that very precious visit, that very precious time, where children and
families come together with their health care professionals … to really focus on the
health of that child — the health of that family,” Dr. Shaw said.
A comment period on the book’s content drew about 3,500 entries, much more than last
time. Reviewing all the comments entailed a lot of work, Dr. Hagan recalled, but it
helped the editors broaden their evidence base and fine-tune the content.
The new edition of Bright Futures is dedicated to Dr. Duncan and reflects the input of numerous experts and liaisons.
Periodicity Schedule updates
The Periodicity Schedule, available at www.aap.org/periodicityschedule and scheduled for publication in the April issue of Pediatrics, updates 11 categories that will impact pediatric practice. They include:
Postpartum depression screening is recommended from the 1-month visit through the