A pediatric prenatal visit during the third trimester is recommended for all expectant families as an important first step in establishing a child’s medical home, as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition. As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow general pediatricians to establish a supportive and trusting relationship with both parents, gather basic information from expectant parents, offer information and advice regarding the infant, and may identify psychosocial risks early and high-risk conditions that may require special care. There are several possible formats for this first visit. The one used depends on the experience and preference of the parents, the style of the pediatrician’s practice, and pragmatic issues of payment.
As the medical specialty that is entirely focused on the health and well-being of the child, embedded in the family, pediatric care ideally begins before pregnancy, with reproductive life planning of adolescents and young adults, and continues during the pregnancy, with an expectant mother and father of any age. This clinical report is an updated revision of the original clinical report from the American Academy of Pediatrics (AAP) on the prenatal visit.1 Although survey results show that 78% of pediatricians offer a prenatal visit, only 5% to 39% of first-time parents actually attend a visit.2 The prenatal visit offers the opportunity to create a lasting personal relationship between parents and the pediatrician, one of the most important values in all ongoing pediatric care. The AAP has put forward the rationale and standards for the prenatal visit for pediatricians in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition (Bright Futures),3 as well as for parents and families (www.healthychildren.org).4 This clinical report augments these approaches to making the prenatal visit an important part of the practice of pediatrics.
Less than 5% of urban poor pregnant women see a pediatrician during the prenatal period although they are at higher risk of adverse pregnancy outcomes; pregnant women in rural areas may have even more difficulty accessing a prenatal visit.5,6 To attempt to reduce disparities in pregnancy outcomes, encouraging nonresident prospective fathers to attend the prenatal visit along with expectant mothers is particularly important, albeit challenging.7
Prenatal contact with a pediatrician may begin with a contact from a prospective parent to the pediatrician’s office to ask whether the practice is accepting new patients and to inquire about hours, fees, hospital affiliation, health insurance accepted, and emergency coverage. These questions may be answered by a member of the office staff or the pediatrician, and this exchange establishes an initial relationship between the office and the parent. During this conversation, the expectant parent can be encouraged to schedule a prenatal visit with the pediatric health care provider, and both parents can be encouraged to attend. The prenatal visit can be enhanced if the parents come prepared with questions. Optimally, this visit should occur at the beginning of the third trimester of pregnancy.
A prenatal visit with the pediatrician is especially important for first-time parents or families who are new to the practice; single parents; women with a high-risk pregnancy or who are experiencing pregnancy complications or multiple gestations; and parents whose previous pregnancies had a complication such as preterm delivery, an infant with a congenital anomaly, a prolonged course in the NICU, or a perinatal death. Same-sex couples and parents expecting via surrogacy may have questions unique to their circumstance. This visit also can be particularly valuable to parents who are planning to adopt a child, because they may have had previous experience with pregnancy complications and/or be sensitized to special vulnerabilities in their infant (see the AAP clinical report The Pediatrician’s Role in Supporting Adoptive Families at http://pediatrics.aappublications.org/content/130/4/e1040). If adoption occurs or is to occur across states or internationally, review of records, need for waiting periods, scheduling of initial visits, concerns about potential fetal exposure (eg, maternal substance use or fetal alcohol spectrum disorders), and additional recommended screenings and/or tests can be discussed.8,9 If needed, pediatricians can consult experts in international adoption or the AAP Council on Foster Care, Adoption, and Kinship Care.10
The most comprehensive prenatal visit is a full office visit, during which a trusting relationship can be established and expectant parents can have time to express their needs, interests, and concerns and receive initial anticipatory guidance. Most pediatricians believe that the prenatal visit is helpful in establishing a relationship with families that is essential for the medical home. Because they may not be able to initiate these visits, pediatricians can discuss the concept with referring obstetricians, family physicians, and internists, who can, in turn, encourage their patients to contact pediatricians for a prenatal visit. Office Web sites and social media can also be used to advertise this service to expectant parents.
The following objectives for a prenatal visit are suggested as important topics to be addressed.2 The actual range of topics covered can be determined by the preference of the provider, the interest of the expectant parent(s), or the presence of an existing complication with the pregnancy or the fetus. Topics not covered prenatally can be presented to parents during the newborn or first postnatal visit.
To provide a foundation on which to build a positive family-pediatric professional partnership, a crucial part of the patient-centered medical home.
To access pertinent aspects of the past obstetric and present prenatal history; to review family history of genetic or chromosomal disorders and to review fetal exposure to substances that may affect the infant.
To introduce anticipatory guidance about early infant care and infant safety practices.
To identify psychosocial factors (eg, perinatal depression) that may affect family function and family adjustment to the newborn (eg, social determinants of health, adverse child experiences, and promoting healthy social-emotional development and resiliency).
Establishing a Positive Pediatrician-Family Relationship, a Crucial Part of the Patient-Centered Medical Home
The prenatal period is an ideal time to start building the health care alliance that may last for many years, commonly until the patient reaches adulthood.11 The prenatal visit often is an opportunity for the family to determine whether their relationship and their mutual philosophies will form the basis of a positive relationship.
The prenatal visit is also an opportunity for parents to invite other supportive adults, including grandparents,12,13 to establish a relationship with the pediatrician and to encourage them to come to future visits and support the new parent(s). A prenatal visit can be used to introduce parents to the concept of a medical home for the child’s health and development needs. Parental familiarity with the pediatric health care provider prenatally may be helpful if a referral or transfer of care occurs because of perinatal complications or the newborn infant’s medical condition.14 Adolescent parents15 and older first-time parents may benefit from the opportunity to share their specific concerns with a knowledgeable professional.
Information From the Prenatal and Family History
Gathering information about pregnancy complications, parental depression, and family medical and social history (especially social determinants of health) is helpful as a background to the context of the pregnancy. This inquiry also conveys to parents an interest in the broader psychosocial environment of the infant, including areas in which support would be most useful, especially if there is any risk of domestic violence.16,–18 Answering parents’ questions about the approach to pediatric care also is helpful. This is a good opportunity to review how the practice uses the tools of social media and e-mail to communicate with families.
Additional topics that may be addressed include:
developmental dysplasia of the hip, early urinary tract infections, asthma, lipid disorders, cardiac disease, sickle cell disease, substance abuse, psychiatric illness, domestic violence, chronic medical conditions, and ongoing medications;
plans for feeding, circumcision, child care, work schedules, and support systems;
parents’ plans regarding child care and expectations about work-life balance;
cultural beliefs, values, and practices related to pregnancy and parenting;
parents’ attitudes about and use of complementary and alternative medications and health care.
If there are other children in the family, pediatricians can provide helpful advice about managing the older sibling’s adjustment. Managing parental expectations about their child is important in laying the foundation for positive attachment. Questions useful to consider as the pediatrician approaches the prenatal visit are listed in the chapter on the prenatal visit in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition.3
Anticipatory Guidance and Enhanced Parenting Skills; Social Determinants of Health
The prenatal visit offers an opportunity to discuss a range of concerns that may be of great interest to the expectant parents and pediatric provider. The following areas for discussion are meant to be a helpful reference. The conversation, the specific concerns of the parents, and time allowed will define which of these issues are discussed at the prenatal visit. The prenatal visit also offers an opportunity for assessment of family risk factors and connections to key evidence-based and other early learning, health, and development programs in the community.
One of the pediatrician’s tasks is to provide guidance to mothers, fathers, and other supportive adults to become more competent caregivers. This can begin with discussion of the parents’ concerns, planned strategies, and cultural and family beliefs and values. Advice can be offered about shared roles in parenting, such as diapering, bathing, nighttime care, and helping with feeding. Pregnancy and delivery make the central importance of the mother in the newborn infant’s life clear, but it is important to talk about the special role fathers and same-sex partners play in good outcomes for children as well.21 A key goal of positive parenting is the reliable provision of the infants’ basic needs—food, shelter, love, and care—and in doing so, fostering the development of trust.22,23 The adverse effects of poverty on child health have been well documented.22,24 Optimal use of supports and resources (eg, the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]) can be discussed and information about access can be provided. Positive parenting also includes providing a steady emotional climate in which reasonable expectations are sustained consistently.25 Avoiding and/or buffering adverse childhood experiences, such as parental postpartum depression, increasingly is seen as an evidence-based part of pediatric care, and this can begin by identifying prenatal risk factors.26 It is important to share evidence-informed online information sources and other local resources about parenting and child development for families. Many excellent resources are available, such as the Building “Piece” of Mind program from the Ohio chapter of the AAP (http://ohioaap.org/tag/parenting/), the Zero to Three program (http://www.zerotothree.org/child-development/), the Triple P Positive Parenting Program (http://www.triplep-parenting.net/glo-en/home), and the Talk, Read, Sing tool kit available from the Clinton Foundation (Too Small to Fail [www.toosmall.org]).
The pediatrician can share with parents the knowledge that children, at an early age, can learn through playful serve-and-return interactions with adults and that playing with and daily reading, singing, and talking to children from birth onward are recommended, as is providing a language-rich environment and minimizing media exposure.
Connections to Community Resources
Office materials and Web sites can demonstrate provider awareness of key early childhood resources in the community, from home visiting, Early Head Start, child care resource and referral agencies, quality child care settings, local libraries, and parent support groups, as well as cardiopulmonary resuscitation courses. A discussion of the types of child care typically available (family care, in-home baby-sitting, family day care, child care centers) is helpful.
Delivery and Nursery Routines
A discussion of the hospital routines around delivery and nursery care may include: who will be in the delivery room and how new infants behave in the first hours and days; qualifying who will provide newborn care in the hospital and what will happen if there is (1) an unanticipated urgent delivery away from the expected hospital, (2) a home birth, or (3) an admission to a special care nursery is also helpful. This discussion might include the newborn infant’s ability to seek and attach to the mother’s breast right after delivery, the related concept of skin-to-skin care, and the 12-hour postdelivery sleep phase after the adrenaline rush of labor. Mothers often choose to have the infant with them continuously during the entire hospital stay, which aids successful lactation.
Thoughts on Feeding the Newborn Infant
This is an appropriate teaching moment for describing to both parents the many advantages of exclusive breastfeeding and how it improves outcomes for both the mother and infant.27,28 Special breastfeeding training of expectant fathers or partners has been shown to increase their support of breastfeeding mothers as well as the duration of breastfeeding.29 For parents living with food insecurity, breastfeeding offers economic advantages as well. Rooming in and avoiding unnecessary supplementation can be mentioned as ways to support nursing.
The benefits of breastfeeding can be reviewed if there are no contraindications, and lactation support services can be discussed.30,–33 However, ultimately, decisions about feeding the infant are made by the parents. If formula feeding is the parents’ choice, they can be supported in their decision and given advice on formula type and preparation and proper bottle use. Ultimately, the goal is a growing, healthy infant and parents who enjoy feeding so that they can be supported in whatever decision they make. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) also is available to help with nutrition discussion and support prenatally, and mothers can be referred to determine whether they are eligible for a nutrition package during pregnancy, if not already participating in the program.
Parental expectations can be shaped so that parents do not become overly concerned if infants take a few days to learn to latch to the breast and lose some weight before the mother’s milk comes in. Infants commonly lose weight for a few days before the mother’s milk comes in but typically regain birth weight at or before 2 weeks of age. If mothers who plan to breastfeed are taking any medication, a helpful reference for the pediatrician to evaluate safety is the LactMed Drugs and Lactation Database (http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm).34
Screening for various infections and conditions that can affect the fetus is an important part of pregnancy, delivery, and birth. The prenatal visit is an excellent time to discuss the benefit of screening and the specific screening tests prospective mothers will experience. For example, the mother is regularly screened by her obstetrician to assess fetal growth and development and may have fetal testing for genetic diseases and chromosomal abnormalities. In addition, the mother may be screened for conditions that may affect the fetus, such as gestational diabetes, pregnancy-induced hypertension, and the presence of infectious agents, such as hepatitis B, cytomegalovirus, group B streptococci, and HIV.
For the infant, the main universal screening programs are used to detect metabolic diseases, sickle cell disease, cystic fibrosis, newborn jaundice, critical congenital cardiac disease, and hearing impairments. Parents may seek more information about risk factors for the management of newborn jaundice. Some discussion of these conditions can be helpful to many families so they understand what is being looked for, how the tests are performed, and what the response to test results will be. Family history may have led to detailed genetic testing and counseling and may warrant special discussion.35,–38 Routine postpartum care can be discussed. The rationale for routine recommendations for vitamin K to prevent gastrointestinal or cerebral hemorrhage, eye ointment to prevent eye infection leading to blindness, and the birth hepatitis B vaccine can be explained.
Discussion of circumcision, including benefits, risks, the surgical process, and analgesia, can be presented at this visit, with particular attention to the family’s religious, personal, and cultural views.39
Infant Visit Routines and Care Offered at the Office
Most parents are interested in understanding what to expect for a routine pediatric visit as well as information about office and telephone hours, the appointment scheduling process, and coverage for night, weekend, and emergency care. The prenatal visit also is a good time to establish the pediatrician’s expectations of the family and explain the use of electronic communications during and after routine office hours, including billing for this service. The routine periodic schedule of well-child care visits from Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition3 can be shared with the parents (http://brightfutures.aap.org/clinical_practice.html), along with information from Bright Futures about behavior, development, and the importance of social determinants of health.
The prenatal visit also is a good time to ask parents about their preferred approach to communication with the office, clarifying office policies on the availability of telephone and electronic communications. Preferred Web sites (HealthyChildren.org) for sharing information and other helpful resources and books can be recommended.
Safety is an important topic to discuss with the parents, particularly advice on “safe sleep”40 and the importance of proper bedding,40,41 proper holding of the infant, water temperature during bathing, the proper use of a pacifier, and hand washing. Encouraging a good family diet, regular checkups with the family physician or obstetrician42 and dentist,43,44 and appropriate rest and exercise also is important. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) increasingly emphasize attention to oral health and smoking cessation during pregnancy, and pediatricians can reinforce these recommendations during the prenatal visit.45,46 Specific safety issues to discuss include the use of car seats, gun safety in the home, smoke detectors and carbon monoxide monitors, and reducing exposures to toxins such as mold and lead.
Emotions in the Newborn Infant
For many families, including those with other children, the unique emotional life of a newborn infant is unfamiliar and can be challenging. It is key to manage expectations and raise parental awareness about the range of temperaments infants can have as well as the strengths and challenges of them. There can be some discussion on how crying can be a normal mode of communication, explaining that a common peak typically occurs during the evening hours at 6 weeks of age and giving advice on how best to respond to it. Parents can be given techniques for soothing fussy infants, such as holding, including cuddling and skin-to-skin contact47; rocking; singing; talking quietly; and dimming lights and playing soft music.
The prenatal visit provides an opportunity to discuss how to recognize when crying is an indicator of actual pain or illness. It is important to establish strategies for parental coping with the stress of an infant crying and the demands of infancy, including setting clear plans for strategies to deal with stress.
Emotions in the Parents
The experience of enhanced, powerful emotions of a wide variety is likely universal to most parents during and after delivery. Even if no serious difficulties with emotions emerge, it is helpful for expectant parents to be aware of the special power of both positive and negative emotions that surround a new person being born and entering their life.
It is also important for all expectant parents to be aware that it is common for many mothers, as many as 10% to 20%,48 and some fathers to experience depression before, during, and/or after delivery. Postpartum depression is largely unappreciated, because stigma prevents a majority of parents from being identified and accessing services.48 Several states have recommended universal postpartum depression screening by pediatricians, and insurers are increasingly paying for these screens. The prenatal visit offers mothers a valuable opportunity to become aware of the facts about depression so they know to call for help from their primary care physician or their obstetrician if they experience significant persistent sadness, which can be compounded by fatigue from lack of sleep.49,–51
The pediatrician can instruct parents that infants usually awaken to feed every 3 hours during the night until approximately 3 months of age, when brain maturation enables one longer sleep stretch in every 24-hour cycle. To shape this longer stretch to the dark hours, parents can wake infants every 3 hours to feed during the day, keep the lights dim after dark to entrain circadian rhythms, and schedule a bedtime feeding at 11:00 pm right from birth so that the longer sleep stretch after 3 months of age begins then.
At the prenatal visit, pediatricians can listen for and make note of fathers’ or partners’ feelings about lack of parenting skills and decreased marital intimacy. This is an opportunity to lay the groundwork for pediatric providers to be available to fathers as well as mothers after the birth of the infant.
Decreasing the Risk of Serious Illness and Effective Response to Medical Problems Should They Occur
The prenatal visit is a good time to review family history of any illnesses or congenital diseases or any concerns the parents have had during the pregnancy. Adolescent parents often benefit from more guidance than more experienced parents, and older-than-usual parents also feel stressed and insecure. Single parents may not have family or other support systems and may benefit from postpartum referral to social service agencies, evidence-based home visiting programs, or parenting programs (Incredible Years, Triple P) in local communities, if available, for help. The absence of the father, parental conflict, a chronic parental physical condition or concern about mental health, and preterm birth or a birth defect in the infant may require additional medical visits and involvement of specialists52,–55 and can present physical, emotional, and financial burdens for the parents. Many expectant parents wish to discuss the value of cord blood banking and the relative merits of private– versus public–cord blood donation.56
During the pregnancy, maternal obesity and maternal drug use8,9 are risk factors for labor complications, birth defects, and/or developmental impairment.57,–59 Maternal diet is important, and ACOG recommendations about the weight gain during pregnancy can be emphasized.
New data are increasingly available about the adverse health effects of environmental toxins during pregnancy (eg, mercury and fish), and pediatricians can work with obstetricians and the ACOG to knowledgably respond to parents’ questions on this topic.60,–63 Pediatric providers may want to request direct contact with obstetric providers and request obstetric records to clarify prenatal complications, particularly regarding abnormalities detected on prenatal ultrasonography that may require postnatal follow-up. New understanding of the relationship between environmental toxins and epigenetic modifications have provided a stronger evidence-based recommendation highlighting the fetal programming of adult diseases.64
The prenatal visit also is a good time to give parents guidelines about the timing of taking their newborn infant out in crowded public places or inviting visitors/relatives to their home. With regard to preventing infections, this is a good moment to discuss and encourage parents and family members to be immunized against pertussis and, if during the right season, influenza. Tetanus-diphtheria-acellular pertussis (Tdap) immunization is recommended for every pregnant woman after 20 weeks’ gestation, for every pregnancy, and for fathers as well.65 Underimmunized siblings at home also present a risk to a newborn infant, and expectant parents can be encouraged to ensure siblings are fully immunized before the delivery.
Many parents have questions about the recommended schedule of immunizations. The prenatal visit is a valuable opportunity to discuss the value of immunizations and the reason for the recommended schedule. It is an opportunity to listen to any parental concerns well before the infant is born, and the decision is on the family. It is also important for the pediatric provider to outline office immunization policy with regard to parents who wish to alter the standard immunization schedule.
Information Sharing With the Family
Although the volume of information and advice may seem overwhelming to expectant parents, they can be given appropriate handouts to supplement and reinforce information provided at the prenatal visit. A follow-up visit or telephone call can be offered if they still have questions. A Web page can be a good source of information and can include parent questionnaires for subsequent visits.
Types of Prenatal Visits
The Full Prenatal Visit
The most comprehensive form of prenatal visit is a scheduled office visit with both expectant parents. Nurse practitioners can have a significant role in conducting prenatal visits. The objectives listed previously are accomplished through an in-person discussion with the provider. Discussion can include office and telephone hours; fees; office staff; hospital affiliations; coverage for night, weekend, and emergency care; arrangements for newborn care after delivery both at the hospital the pediatricians visit and at a hospital where the pediatrician is not on the staff; and the pediatrician’s expectations of the family. A handout containing this information can be helpful for the family, including information on how and when to schedule the first visit after newborn discharge and how to retrieve the discharge summary if care was provided by a hospitalist. This type of visit is most important for first-time parents, for adolescent and other young parents, when pregnancy complications or newborn problems are anticipated, or when parents are unusually anxious for any reason. The establishment of a mutual commitment to a sound and rewarding family-physician relationship usually results from the visit.
If women with high-risk pregnancies require bed rest, there may be a need for a prenatal visit with only 1 parent and/or telephone calls. These contacts can include the same content as the full prenatal visit. The outcome should be the same mutual commitment as from the full prenatal visit in the office. If an infant is born prematurely, before a prenatal visit could occur, it is often helpful to meet with the parents in a modified prenatal visit before the infant is discharged from the NICU. In the tragic circumstance of a pregnancy loss after a prenatal visit, a follow-up expression of sympathy by the pediatric provider can feel supportive.
The Brief Visit To Get Acquainted
Some pediatricians may offer a less formal prenatal visit than a full consultation, and some parents also may prefer this option. A meet-and-greet session, individually or in a group, can include meeting key staff members such as the practice manager, taking a short tour of the office, and receiving other administrative information and handouts. This type of visit may be appropriate for parents before deciding on scheduling a full prenatal visit. Other models include group visits at the maternity hospital as part of a prenatal class or at community events for expectant parents.
The Basic Contact or Telephone Call
The initial prenatal contact often is an expectant parent’s call to the pediatrician’s office. The staff member can offer a brief description of the practice, basic information including a source of referral, expected delivery date, and type of insurance and can be invited to make an appointment for a full prenatal visit. An office information handout may be sent to the expectant parents, if requested.
No Prenatal Contact
If no prenatal contact has been made, the objectives and discussion of the prenatal visit can be presented to the parents in the newborn visit or first postnatal visit. Because of other priorities, the parents may not absorb some of this discussion; therefore, a handout containing pertinent information may be used at this type of visit. At the infant’s first office visit, parents should be encouraged to have an additional family member accompany them to care for the infant while the parents and pediatrician confer.
Pediatricians or office staff can discuss with parents whether the visit will be covered by the expectant parent’s insurance and whether a referral will be required. A discussion of insurance plans that the practice accepts may be included. Payment for a prenatal visit often requires advocacy with third-party payers, both individually and through pediatric councils. Both the recommendations of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition3 and this clinical report can provide further support for advocacy. Pediatric providers may seek advice from AAP coding resources and may review acceptable codes with their health plans.
A prenatal visit is an important first step to help expectant families (especially first-time parents) establish their child’s medical home. The visit is a unique opportunity to address the relationship between the family and practice and for the bidirectional sharing of information between the parents and pediatric provider.
Pediatric practices can effectively incorporate prenatal visits into their routine. Services can be flexible and designed to meet the needs of expectant parents. A full prenatal visit is preferred, if feasible.
Payment for full prenatal visits is supported by the evidence in Bright Futures and this report. State chapters of the AAP (as through pediatric councils) and pediatric practices can advocate to payers the short-term and long-term benefits of prenatal visits on the health outcomes of infants and their parents.
Pediatricians can share their established practices on prenatal visits with local obstetricians, internists, and family physicians, and with expectant parents.
Pediatric residents can effectively be taught during residency about the content and importance of the prenatal visit.
Increased partnerships with colleagues in obstetrics and gynecology, who are now routinely screening mothers for perinatal depression, are encouraged. Whenever risk factors are identified, obstetric and gynecologic colleagues can be encouraged to refer expectant parents for prenatal pediatric visits so that postpartum family care is optimized.
A comprehensive review of this topic with suggested questions and specific suggestions for expectant parents can be found in the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition.3
Examples of Questions To Use in the Prenatal Visit66
What kinds of previous experience with infants have you had?
Are you working? Are you planning to return to work after delivery?
How are the siblings adjusting to the pregnancy?
Have you attended prenatal classes, and have they been helpful?
What kind of relationship did you have with your parents when you were growing up?
Are you planning to rear your infant in a manner similar to or different from the way your parents reared you?
What expectations do you have about this infant?
What worries and concerns do you have?
What are your plans about feeding the infant (offer support, whether for breast or formula feeding)?
To specifically engage the father/partner, when appropriate, address at least one question to just the father/partner, for example, if the infant is a boy, do you plan to have him circumcised?
Was this a convenient time for you to be pregnant?
How do you cope when you are stressed?
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FUNDING: No external funding.
Michael Yogman, MD, FAAP
Arthur Lavin, MD, FAAP
George Cohen, MD, FAAP
Committee on Psychosocial Aspects of Child and Family Health, 2015–2016
Michael Yogman, MD, FAAP, Chairperson
Arthur Lavin, MD, FAAP
Keith M. Lemmon, MD, FAAP
Gerri Mattson, MD, FAAP
Jason Richard Rafferty, MD
Lawrence Sagin Wissow, MD, MPH, FAAP
George J. Cohen, MD, FAAP
Sharon Berry, PhD – Society of Pediatric Psychology
Terry Carmichael, MSW – National Association of Social Workers
Edward R. Christophersen, PhD, FAAP (hon) – Society of Pediatric Psychology
Norah Johnson, PhD, RN, CPNP – National Association of Pediatric Nurse Practitioners
L. Read Sulik, MD – American Academy of Child and Adolescent Psychiatry
Stephanie Domain, MS
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.