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Surgeon General Reports, SAMHSA TIPs, SAMHSA PEPs Put Prevention Into Practice (Static collection) Clinician's Handbook of Preventive Services, 2nd Edition. PPIP Children and Adolescents Screening 1. Anemia Improved nutrition has eased the problem of childhood anemia in the United States. However, certain groups of children, particularly infants and adolescent girls, remain at significant risk. Factors that place infants at high risk include low socioeconomic status, consumption of cow's milk before age 1 year, consumption of formula not fortified with iron, and low birth weight. Untreated anemia can lead to fatigue, apathy, impairment of growth and development, and decreased resistance to infection. Iron deficiency is the most common cause of anemia in children and adolescents. Hemoglobinopathies, such as sickle cell disease and thalassemia, are also significant causes. See chapters 8 and 27 for information on screening for hemoglobinopathies in newborns and adults, respectively. Recommendations of Major Authorities
1.
Three basic methods are used to determine hemoglobin levels and hematocrits: venipuncture with analysis by automated cell counter, capillary sampling with analysis by hemoglobinometer, or capillary sampling with microhematocrit analysis by centrifuge. (
NOTE:
The microhematocrit method yields slightly higher values and is somewhat less sensitive than the automated cell counter method. The capillary methods may provide less reliable results because of greater variation in sampling technique than venipuncture.)
2. In general, do not screen for anemia in a child who has had fever or infection during the preceding 2 to 3 weeks. 3. If the capillary method is used, observe the following principles of collection:
4. Table 1.1 shows hemoglobin and hematocrit cut points for the diagnosis of anemia in children, which are derived from the Second National Health and Nutrition Examination Survey (NHANES II) conducted from 1976 through 1980. Although NHANES II did not provide data for children younger than 1 year of age, the cut points for 6-month-old children determined by extrapolation are only a fraction of a unit less than those for 1-year-old children.
American Academy of Family Physicians. . Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. American Academy of Pediatrics, Committee on Nutrition. . Pediatric Nutrition Handbook. 3rd ed. Elk Grove Village, Il: American Academy of Pediatrics; 1993. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. . Recommendations for pediatric preventive health care. Pediatrics. 1995. 96: 373-374. (PubMed) Canadian Task Force on the Periodic Health Examination. . Prevention of iron deficiency anemia in infants. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 23. Centers for Disease Control. . CDC criteria for anemia in children and childbearing-aged women. MMWR. 1989. 38: 400-404. Dallman PR. . Has routine screening of infants for anemia become obsolete in the United States? Pediatrics. 1987. 80: 439-441. (PubMed) Dallman PR. . New approaches to screening for iron deficiency. J Pediatr. 1977. 90: 678-681. (PubMed) Dallman PR, Yip R, Johnson C. . Prevalence and causes of anemia in the United States, 1976 to 1980. Am J Clin Nutr. 1984. 39: 437-445. View this and related citations using Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Lozoff B, Brittenham GM, Wolf AW, et al. . Iron deficiency anemia and iron therapy effects on infant developmental test performance. Pediatrics. 1987. 79: 981-995. (PubMed) Meites S, Levitt MJ. . Skin-puncture and blood-collecting techniques for infants. Clin Chem. 1979. 25: 183-189. (PubMed) Randolph VS. . Considerations for the clinical laboratory serving the pediatric patient. Am J Med Technol. 1982. 48: -. Reeves JD, Yip R, Kiley VA, Dallman PR. . Iron deficiency in infants: the influence of mild antecedent infection. J Pediatr. 1984. 105: 874-879. (PubMed) Thomas WJ, Collins TM. . Comparison of venipuncture blood counts with microcapillary measurements in screening for anemia in one-year-old infants. J Pediatr. 1982. 101: 32-35. (PubMed) US Preventive Services Task Force. . Screening for iron deficiency anemia. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 22. Yip R, Binkin NJ, Fleshood L, Trowbridge FL. . Declining prevalence of anemia among low-income children in the United States. JAMA. 1987. 258: 1619-1623. (PubMed) Young PC, Hamill BH, Wasserman RC, Dickerman JD. . Evaluation of the capillary microhematocrit as a screening test for anemia in pediatric office practice. Pediatrics. 1986. 78: 206-209. (PubMed) Tables Table 1.1. Hemoglobin and Hematocrit Cut Points for Anemia in Children 1 Year of Age or Older
Important changes have occurred in the measurement, epidemiology, and significance of childhood blood pressure since the publication of the first edition of the Clinician's Handbook. These changes were summarized in an update from The National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents (October, 1996). Current understanding of childhood blood pressure not only recognizes the importance of identification of children with hypertension due to secondary conditions but also the realization that mild elevations in blood pressure during childhood (and particularly adolescence) are more common than previously thought. Elevated blood pressure in some children may represent the early onset of essential hypertension. Blood pressure varies throughout the day in children and adults because of normal diurnal fluctuation and other factors such as physical activity and emotional stress. Body size is the most important determinant of blood pressure in children. New tables of blood pressure percentiles (Tables 2.1 and 2.2) have been released; these tables consider height in addition to age and sex. Hypertension is defined as average systolic or diastolic blood pressure greater than or equal to the 95th percentile for age, sex, and height measured on at least three separate occasions. Elevated blood pressure must be confirmed on repeated visits before characterizing an individual as having hypertension. A more precise characterization of an individual's blood pressure level is an average of multiple measurements taken over weeks to months. With repeated measurement using standardized techniques, only about 1% of children and adolescents will be diagnosed with hypertension. Recommendations of Major Authorities
1.
Advise patients, especially adolescents, not to smoke or otherwise use tobacco or ingest caffeine, including cola products, for at least 30 minutes before the measurement.
Patient Resources
2. Perform the measurement in a controlled area and after 3 to 5 minutes of rest with the child in the seated position. The right arm should be fully exposed and the cubital fossa supported at heart level. 3. The mercury column sphygmomanometer is preferred over the calibrated aneroid manometer. 4. Choose an appropriately sized cuff. The bladder width should be 40% of the arm circumference measured at midpoint between the olecranon and acromion (Figure 2.1). This usually translates into a cuff that covers 80% to 100% of the circumference of the arm without impinging on the antecubital fossa (Figure 2.2). Use of a cuff that is too small will result in falsely elevated measurements. Use of a cuff that is too large will result in falsely low measurements. 5. Place the bell of the stethoscope lightly on the antecubital fossa over the brachial artery. Applying too much pressure may lead to inaccurate measurements. Rapidly inflate the cuff to approximately 20 mm Hg above the point at which the pulse is no longer audible. Then deflate the cuff at a rate of 2 to 3 mm Hg per second. The onset of a tapping sound (the first Korotkoff sound) is used to determine systolic blood pressure, and the disappearance of Korotkoff sounds determines the diastolic blood pressure. 6. Documentation of the patient's position, limb used, and cuff size may be required for consistency of repeated blood pressure measurements. 7. The systolic and diastolic blood pressures corresponding to the 90th and 95th percentiles according to gender, age, and percentile of height are shown in Tables 2.1 and 2.2. The height percentile is determined from the standard growth charts. A child is considered normotensive if the blood pressure is below the 90th percentile. Blood pressures in the 90th through 94th percentiles are considered high normal, and those at or above the 95th percentile are considered elevated. 8. Standards for systolic and diastolic BP for infants younger than 1 year are available. In children of this age, systolic BP is used to define hypertension.
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. . Recommendations for pediatric preventive health care. Pediatrics. 1995. 96: 373-374. (PubMed) American Medical Association. . Rationale and recommendation: hypertension. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Il: American Medical Association; 1994: chap 8. de Swiet M, Dillon MJ. . Hypertension in children. Br Med J. 1989. 299(6697): 469-470. Fixler DE, Laird WP. . Validity of mass blood pressure screening in children. Pediatrics. 1983. 72: 459-463. (PubMed) Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health; 1994. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. . The Fifth Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, Md: National Institutes of Health; 1993. US Department of Health and Human Services publication NIH 93-1088. (See also, Arch Intern Med. 1993;153:154-183.) Lauer RM, Burns TL, Clarke WR. . Assessing children's blood pressureconsiderations of age and body size:the Muscatine study. Pediatrics. 1985. 75: 1081-1090. (PubMed) Mehta SK. . Pediatric hypertension: a challenge for pediatricians. Am J Dis Child. 1987. 141: 893-894. (PubMed) National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. . Update on the 1987 task force report on high blood pressure in children and adolescents: a working group report from the National High Blood Pressure Education Program. Bethesda, Md: National Institutes of Health; 1996. US Department of Health and Human Services publication NIH 96-3790. Sinaiko AR, Gomez-Marin O, Prineas RJ. . Prevalence of "significant" hypertension in junior high school-aged children: the Children and Adolescent Blood Pressure Program. J Pediatr. 1989. 114: 664-669. Task Force on Blood Pressure Control in Children. . Report of the Second Task Force on Blood Pressure Control in Children1987. Pediatrics. 1987. 79: 1-25. US Preventive Services Task Force. . Screening for hypertension. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 3. Tables Table 2.1. Blood Pressure Levels for the 90th and 95th Percentiles of Blood Pressure for Boys Aged 1 to 17 Years by Percentiles of Height
Figure 2.1 Determination of proper cuff size: step 1. The cuff bladder width should be approximately 40% of the circumference of the arm measured at a point midway between the olecranon and acromion.
The cuff bladder should cover 80% to 100% of the circumference of the arm.
Body measurement of infants and children helps clinicians recognize significant childhood problems, including growth retardation, malnutrition, obesity, and developmental abnormalities. Measurement of head circumference can identify abnormal brain development in infants, including hydrocephalus. In older children and adolescents, body measurement can identify those who are overweight and those with possible eating disorders. Both of these conditions are targets for screening in this population. The prevalence of overweight in children is increasing and has been associated with development of heart disease and Type 2 diabetes mellitus in adulthood. Recommendations of Major Authorities
1.
To ensure accurate measurements of infants and young children, use an assistant, and if necessary, take measurements more than once, particularly when children are very young or uncooperative.
2. Determine the height of children younger than 2 years of age by measuring their length while they are recumbent. Use a measuring board with a stationary headboard and a sliding vertical foot piece, if one is available. Otherwise, use a horizontal surface, a stationary vertical surface, a movable vertical-surfaced object, and a measuring tape. The general principles for taking the measurement are the same, regardless of the apparatus used:
3. Obtain the standing height of children beginning at 2 years of age. Use of a stadiometer, an instrument specifically designed for height measurements, is preferred. However, accurate measurements may be obtained by using a graduated ruler or tape attached to a wall and placing a flat-surfaced object horizontally on top of the child's head. Height-measuring rods that are attached to weight scales tend to become inaccurate with use; in general, do not use them unless they are checked frequently for accuracy. The general principles for taking the measurement are as follows:
4. Use a balance-beam or electronic scale to weigh infants and children. Spring-type scales are not sufficiently accurate for this use. Check the scale before each use to ensure that it is zeroed. The infant or child should wear only a dry diaper or light undergarment while being weighed. Check scales regularly for accuracy, and make an effort to use the same scale on subsequent visits. 5. Measure a child's head circumference by extending a nonstretchable measuring tape (disposable paper tapes are better than cloth) around the most prominent part of the occiput to the middle of the forehead. Tighten the tape to compress the hair. 6. Plot measurements on age- and gender-specific National Center for Health Statistics (NCHS) growth charts for comparison with NCHS reference values. Recording serial measurements over time provides an accurate record of growth; large or sustained deviations signal a potential problem. Interpret measurements within the context of the individual child's family and growth history. If a child's measurements fall within the 10th through 25th percentile range or the 75th through 90th percentile range, assess past growth patterns and genetic and environmental factors to determine if follow-up is necessary. Recheck measurements that are below the 5th percentile or above the 95th percentile. If these measurements are confirmed, further medical evaluations may be needed.
7.
Some authorities, including the American Medical Association, recommend using body mass index (BMI) calculation to assess the weight of adolescents. (
See chapter 29
for information about the calculation and use of BMI.) However, because of the lack of standardized recommended values to assess BMI in adolescents, growth charts are the preferred method for assessing their weight.
Patient Resources
Growth Charts: Mead Johnson Nutritional Division. For the name and telephone number of an area representative, call: (812)429-5000. Growth Charts: Ross Laboratories, Dept L-1120, Columbus, OH 43260; (800)227-5767.
American Academy of Family Physicians. . Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. American Medical Association. . Rationale and recommendation: dietary habits, eating disorders, and obesity. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994: chap 5. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. . Recommendations for pediatric preventive health care. Pediatrics. 1995. 96: 373-374. (PubMed) Babson SG, Benda GI. . Growth graphs for the clinical assessment of infants of varying gestational age. JPediatr. 1976. 89: 814-820. Canadian Task Force on the Periodic Health Examination. . Screening for childhood obesity. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 30. Canadian Task Force on the Periodic Health Examination. . Well baby care in the first 2 years of life. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 24. Casey PH, Kraemer HC, Bernbaum J, et al. . Growth patterns of low birth weight preterm infants:an analysis of alarge, varied sample. J Pediatr. 1990. 117: 289-307. Chinn S, Price CE, Rona RJ. . Need for new reference curves for height. Arch Dis Child. 1989. 64: 1545-1553. (PubMed) Cronk C, Crocker AC, Pueschel SM, et al. . Growth charts for children with Down syndrome:1 month to 18 years of age. Pediatrics. 1988. 81: 102-110. (PubMed) Dine MS, Gartside PS, Glueck CJ, et al. . Relationship of head circumference to length in the first 400 days of life. Pediatrics. 1981. 67: 506-507. (PubMed) Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Hamill PVV, Drizd TA, Johnson CL, et al. . Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr. 1979. 32: 607-629. View this and related citations using (PubMed) Lohman TG, Roche AF, Martorell R. . Anthropometric Standardization Reference Manual. Champaign, Ill: Human Kinetics Books; 1988. Moore WM, Roche AF. . Pediatric Anthropometry. Columbus, Oh: Ross Laboratories; 1982. Naeraa RW, Nielsen J. . Standards for growth and final height in Turner's syndrome. Acta Paediatr Scand. 1990. 79: 182-190. (PubMed) Nutritional Screening of Children: A Manual for Screening and Followup. . Washington, DC: US Department of Health and Human Services, Public Health Service, Health Services Administration, Bureau of Community Health Services,Office of Maternal and Child Health; 1981. US Department of Health and Human Services publication HSA 81-5114. National Center for Health Statistics Growth Charts. . Monthly Vital Statistics Report. Hyattsville, Md: US Department of Health, Education, and Welfare; 1976;25:1-22. USHEW publication HRA 76-1120. US Preventive Services Task Force. . Screening for obesity. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 21. Vaughan VC. . On the utility of growth curves. JAMA. 1992. 267: 975-976. (PubMed) Yip R, Scanlon K, Trowbridge F. . Improving the growth status of Asian refugee children in the United States. JAMA. 1992. 267: 937-940. (PubMed) 4. Cholesterol Coronary heart disease (CHD) is the major cause of death in the United States. The atherosclerotic process that leads to CHD often begins in childhood. Because unfavorable lipoprotein levels are linked to early atherosclerotic changes in children, and because children with high cholesterol levels are at increased risk of having high cholesterol levels as adults, identifying such children and intervening to decrease their cholesterol levels have been suggested as a means of preventing CHD in adulthood. Children from higher risk families (with a pattern of hypercholesterolemia or premature CHD in the adult members) who have elevated serum cholesterol levels appear to be at a particularly increased risk for CHD when they reach adulthood. This association is the basis for some of the recommendations made by major authorities for the selective screening of children for elevated cholesterol. For the general pediatric population over age 2 years, counseling to encourage a reduced intake of dietary fat, especially saturated fats, is recommended. Children identified with high cholesterol levels may be considered for dietary or drug interventions to lower their cholesterol level. In the Dietary Intervention Study in Children (DISC), diet produced a significant reduction in cholesterol levels without adverse effects on growth and development, but the effects of drug treatment over periods of 40 years or more have not been established. See chapter 20 for information on nutrition counseling in children/adolescents. Recommendations of Major Authorities
1.
Children may eat a normal diet before total cholesterol screening. Children undergoing lipoprotein analysis should fast, ingesting nothing but water for 12 hours before the blood sample is taken.
Patient Resources
2. Do not screen children who are acutely ill, including those with infectious diseases. Do not screen pregnant adolescents. 3. A venous sample obtained with the patient in the sitting position yields the most accurate results; recumbency lowers lipid levels. Documentation of position is important when comparing follow-up measurements. 4. Take into account the cholesterol-raising effect of certain medications, including corticosteroids, isotretinoin, thiazides, anticonvulsants, beta blockers, and certain anabolic steroids. If a patient meeting screening criteria takes one of these drugs, a potential strategy is to perform the test, and if the result is elevated, consider the magnitude of the elevation and the ease and safety of suspending medication for retesting in the absence of drugs. 5. The laboratory used for analysis should participate in a program of external standardization to ensure compliance with standards of precision and accuracy. The National Cholesterol Education Program's Laboratory Standardization Panel recommends that bias not exceed ±5% from the true value and that the intralaboratory coefficient of variation not exceed ±5%. 6. The National Cholesterol Education Program has recommended protocols for assessing cholesterol levels in the screening of children (Figures 4.1 and 4.2).
American Academy of Pediatrics. . Prudent life-style for children: dietary fat and cholesterol. Pediatrics. 1986. 78: 521-525. (PubMed) American Academy of Pediatrics. . Pediatric Nutrition Handbook. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1993. American Academy of Pediatrics, Committee on Nutrition. . Statement on cholesterol. Pediatrics. 1992. 90: 469-473. (PubMed) American Medical Association. . Rationale and recommendation: hyperlipidemia. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Il: American Medical Association; 1994: chap 9. Bao W, Srinivasan SR, Wattigney WA, Bao W, Berenson GS. . Usefulness of childhood low-density lipoprotein cholesterol level in predicting adult dyslipidemia and other cardiovascular risks. Arch Intern Med. 1996. 156: 1315-20. (PubMed) Canadian Task Force on the Periodic Health Examination. . Lowering the blood total cholesterol level to prevent coronary heart disease. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 54. The Dietary Intervention Study In Children Collaborative Research Group. . Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol. JAMA. 1995. 273: 1429-35. (PubMed) Diller PM, Huster GA, Leach AD, Laskamziski PM, Sprecher DL. . Definition and application of the discretionary screening indicators according to the National Cholesterol Education Program for children and adolescents. J Pediatr. 1995. 426: 345-52. Garcia RE, Moodie DS. . Routine cholesterol surveillance in childhood. Pediatrics. 1989. 84: 751-755. (PubMed) Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Kuehl KS. . Cholesterol screening in childhood. Targeted versus universal approaches. Ann NY Acad Sci. 1991. 623: 193-199. (PubMed) National Cholesterol Education Program. . Recommendations for Improving Cholesterol Measurement. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1990. US Department of Health and Human Services, Public Health Service publication NIH 90-2964. National Cholesterol Education Program, Expert Panel on Blood Cholesterol Levels in Children and Adolescents. . Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1991. US Department of Health and Human Services, Public Health Service publication NIH 91-2732. Newman WP, Wattigney W, Berenson G. . Autopsy studies in United States children and adolescents. Relationship of risk factors to atherosclerotic lesions. Ann NY Acad Sci. 1991. 623: 17-25. Newman TB, Browner W, Hulley SB. . The case against childhood cholesterol screening. JAMA. 1990. 264: 3039-3043. (PubMed) Resnicow K, Berenson G, Shea S, Srinivasan S, et al. . The case against the "case against childhood cholesterol screening." JAMA. 1991. 265: 3003-3005. (PubMed) Resnicow K, Morley-Kotchen J, Wynder E. . Plasma cholesterol levels of 6585 children in the United States; results of the know your body screening in five states. Pediatrics. 1989. 84: 969-976. (PubMed) US Preventive Services Task Force. . Screening for blood cholesterol. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 2. Figures Figure 4.1 Assessment and Follow-up of Total Cholesterol Measurements
Depression in children and adolescents is a significant health problem in the United States and is often overlooked or misdiagnosed in the primary care setting. The incidence of major depressive disorders in children is approximately 2% to 4% and increases two- to threefold during adolescence. A family history of depression, particularly parental, is a major risk factor for childhood depression, but no other specific risk factors have been consistently identified. The following factors may be associated with a variety of adverse mental health outcomes in children, including depression: a history of verbal, physical, or sexual abuse; frequent separation from or loss of a loved one; attention deficit disorder; hyperactivity; chronic illness; poverty; and mental retardation. Complications of depression in childhood and adolescence include poor school performance, poor peer relations, alcohol and drug use, promiscuity, teenage pregnancy, other psychiatric illness, and suicide. Suicide is the third leading cause of death among persons aged 15 to 24 years, following unintentional injuries and homicide. The rate of suicide among young males is five times that among young females. Firearms are the most common method of suicide for young males and females. Among young females, attempted suicide is reported more frequently than is completed suicide, although no national data are available. Risk factors for suicide frequently occur in combination. The strongest risk factors for both attempted and completed suicide by children and adolescents are mental disorders, especially clinical depression and conduct problems, and substance abuse. Other risk factors include a family history of mental or addictive disorders or suicide, family violence, previous suicide attempts, and availability and accessibility of firearms in the home. Acute adverse life events such as incarceration or the breakup of a relationship, in association with an underlying psychiatric disorder or other risk factors, and the presence of a firearm in the home can be a potentially dangerous combination leading to suicide. Recommendations of Major Authorities
Depression
1.
Become familiar with the risk factors for and symptoms of depression (See Recommendations of Major Authorities and
Table 5.1).
Suicide
2. Identify any risk factors or symptoms indicating the need for in-depth evaluation by a mental health professional.
1.
Become familiar with the risk factors for suicide (See Recommendations of Major Authorities).
Patient Resources
2. Inquire about suicidal thoughts in a direct, straightforward manner. 3. Question those with suicidal thoughts about the extent and specificity of plans for suicide. Immediate referral to a mental health professional is advisable, especially for individuals with serious intent. 4. Counsel parents about the importance of restricting the access of children and adolescents to dangerous prescription drugs and firearms in the home.
American Academy of Pediatrics, Committee on Adolescence. . Suicide and suicide attempts in adolescents and young adults. Pediatrics. 1988. 81: 322-324. (PubMed) Angold A, Costello EJ. . The epidemiology of depression in children and adolescents. In: Goodyer IM, ed. The Depressed Child and Adolescent: Developmental and Clinical Perspectives. Cambridge Ma: Cambridge University Press; 1995:127-147. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. . Guidelines for Health Supervision. Elk Grove Village, Ill: American Academy of Pediatrics; 1988. American Medical Association. . Rationale and recommendation: depression (severe and recurrent) and suicide. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Il: American Medical Association; 1994: chap 12. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. . Washington, DC: American Psychiatric Association; 1994. Brent DA, Perper JA, Goldstein CE, et al. . Risk factors for adolescent suicide. Arch Gen Psychiatry. 1988. 45: 581-587. (PubMed) Canadian Task Force on the Periodic Health Examination. . Early detection of depression. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 39. Canadian Task Force on the Periodic Health Examination. . Prevention of suicide. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 40. Chang G, Warner V, Weissman MM. . Physicians' recognition of psychiatric disorders in children and adolescents. Am J Dis Child. 1988. 142: 736-739. (PubMed) Costello EJ, Angold A. . Scales to assess child and adolescent depression: checklists, screens, and nets. J Am Acad Child Adolesc Psychiatry. 1988. 27: 726-737. (PubMed) Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Grayson P, Carlson G. . The utility of a DSM-III-R-based checklist in screening child psychiatric patients. J Am Acad Child Adolesc Psychiatry. 1991. 30: 669-673. (PubMed) Kashani J, Sherman D. . Childhood depression: epidemiology, etiological models, and treatment implications. Integr Psychiatry. 1988. 6: 1-21. Lewinsohn PM, Rohde P, Seeley JR. . Adolescent suicidal ideation and attempts: Prevalence, risk factors, clinical implications. Clinical Psychology: Science and Practice. 1996. 3: 25-46. Moscicki EK. . Epidemiology of suicidal behavior. Suicide and life-threatening behavior: Suicide Prevention: Toward the year 2000 (Special Issue). 1995. 25: 22-35. Roberts N, Vargo B, Ferguson HB. . Measurement of anxiety and depression in children and adolescents. Psychiatr Clin North Am. 1989. 12: 837-860. (PubMed) Slap G, Vorters D, Khalid N, Margulies S, Forke C. . Adolescent suicide attempters: do physicians recognize them? J Adolesc Health. 1992. 13: 286-292. (PubMed) US Preventive Services Task Force. . Screening for depression. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services, 1996: chap 49. US Preventive Services Task Force. . Screening for suicide risk. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services, 1996: chap 50. Tables Table 5.1. Symptoms of Major Depression
An estimated 1% to 2% of infants and children in the United States suffer from hearing impairment. Approximately half of these cases are congenital or are acquired during infancy. Severe or profound hearing loss affects one of every 750 live births. Approximately 5% of infants in neonatal intensive care units have evidence of significant hearing loss. Some 8 million school-aged children experience temporary hearing loss, which usually occurs as a complication of otitis media with middle ear effusion. Hearing is necessary for normal development of speech and language and is also important for acquiring psychosocial skills during infancy and childhood. Because most speech and language development occurs between birth and 3 years of age, early detection of hearing impairment in infants and children and initiation of medical and educational interventions are critical. Refer to chapter 35 for information on hearing screening in adults. Recommendations of Major AuthoritiesNormal-Risk Children
Family history of hereditary sensorineural hearing loss; in utero infection (eg, cytomegalovirus, rubella, syphilis, herpes, or toxoplasmosis); craniofacial anomalies, including those with morphological abnormalities of the pinna and ear canal; birth weight less than 1500 grams (3.3 lbs); hyperbilirubinemia at a serum level requiring exchange transfusion; ototoxic medications, including but not limited to aminoglycosides, used in multiple courses or in combination with loop diuretics; bacterial meningitis; Apgar scores of 0 to 4 at 1 minute or 0 to 6 at 5 minutes; mechanical ventilation lasting 5 days or longer; and stigmata or other findings associated with a syndrome known to include a sensorineural and/or conductive hearing loss. Infants and children less than 2 years of age with one or more of the following risk criteria should have audiology screening. Risk Criteria for Ages 29 days to 2 Years:Parent/care-giver concern regarding hearing, speech, language, and/or developmental delay; bacterial meningitis or other infections associated with sensorineural hearing loss; head trauma associated with loss of consciousness or skull fracture; stigmata or other findings associated with a syndrome known to include a sensorineural and/or conductive hearing loss; ototoxic medications, including but not limited to aminoglycosides, used in multiple courses or in combination with loop diuretics; recurrent or persistent otitis media with effusion for at least 3 months associated with hearing loss; anatomic deformities and other disorders that affect eustachian tube function; neurofibromatosis type II and neurodegenerative disorders. Infants and children with the following risk factors for delayed-onset hearing loss require hearing evaluation every 6 months until 3 years of age. Risk Factors for Delayed-Onset Hearing Loss:Family history of hereditary childhood hearing loss; in utero infection, such as cytomegalovirus, rubella, syphilis, herpes, or toxoplasmosis; neurofibromatosis type II and neurodegenerative disorders; recurrent or persistent otitis media with effusion, anatomic deformities, and other disorders that affect eustachian tube function; neurodegenerative disorders.
1. Assess the family and medical history of every child for risk factors for hearing impairment. 2. Ask parents about the auditory responsiveness and speech and language development of young children. Any parental reports of impairment should be seriously evaluated. 3. In infants, assessment of hearing by observational techniques is very imprecise. Consider referring all infants and young children with suspected hearing difficulties to an audiologist. 4. When performing physical examinations, remain alert for structural defects of the ear, head, and neck. Remain alert for abnormalities of the ear canal (inflammation, cerumen impaction, tumors, or foreign bodies) and the eardrum (perforation, retraction, or evidence of effusion). 5. Children as young as 6 months of age, depending on how cooperative they are, may be screened by pure-tone audiometry. Two screening methods are suggested as the most appropriate tools for children who are functioning at 6 months to 3 years developmental age: visual reinforcement audiometry (VRA) and conditioned play audiometry (CPA). For children from approximately 6 months through 2 years of age, VRA is the recognized method of choice. As children mature beyond their second birthday, CPA may be attempted. For those children who can be conditioned for VRA, screen using earphones (conventional or insert), with 1000, 2000, and 4000 Hz tones at 30 dB HL. For those children who can be conditioned for play audiometry, screen using earphones (conventional or insert), with 1000, 2000, and 4000 Hz tones at 20 dB HL. Hand-held audiometers are of unproven effectiveness in screening children. After 6 months of age, any child may be screened for middle ear dysfunction using tympanometry. Perform tympanometry with a low frequency (220, 226 Hz) probe tone and a positive to negative air pressure sweep. Middle ear pressure peaks between -150 mmhos and +150 mmhos are considered normal. Patients with pressure peaks outside this range or lack of any identifiable pressure peak should be referred for otologic follow-up. 6. Repeat screening to substantiate audiometric evidence of hearing impairment. Remove and reposition the earphones and carefully repeat the instructions to the child to assure proper understanding and attention to the test. Referral to a qualified specialist (ie, audiologist, otolaryngologist) is recommended for confirmation and work-up of hearing impairment. Patient Resources
National Institute on Deafness and Other Communication Disorders. Internet address: http://www.nih.gov/nidcd American Speech-Language-Hearing Association.
American Academy of Otolaryngology-Head and Neck Surgery, Joint Committee on Infant Hearing. . 1990 position statement. American Academy of Otolaryngology-Headand Neck Surgery Bulletin. March 1991:15-18. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. . Recommendations for pediatric preventive health care. Pediatrics. 1995. 96: 373-374. (PubMed) American Academy of Pediatrics. . Managing otitis media with effusion in young children. Pediatrics. 1994. 94: 766-773. (PubMed) American Academy of Pediatrics. . Joint Committee on Infant Hearing position statement 1982. In: Policy Reference Guide: A Comprehensive Guide to AAP Policy Statements through December 1991. Elk Grove Village, Ill: American Academy of Pediatrics;1991;333-334. American Academy of Pediatrics. . Middle ear disease and language development. In: Policy Reference Guide: A Comprehensive Guide to AAP Policy Statements through December 1991. Elk Grove Village, Ill: American Academy of Pediatrics;1991;418. American Speech-Language-Hearing Association. . Guidelines for the audiologic assessment of children from birth through 36 months of age. ASHA. 1991. 33(suppl 5): 37-43. American Speech-Language-Hearing Association. . Audiologic screening of newborn infants who are at risk for hearing impairment. ASHA. 1989. 31(3): 89-92. American Speech-Language-Hearing Association. . Guidelines for identification audiometry. ASHA.1985;May:49-53. View this and related citations usingView this and related citations using American Speech-Language-Hearing Association. . Guidelines for screening for hearing impairment and middle-ear disorders. ASHA. 1990. 32(suppl 2): 17-24. American Speech-Language-Hearing Association. . Preferred practice patterns for the professions of speech-language pathology and audiology. Rockville, MD: ASHA. In press. American Speech-Language-Hearing Association. . The prevention of communication disorders tutorial. ASHA. 1991. 33(suppl 6): 15-41. (PubMed) Canadian Task Force on the Periodic Health Examination. . Routine preschool screening for visual and hearing problems. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 27. Canadian Task Force on the Periodic Health Examination. . Well-baby care in the first 2 years of life. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 24. Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Joint Committee on Infant Hearing. . Joint Committee on Infant Hearing 1994 position statement. Pediatrics. 1995. 95: 152-156. (PubMed) National Institutes of Health. . Early Identification of Hearing Impairment in Infants and Young Children. Bethesda, Md: National Institutes of Health. In press. Thompson MD, Thompson G. . Early identification of hearing loss: listen to parents. Clin Pediatr. 1991. 30: 77-80. US Preventive Services Task Force. . Screening for hearing impairment. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 35. Watkin PM, Baldwin M, Laoide S. . Parental suspicion and identification of hearing impairment. ArchDis Child. 1990. 65: 846-850. 7. Lead Childhood lead poisoning is one of the most common, preventable health problems in the United States. From 1991 to 1994, an estimated 890,000 US children aged 1 to 5 years (4.4% of all children in this age group) had blood lead levels greater than or equal to 10 µg/dL, the current definition of lead toxicity. Although rates of lead poisoning are higher among low-income, inner-city children, no socioeconomic group, geographic area, or racial or ethnic population is spared. Studies have shown that blood lead levels as low as 10 to 15 µg/dL are associated with diminished intelligence, impaired neurobehavioral development, decreased hearing acuity, and growth inhibition. Higher levels can cause severe damage to the central nervous, renal, and hematopoietic systems and can be fatal. Children at risk for lead poisoning who are screened can be followed or treated based on their blood lead levels. If lead poisoning is diagnosed, the clinician needs to call the appropriate local health authority to help determine the lead source. In several states, reporting to the local health department is required. Local public health departments may initiate community-wide educational programs and environmental assessments in response to such reports. Expert consultation for treating and following lead toxicity should be obtained by contacting the state or local health department, a university medical center, or a certified regional poison control center. Recommendations of Major Authorities
1.
Begin risk assessment and counseling during prenatal visits and continue after birth during regular office visits until the child is at least 6 years of age. Counsel parents against sanding old lead paint while remodeling during pregnancy.
Patient Resources2. Evaluate each child's risk of lead toxicity. Use of a structured set of questions such as that developed by CDC (Table 7.1) can be very helpful. If the answer to any of the questions is positive, consider the child at high risk for exposure. 3. Measurement of the blood lead level is more sensitive and specific than measurement of the erythrocyte protoporphyrin (EP) level. 4. Screening blood lead levels may be obtained from capillary sampling. Follow the precautions listed in Table 7.2 to minimize the chance of contamination from environmental sources. Confirm elevated blood lead test results (15 µg/dL or greater) obtained on capillary specimens by using venous blood. A child with a capillary lead level of 70 µg/dL or greater requires immediate retesting using a venous sample. 5. Interpret and manage blood lead test results according to the CDC recommendations listed in Table 7.3. Several states require primary care providers and persons in charge of lead screening programs to report both presumptive and confirmed cases of lead toxicity to the appropriate health agency. 6. Laboratories where blood is tested for lead levels must participate in a blood-lead proficiency testing program, such as the collaborative program between the Health Resources and Services Administration and CDC. Information on this program is available by calling the Wisconsin State Hygiene Laboratory (608)262-1146. 7. Because iron deficiency can enhance lead absorption and toxicity, test all children with blood lead levels of 20 µg/dL or greater for iron deficiency. 8. Provide guidance to parents about creating an environment safe from lead exposure for their children. Include advice on eliminating peeling or chipping paint, decreasing the lead content of water, preventing contact via hobbies or contaminated work clothing, remaining alert for pica behavior, and assuring good hygiene. ( See Patient Resources for publications to aid in counseling.)
Agency for Toxic Substances and Disease Registry. . Case Studies in Environmental Medicine: Lead Toxicity. Atlanta, Ga: Agency for Toxic Substances and Disease Registry, Centers for Disease Control; September 1992. US Department of Health and Human Services. American Academy of Family Physicians. . Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. Canadian Task Force on the Periodic Health Examination. . Screening children for lead exposure in Canada. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 25. Centers for Disease Control and Prevention. . Update: Blood Lead LevelsUnited States, 1991-1994. MMWR. 1997. 46(7): 141-144. Centers for Disease Control. . Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control. Atlanta, GA: Centers for Disease Control; 1991. US Department of Health and Human Services. Crocetti AF, Mushak P, Schwartz J. . Determination of numbers of lead-exposed US children by areas of the United States: an integrated summary of a report to the US Congress on childhood lead poisoning. Environ Health Perspect. 1990. 89: 109-120. (PubMed) DeBaun MR, Sox HC. . Setting the optimal erythrocyte protoporphyrin screening decision threshold for lead poisoning: a decision analytic approach. Pediatrics. 1991. 88: 121-131. (PubMed) Mahaffey KR, Annest JL, Roberts J, Murphy RS. . National estimates of blood lead levels: United States, 1976-1980. N Engl J Med. 1982. 307: 573-579. (PubMed) Needleman HL. . The persistent threat of lead: a singular opportunity. Am J Public Health. 1989. 79: 643-645. (PubMed) Needleman HL, Schell A, Bellinger D, Leviton A, Allred EN. . The long-term effects of exposure to low doses of lead in childhood: an 11-year follow-up report. N Engl J Med. 1990. 322: 83-88. (PubMed) Ratcliffe SD, Lee J, Lutz LJ, Woolley FR, et al. . Lead toxicity and iron deficiency in Utah migrant children. Am J Public Health. 1989. 79: 631-633. (PubMed) Ruff HA, Bijur PE, Markowitz M, Yeou-Cheng M, Rosen JF. . Declining blood lead levels and cognitive changes in moderately lead-poisoned children. JAMA. 1993. 269: 1641-1654. (PubMed) US Preventive Services Task Force. . Screening for elevated lead levels in childhood and pregnancy. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 23. Tables Table 7.1. Recommended Questions for Assessing Lead Exposure Risk
Virtually all states require screening of newborns for congenital hypothyroidism and phenylketonuria (PKU). Testing for galactosemia and hemoglobinopathies is required in a majority of states, and some states require screening of newborns for maple syrup urine disease, homocystinuria, biotinidase deficiency, tyrosinemia, congenital adrenal hyperplasia, cystic fibrosis, and toxoplasmosis. Table 8.1 provides a state-by-state listing of newborn screening policies. Hypothyroidism Phenylketonuria (PKU) Galactosemia Hemoglobinopathies
National authorities have made recommendations for the following specific conditions: Hypothyroidism
Schedule 1
1.
For the full-term, well neonate, obtain the specimen as close as possible to the time of discharge from the nursery and in no case later than 7 days of age. If the initial specimen is obtained earlier than 24 hours after birth, obtain a second specimen at 1 or 2 weeks of age to decrease the probability that PKU and other disorders with metabolite accumulation will be missed.
Collection Technique
2
2. For any premature infant, any infant receiving parenteral feeding, or any neonate being treated for illness, obtain a specimen for screening at or near the seventh day of life if a specimen has not been obtained before that time, regardless of feeding status. For infants requiring transfusion or dialysis before the standard time for obtaining a specimen, obtain the sample for screening before transfusion or dialysis, if the neonate's condition is amenable. If asample cannot be obtained beforehand, ensure that an adequate specimen is obtained at a time when the plasma or red blood cells, or both, will again reflect the child's own metabolic processes or phenotype.
1.
Apply the same standards and techniques for the collection of blood specimens for neonatal screening programs for all of the congenital diseases. State screening agencies hold individual hospitals accountable for instituting policies thatassure proper collection of filter-paper blood samples.
Documentation
2. Enter the required information on the specimen collection kit with a ballpoint pen, not a soft-tip pen or typewriter. 3. Universal precautions: Use all appropriate precautions, including wearing gloves, when handling blood, and dispose of used lancets in a biohazard container for sharp objects. 4. Site Selection: The source of blood must be the most lateral surface of the plantar aspect (walking surface) of the infant's heel. Skin punctures to obtain blood specimens must not be performed on the central area of the newborn's foot (area of the arch) or on the fingers of newborns. Puncturing the heel on the posterior curvature will permit blood to flow away from the puncture, making proper spotting difficult. Do not lance a previous puncture site. 5. Site Preparation: Warm the puncture site to increase blood flow. Place a warm, moist towel at a temperature no higher than 42°C (108°F) on the site for 3 minutes. Holding the infant's leg in a position lower than the heart will increase venous pressure. 6. Cleaning the Site: Clean the infant's heel with 70% isopropyl alcohol (rubbing alcohol). Wipe away excess alcohol with a dry sterile gauze or cotton ball, and allow the heel to air-dry thoroughly. Failure to wipe off alcohol residue may dilute the specimen and adversely affect test results. 7. Puncture: To ensure sufficient blood flow, puncture the plantar surface of the infant's heel with a sterile lancet to a depth of 2.0 to 2.4 mm or with an automated lancet device. Wipe away the first drop of blood with sterile gauze. In small premature infants, the heel bone may be no more than 2.4 mm beneath the plantar heel skin surface and half this distance at the posterior curvature of the heel. Puncturing deeper may risk bone damage. Do not milk or squeeze the puncture site, as this may cause hemolysis and admixture of tissue fluids with the specimen. 8. Filter Paper Handling and Application: Avoid touching the area within the printed circle on the filter paper before collection. Gently touch the filter paper against a large drop of blood and, in one step, allow a sufficient quantity of blood to soak through to completely fill the circle on the filter paper. Do not press the paper against the puncture site on the heel. Apply blood to only one side of the filter paper. Examine both sides of thefilter paper to assure that the blood penetrates and saturates the paper. Do not layer successive drops of blood within the circle. If blood flow diminishes so that the circle is incompletely filled, repeat the sampling steps at a different site. Do not touch the blood sample after collection; do not allow water, feeding formulas, antiseptic solutions, or any other contaminant to come into contact with the sample. Allow the sample to dry thoroughly before insertion into the envelope. Insufficient drying can adversely affect test results. 9. Hemostasis: After blood has been collected from the heel of the newborn, elevate the foot above the body and press a sterile gauze pad or cotton ball against the puncture site until the bleeding stops. Ensure that children receive proper newborn screening and that test results are reviewed. Be aware of patients who are at increased risk for not being screened. Such patients include sick or premature neonates, neonates undergoing adoption or being transferred within or between hospitals, infants born at home, children of transient or homeless families, and infants born outside the United States and Canada. Document newborn screening results in an easily accessible part of the patient record for future reference. Follow-upConfirm all abnormal results with retesting. With certain rare exceptions (eg, galactosemia and maple syrup urine disease), do not initiate treatment until a confirmatory test result has been obtained. Prompt physical examination of patients with abnormal results is important. Start all patients with sickle cell disease on penicillin prophylaxis as soon as the diagnosis is confirmed. CounselingProvide appropriate counseling to all parents of children with abnormal test results. Provide information about the significance of the results and the need for retesting, the implications for the child's health, treatment regimens, symptoms to be alert for, and genetic issues for future childbearing. Patient Resources
American Academy of Family Physicians. . Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. American Academy of Pediatrics, Committee on Genetics. . Issues in newborn screening. Pediatrics. 1992. 89: 345-349. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Health supervision for children with sickle cell diseases and their families. Pediatrics. 1996. 98: 467-472. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Health supervision for children with achondroplasia. Pediatrics. 1995. 95: 443-451. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Health supervision for children with Down syndrome. Pediatrics. 1994. 93: 855-859. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Newborn screening fact sheets. Pediatrics. 1989. 83: 449-464. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Prenatal genetic diagnosis for pediatricians. Pediatrics. 1994. 93: 1010-1015. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Health supervision for children with fragile X syndrome. Pediatrics. 1996. 98: 297-300. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Health supervision for children with Marfan syndrome. Pediatrics. 1996. 98: 978-982. (PubMed) American Academy of Pediatrics, Committee on genetics. . Health supervision for children with neurofibromatosis. Pediatrics. 1995. 96: 368-372. (PubMed) American Academy of Pediatrics, Committee on Genetics. . Health supervision for children with Turner syndrome. Pediatrics. 1995. 96: 1166-1173. (PubMed) American Academy of Pediatrics, Section on Endocrinology and Committee on Genetics, American Thyroid Association, Committee on Public Health. . Newborn screening for congenital hypothyroidism: recommendations for guidelines. Pediatrics. 1993. 91: 1203-1209. (PubMed) Canadian Task Force on the Periodic Health Examination. . Screening for congenital hypothyroidism. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 18. Canadian Task Force on the Periodic Health Examination. . Screening for hemoglobinopathies in Canada. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 20. Canadian Task Force on the Periodic Health Examination. . Screening for phenylketonuria. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 17. Donnell G, ed. . Galactosemia: New Frontiers in Research. Bethesda, MD: National Institutes of Health, National Institute of Child Health and Development; 1993. Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Illinois Department of Public Health. . An Overview of Newborn Screening Programs in the United States and Canada. Springfield, Ill: Illinois Department of Public Health; 1996. National Committee for Clinical Laboratory Standards. . Blood Collection on Filter Paper for Neonatal Screening ProgramsSecond Edition; Approved Standard. Villanova, Pa: National Committee for Clinical Laboratory Standards; 1992. National Institutes of Health. . Newborn Screening for Sickle Cell Disease and Other Hemoglobinopathies. National Institutes of Health Consensus Development Conference Statement. 1987. 6(9): 1-22. National Screening Status Report. . Infant Screening. 1993. 16(1): -. Sickle Cell Disease Guideline Panel, Agency for Health Care Policy and Research. . Sickle Cell Disease: Screening, Diagnosis, Management, and Counseling in Newborns and Infants. Clinical Practice Guideline No. 6. Rockville, Md: US Department of Health and Human Services; April 1993. DHHS publication AHCPR 93-0562. Therrell BL, ed. . Methods for Neonatal Screening. Washington, DC: American Public Health Association, 1993. US Preventive Services Task Force. . Screening for congenital hypothyroidism. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 45. US Preventive Services Task Force. . Screening for hemoglobinopathies. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 43. US Preventive Services Task Force. . Screening for phenylketonuria. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 44. Tables Table 8.1. Newborn Screening By State
Tuberculosis (TB) continues to be a public health problem in the United States for both children and adults. Although the number of new TB cases in the United States among children younger than 15 years of age declined steadily from 1953 (when national surveillance for TB began) until 1988, the number of new cases increased 51% between 1988 and 1992 (from 1133 to 1708). Despite a drop in new TB cases in children between 1992 and 1995, 38% more new cases occurred in 1995 compared with 1988. Factors contributing to the increase in the number of TB cases include adverse social and economic conditions, the epidemic of human immunodeficiency virus (HIV) infection, immigration of individuals with Mycobacterium tuberculosis infection, and noncompliance of clinicians and patients with recommended screening and treatment regimens. The recent emergence of multiple-drug-resistant strains of M. tuberculosis has added urgency to the need for improved preventive efforts to combat the disease. Of additional concern is that the number of TB cases among children younger than age 2 years is twice that among older children. Young children, in whom early TB disease may go unrecognized because their TB skin tests may be negative and because they may have few symptoms of disease, are more likely to develop severe disease such as meningitis or miliary tuberculosis than older children or adults. Young children are also more likely to progress from primary TB infection to active disease in a shorter time period than older children and adults. The diagnosis of TB disease in a child is a sentinel event, signifying recent and ongoing transmission of M. tuberculosis in the community. In most states, the clinician is responsible for reporting cases of TB to the appropriate local or state health department, in order to initiate an epidemiologic investigation to identify and to treat infectious cases and contacts in the community. Pediatric populations at high risk for TB disease include foreign born, African American, and Hispanic children. General populations at high risk of tuberculous infection include: 1) close contacts of persons known or suspected to have TB; 2) persons infected with HIV; 3) persons who inject illicit drugs or other locally identified high-risk substance abusers (eg, crack cocaine users); 4) persons who have medical risk factors known to increase the risk for TB disease if infection occurs; 5) residents and employees of high-risk congregate settings (eg, correctional institutions, nursing homes, mental institutions, other long-term residential facilities, and shelters for the homeless); 6) health-care workers who serve high-risk clients; 7) foreign-born persons, including children, who have arrived within 5 years from countries with a high incidence or prevalence of TB; and 8) some medically underserved, low-income populations. Conditions and chronic diseases that predispose patients to development of TB disease include HIV infection, diabetes mellitus, end-stage renal disease, and hematologic and reticuloendothelial diseases; history of intestinal bypass or gastrectomy, chronic malabsorption syndromes, silicosis, cancers of the upper gastrointestinal tract or oropharynx, prolonged steroid use, and immunosuppressive therapy; and being 10% or more below desirable body weight. Screening for TB consists of an intradermal injection of purified protein derivative (Mantoux test). A positive skin reaction (Table 9.1) necessitates additional work-up (chest x-rays, sputum smears and cultures) to differentiate between TB infection and TB disease. A drug regimen based on this evaluation will either be a prophylactic treatment of TB infection or a multi-drug treatment of TB disease (based on the organism's antibiotic sensitivities). Isoniazid prophylaxis has been shown to be effective in preventing the progression of TB infection to clinical TB disease. When isoniazid is taken for 12 months, it reduces the occurrence of TB disease by 54% to 88%. The efficacy of isoniazid is directly related to the length of prophylaxis, the extent of patient compliance with the prophylactic regimen, and the susceptibility of the infecting organism to isoniazid. In the United States, the use of Bacillus of Calmette and Guérin (BCG) vaccine to prevent TB infection is rarely indicated; however, new recommendations have been developed in light of two meta-analyses of BCG vaccine clinical trials, as well as the increase in TB cases and the outbreaks of multi-drug-resistant TB. The meta-analyses of BCG protective efficacy indicated that the vaccine efficacy for preventing serious forms of TB in children (meningeal and miliary) was high (>80%). (See Basics of: BCG Vaccination.) Tuberculosis disease is currently designated as an infectious disease notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases. Recommendations of Major AuthoritiesScreening
NOTE: Persons who are not likely to be infected with M. tuberculosis generally should not undergo skin testing, because the predictive value of a positive skin test in low-risk populations is poor.
1.
The Mantoux test is the standard method of testing. Multiple-puncture tests should not be used to determine whether a person is infected.
Basics of Tuberculosis Prophylaxis
2. For the Mantoux test, use 0.1 mL of purified protein derivative (PPD) containing 5 tuberculin units. Administer PPD using a disposable tuberculin syringe, with the bevel of the needle facing upward. Administer the injection intradermally on the volar surface of the forearm to produce a pale, discrete elevation of the skin (weal) 6 to 10 mm in diameter. The weal disappears shortly after the test is administered. 3. Read the test 48 to 72 hours after injection by measuring the diameter of induration (not erythema) transverse to the long axis of the forearm. Record the actual millimeters of induration. Do not consider the erythema that may surround the area of induration. 4. The definition of a positive skin test reaction depends on the likelihood of tuberculosis infection and the risk of tuberculosis disease if infection has occurred. A positive skin reaction can be expected 2 to 10 weeks after infection with TB has occurred. 5. Do not retest patients who have a documented history of a positive Mantoux test; such testing has no diagnostic utility. 6. Live-virus vaccines, such as measles-mumps-rubella (MMR), varicella (VCV), and oral polio vaccine (OPV), may interfere with a response to a tuberculin skin test. The tuberculin skin test should either be administered on the same day as the live-virus vaccinations, or postponed until 4 to 6 weeks after the vaccinations. 1. Indications A child with a positive Mantoux test result but without active disease is a candidate for isoniazid prophylaxis. Active disease is excluded by a normal chest radiograph and a lack of symptoms suggesting TB disease. See Table 43.1 for more information on general indications for prophylaxis. Special pediatric cases should be considered candidates for isoniazid prophylaxis even if they lack documentation of a positive Mantoux test:
The recommended dosage of isoniazid is 10 to 15 mg/kg (up to a maximum of 300 mg) given orally once daily. For noncompliant patients, 15 mg/kg (to a maximum of 900 mg) may be given twice weekly under the direct observation of a health professional. 3. DurationContinue isoniazid prophylaxis for 6 to 12 months. Recommendations regarding the duration of isoniazid prophylaxis vary (See Recommendations of Major Authorities: Prophylaxis). 4. PrecautionsPatients receiving isoniazid prophylaxis must be monitored monthly for signs and symptoms of hepatotoxicity, including loss of appetite, nausea, vomiting, persistent dark urine, jaundice, fever, and abdominal tenderness (especially in the right upper quadrant). Isoniazid should be discontinued at the first sign of hepatotoxicity, and the patient evaluated for the cause of hepatitis. If isoniazid is not the cause of hepatotoxicity, consider reinstating isoniazid preventive therapy once the patient is clinically stable. In otherwise healthy children, the incidence of hepatitis during isoniazid therapy is low enough that routine screening with liver function testing is not required. Peripheral neuritis and convulsions caused by inhibition of pyridoxine metabolism by isoniazid have rarely occurred. When neuritis or convulsions occur during isoniazid treatment, consider accidental overdosage as a possible cause. Pyridoxine supplementation may be considered on an individual basis for breast-feeding children, children with deficient diets (particularly those low in meat and milk), and pregnant women. Basics of BCG Vaccination1. Indications Recommendations differ slightly among authorities. (See Recommendations of Major Authorities.) 2. Vaccine TypesOne BCG vaccine (Tice) is available in the United States. Other BCG preparations that are available for the treatment of bladder cancer are not intended for use as vaccines. Other vaccines are in use in Canada and Mexico. 3. Dose and Administration> 30 days old: Drop 0.3 mL of the vaccine on the cleansed surface of the skin in the lower deltoid area. Administer the vaccine percutaneously by applying a multiple-puncture disc through the vaccine; the vaccine should flow into the puncture wounds and dry. A dressing is not required, but advise the patient to keep the site dry for 24 hours. <30 days old: Administer only half the usual dose to infants younger than 30 days old. If an infant's indications for vaccination persist (ie, the TB skin test result is <5 mm induration), administer a full dose of vaccine at 1year of age. 4. ContraindicationsUntil the risks and benefits of BCG vaccination in immunocompromised populations are defined, BCG vaccination should not be administered to persons with impaired immune responses (ie, HIV infection, congenital immunodeficiency, leukemia, lymphoma, or generalized malignancy) or suppressed immune responses (from steroids, alkylating agents, antimetabolites, or radiation.) Although no harmful effects to the fetus have been associated with BCG vaccination, its use is not recommended during pregnancy. 5. Adverse reactionsA bluish-red pustule usually forms at the site within 2 to 3 weeks. After 6 weeks, the pustule ulcerates and forms a lesion approximately 5 mm in diameter. Healing is usually complete within 3 months, but a permanent scar usually occurs at the site. Keep draining lesions clean and bandaged. Hypertrophic scars occur in 28% to 33% of vaccinated persons, and keloid scars occur in 2% to 4% of vaccinees. Although BCG vaccination often results in local adverse effects, serious or long-term complications are rare. Moderate axillary or cervical lymphadenopathy, induration and subsequent pustule formation at the injection site can be expected. More severe local reactions include ulceration at the site and regional suppurative lymphadenitis. Disseminated BCG infection is a rare occurrence, but it is the most serious complication of the vaccine, and can occur from 4 months to 2 years after the vaccination. 6. InteractionsBCG vaccination can cause false-positive Mantoux reactions, but these tuberculin skin test reactions decrease with time after vaccination, and reactions of 15 mm induration or larger are rare. The presence or size of a post-vaccination tuberculin skin-test reaction does not predict whether BCG will provide any protection against TB disease. In general, consider BCG-vaccinated individuals with positive Mantoux test results to have true infection with M. tuberculosis. 7. Follow-upPerform tuberculin skin testing 3 months after BCG vaccination; record test results, in millimeters of induration, in the patient's medical record. The vaccinated person may continue to participate in ongoing skin-testing programs if results remain negative (<5 mm induration). Vaccinees who have positive skin-test results ( > 5 mm induration) after vaccination should not be retested unless exposed to a person with infectious TB. A diagnosis of TB infection and the use of preventive therapy should be considered for any BCG-vaccinated person who has a tuberculin skin-test reaction of 10 mm of induration, particularly if any of the following circumstances are present:
American Academy of Family Physicians. . Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. American Academy of Pediatrics, Committee on Infectious Diseases. . Tuberculosis. In: 1994 Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, Ill: American Academy of Pediatrics; 1994:480-500. American Academy of Pediatrics, Committee on Infectious Diseases. . Update on tuberculosis skin testing of children. Pediatrics. 1996. 97(2): 282-284. (PubMed) American Medical Association. . Rationale and recommendation: Infectious diseases. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994: chap 15. American Thoracic Society. . Control of tuberculosis in the United States. Am Rev Respir Dis. 1992. 146: 1623-1633. (PubMed) American Thoracic Society/Centers for Disease Control. . Diagnostic standards and classification of tuberculosis. Am Rev Respir Dis. 1990. 142: 725-735. (PubMed) American Thoracic Society. . Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med. 1994. 149: 1359-1374. (PubMed) Canadian Task Force on the Periodic Health Examination. . Screening and isoniazid prophylactic therapy for tuberculosis. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 62. Centers for Disease Control. . Prevention and control of tuberculosis in US communities with at-risk minority populations and prevention and control of tuberculosis among homeless persons. MMWR. 1992. 4: 1-23. Centers for Disease Control and Prevention. . Screening for tuberculosis and tuberculous infection in high-risk populations: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR. 1995. 44(RR-11): 19-34. (PubMed) Centers for Disease Control and Prevention. . Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR. 1994;43(RR-13). Centers for Disease Control and Prevention. . Essential components of a tuberculosis prevention and control program; and Screening for tuberculosis and tuberculosis infection in high-risk populations; recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR. 1995;44(RR-11). Centers for Disease Control and Prevention. . The role of BCG vaccine in the prevention and control of tuberculosis in the United States: a joint statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices. MMWR. 1996. 45(RR-4): 1-18. Colditz GA, Brewer TF, Berkey CS, et al. . Efficacy of BCG vaccine in the prevention of tuberculosis: meta-analysis of published literature. JAMA. 1994. 271: 698-702. (PubMed) Huebner RE, Schein MF, Bass JB. . The tuberculin skin test. Clin Infect Dis. 1993. 17: 968-975. (PubMed) Physician's Desk Reference. . Oradell, NJ: Medical Economics Company; 1993:898-899; 1689-1692. Pust, RE. . Tuberculosis in the 1990s: resurgence, regimens, and resources. South Med J. 1992. 85: 584-593. (PubMed) US Preventive Services Task Force. . Screening for tuberculosis infection (including BCG immunization). In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 25. Ussery XT, Valway SE, McKenna M, Cauthen GM, McCray E, Onorato IM. . Epidemiology of tuberculosis among children in the United States: 1985 to 1994. Pediatr Infect Dis J. 1996. 15: 697-704. (PubMed) Tables Table 9.1. Definition of a Positive Mantoux Skin Test (5 Tuberculin Units of Purified Protein Derivative) in Children
Urinalysis can detect many abnormalities in the urine, including the presence of glucose, protein, red and white blood cells, bacteria, and bacterial breakdown products. Screening the urine of asymptomatic children for the presence of red blood cells and protein is generally not productive, because the causative disorders tend to be transient and benign. Screening for glucosuria is also of questionable value, because renal thresholds for glucose spillage vary, and the interval between onset of glucosuria and onset of the symptoms of diabetes mellitus is short. Screening for indicators of occult infection, such as white blood cells and bacteria, may be beneficial as a means of promoting early treatment. During infancy, the prevalence of asymptomatic bacteriuria is higher among boys (2.5%) than among girls (0.9%), in part because boys have structural abnormalities of the urinary tract more frequently than girls. After infancy, the prevalence of asymptomatic bacteriuria is much higher among girls (1% to 2%) than among boys (<0.1%). Asymptomatic bacteriuria develops into symptomatic urinary tract infections in fewer than 10% of cases. Urinary tract infections can lead to renal scarring and permanent renal damage. Such damage generally occurs in children before 2 to 3 years of age, when screening is difficult because of problems of specimen collection. Treatment of asymptomatic bacteriuria with antibiotics may alter the composition of body flora and lead to infection with resistant bacteria. Asymptomatic sexually transmitted diseases, particularly infection with Chlamydia trachomatis, are common in adolescents and young adults. The prevalence of asymptomatic chlamydial urethral infection in young males ranges from 6% to 11%. These infections can be passed to female partners, resulting in pelvic inflammatory disease, ectopic pregnancy, and infertility. Recently, dipstick urinalysis has been advocated as a noninvasive initial screening technique for detecting such occult infections in sexually active young males. Such testing has moderate sensitivity and low specificity, necessitating additional follow-up testing of patients with positive results. The FDA has not approved these tests for screening for sexually transmitted diseases including C. trachomatis. Recommendations of Major Authorities
1.
To obtain urine from infants and young children, apply a plastic urine bag to the perineum. This method is associated with a relatively high rate of false-positive results (up to 30%) because of contamination. Positive test results of urine obtained by bag collection should be confirmed by catheterization or suprapubic aspiration.
Provider Resources
2. In screening children and adolescents for bacteriuria, obtain specimens using midstream "clean catch" techniques. This method permits follow-up culture testing of dipstick-positive specimens. The vulva of girls and the glans of boys should be cleansed well with a mild soap solution. Do not use antiseptic solutions because of the potential for suppressing bacterial growth in the sample. During urination, the labia of girls should be held open to avoid impinging on the flow of urine. This may be accomplished without manual holding by having the girl sit backward with legs astride a toilet seat. The foreskin of uncircumcised boys should be retracted to avoid impinging on the flow of urine. 3. The sensitivity of screening for bacteriuria may be improved by obtaining a specimen from the first void of the day, which is more concentrated and contains higher amounts of bacteria and bacterial breakdown products compared with subsequent voids. Specimen collection from later voids is acceptable and may be more practical. 4. The dipstick leukocyte esterase test is the most efficient way to screen specimens for bacteriuria. The sensitivity and specificity of both this test and the more labor-intensive microscopic analysis are roughly equivalent (approximately 80%). The nitrite test is also available on many dipsticks, but its low sensitivity, approximately 30%, makes it an inadequate screening tool if used alone. A positive nitrite test result, however, is approximately 99% specific for significant bacteriuria. 5. To screen males for sexually transmitted diseases, collect a urine sample from the first 15 to 20 mL of a void and test the unspun sample with a leukocyte esterase dipstick. Because of the poor specificity and relatively high cost of this test, as well as the potential morbidity associated with treatment, confirm positive test results with more specific techniques, such as enzyme immunoassay and/or culture. Negative results from symptomatic males should always be confirmed by enzyme immunoassay and/or culture.
American Academy of Family Physicians. . Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. . Recommendations for pediatric preventive health care. Pediatrics. 1995. 96: 373-374. (PubMed) American Medical Association. . Guidelines for adolescent preventive services. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994:xxix-xxxviii. Aronson MD, Phillips RS. . Screening young men for Chlamydia infection. JAMA. 1993. 270: 2097-2098. (PubMed) Boehm JJ, Haynes JL. . Bacteriology of "midstream catch" urines. Am J Dis Child. 1966. 111: 366-369. (PubMed) Canadian Task Force on the Periodic Health Examination. . Screening for urinary infection in asymptomatic infants and children. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 21. Canadian Task Force on the Periodic Health Examination. . The periodic health examination 1979. Can Med Assoc J. 1979. 121: 1193-1254. (PubMed) Dodge WF. . Cost effectiveness of renal disease screening. Am J Dis Child. 1977. 131: 1274-1280. (PubMed) Edelmann CM, Ogwo JE, Fine BP, Martinez AB. . The prevalence of bacteriuria in full-term and premature newborn infants. J Pediatr. 1973. 82: 125-132. (PubMed) Genc M, Ruusuvaara, Mardh PA. . An economic evaluation of screening for Chlamydia trachomatis in adolescent males. JAMA. 1993. 270: 2057-2064. (PubMed) Goldsmith BM, Campos JM. . Comparison of urine dipstick, microscopy, and culture for the detection of bacteriuria in children. Clin Pediatr. 1990. 29: 214-218. Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Lindberg U. . Asymptomatic bacteriuria in school girls: V. The clinical course and response to treatment. Acta Paediatr Scand. 1975. 64: 718-724. (PubMed) Lohr JA, Donowitz LG, Dudley SM. . Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in boys. J Pediatr. 1986. 109: 659-660. (PubMed) Lohr JA, Donowitz LG, Dudley SM. . Bacterial contamination rates in voided urine collections in girls. J Pediatr. 1989. 114: 91-93. (PubMed) Kemper KJ, Avner ED. . The case against screening urinalyses for asymptomatic bacteriuria in children. Am J Dis Child. 1992. 146: 343-346. (PubMed) Kunin CM. . Detection, Prevention and Management of Urinary Tract Infections. 4th ed. Philadelphia, Pa: Lea & Febiger, 1987. Mitchell N, Stapleton FB. . Routine admission urinalysis examination in pediatric patients: a poor value. Pediatrics. 1990. 86: 345-349. (PubMed) Quinn C, Gaydos C, Shepherd M, Bobo L, et al. . Epidemiologic and microbiologic correlates of Chlamydia trachomatis infection in sexual partnerships. JAMA. 1996. 276: 1727-1742. Schlager TA, Dunn ML, Dudley SM, Lohr JA. . Bacterial contamination rate of urine collected in a urine bag from healthy non-toilet-trained male infants. J Pediatr. 1990. 116: 738-739. (PubMed) Shafer M, Schachter J, Moncada J, et al. . Evaluation of urine-based screening strategies to detect Chlamydia trachomatis among sexually active asymptomatic young males. JAMA. 1993. 270: 2065-2070. (PubMed) US Preventive Services Task Force. . Screening for asymptomatic bacteriuria. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 31. Zhanel GG, Harding GKM, Guay DRP. . Asymptomatic bacteriuria. Which patients should be treated? Arch Intern Med. 1990. 150: 1389-1396. (PubMed) 11. Vision Refractive errors are the most common vision disorders in children, occurring in 20% of children by age 16years. Amblyopia ("lazy eye") develops in 2% to 5% of children, and the risk of developing this disorder is greatest during the first 2 to 3 years of life. The potential for its development exists, however, until visual development is complete at 9 years of age. Untreated amblyopia may result in irreversible visual deficits. Strabismus,one of the primary causes of amblyopia, occurs in 2% of children. Other eye diseases occurring during infancy and childhood include cataracts (1 per 1000 live births), congenital glaucoma (1 per 10,000 live births), and retinoblastoma (1 per 20,000 live births). Through careful history, examination, vision testing, and appropriate referral, amblyopia and other ophthalmologic disorders can be detected and visual impairment can be lessened or averted. Early detection and prompt intervention are essential. Recommendations of Major AuthoritiesNormal-Risk Children
1. History When screening for present or potential visual disorders, consider the following factors:
A comprehensive examination of the eye includes the lids, lashes, tear ducts, orbit, conjunctiva, sclera, cornea, iris, pupillary responsiveness, range of motion, anterior chamber, lens, vitreous, retina, and optic nerve and vessels. Gaining the cooperation of a young child with an ophthalmoscopic examination can be difficult. It may be helpful to demonstrate the examination procedure on the parent beforehand and to have the child sit on the parent's lap. 3. Testing ProceduresRed Reflex: Perform this exam with an ophthalmoscope or other light source. In a darkened room, hold the light source at arm's length from the infant, and draw the infant's attention to look directly at the light. Both retinal reflexes should be red or red-orange and of equal intensity. Corneal Light Reflex:To detect strabismus, perform this test with an ophthalmoscope or other light source. Corneal light reflections should fall symmetrically on corresponding points of the patient's eyes. Improper alignment will appear as asymmetry of reflections. Differential Occlusion:Gently cover the infant's eyes, one at a time. Aversion to the occlusion is normal. This test may give a false-positive result and is generally less accurate than the corneal light reflex test for detecting strabismus. Fixation:Hold a light or a small object in front of the infant. Normal eyes will be aligned in the same direction, without deviation. Cover/Uncover:Have the child focus on a stationary target. Place a hand or cover in front of one eye, and observe the other eye. Movement of the observed eye is abnormal and demonstrates the presence of strabismus. As the covered eye is uncovered, observe it for movement. Movement is abnormal and indicates the presence of heterophoria. Stereo testing:To detect stereopsis (binocular depth perception), use a stereo testing technique, such as the Random Dot E stereogram. While wearing polarized glasses, the child views test cards that contain fields of random dots. If stereopsis is present, the child will see a form stand out from the background of the cards. Visual Acuity:Several eye charts are available to test visual acuity in children. In order of decreasing cognitive difficulty, these are: Snellen Letters, Snellen Numbers, Tumbling E, HOTV, Allen Figures, and LH (Leah Hyvarinen) Test. Use the test with the highest level of difficulty that the child is capable of performing. In general, the Snellen tests are too advanced for preschool-aged children. Test for visual acuity at 10, 15, or 20 feet using the appropriate chart. Using a distance of 10 feet for young children may result in better compliance because of closer interaction with the examiner. To ensure that a young child does not "peek" with the eye not being tested, hold the occluder for the child or use an adhesive occluder. Give a passing score for each line on which the child gives more than 50% correct responses. Recommended criteria for referral to an ophthalmologist or optometrist vary slightly. In general, refer any child with a difference between eye scores of two or more lines; children younger than age 5 years who score 20/40 or worse in either eye; and children aged 5 years or older who score 20/30 or worse in either eye. 4. Safety CounselingCounsel parents and children about eye safety and the appropriate use of protective equipment. Children who participate in school shop or science labs or in certain sports (ie, racquetball, squash) should wear safety lenses and safety frames approved by the American National Standards Institute. Children with good vision in only one eye should wear safety lenses and safety frames to protect the good eye, even if they do not otherwise need to wear glasses. Patient Resources
American Academy of Family Physicians. . Sumary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997. American Academy of Ophthalmology. . Infant and Children's Vision Screening: Policy Statement. San Francisco, Calif: American Academy of Ophthalmology; 1991. American Academy of Ophthalmology, Quality of Care Committee, Pediatric Ophthalmology Panel. . Comprehensive Pediatric Eye Evaluation. San Francisco, Calif: American Academy of Ophthalmology; 1992. American Optometric Association. . Guidelines for Preventive Eye Care. St. Louis, Mo: American Optometric Associaiton; 1993. American Optometric Association. . Pediatric Eye and Vision Examination. St. Louis, Mo: American Optometric Association; 1994. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. . Recommendations for pediatric preventive health care. Pediatrics. 1995. 96: 373-374. (PubMed) Canadian Task Force on the Periodic Health Examination. . The periodic health examination. Can Med Assoc J. 1979. 121: 1194-1254. Canadian Task Force on the Periodic Health Examination. . Periodic health examination: 2; 1989 update. Can Med Assoc J. 1989. 141: 4-24. Canadian Task Force on the Periodic Health Examination. . Routine preschool screening for visual and hearing problems. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 27. Canadian Task Force on the Periodic Health Examination. . Well baby care in the first 2 years of life. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 24. Gaynon MW. . Retinopathy of prematurity. Pediatrician. 1990. 17: 127-133. (PubMed) Green M, ed. . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994. Hope C. . Random dot stereogram E in vision screening of children. Austr N Zea J Ophthalmol. 1990. 18: 319-324. Romano PE. . Advances in vision and eye screening: screening at six months of age. Pediatrician. 1990. 17: 134-141. (PubMed) Romano PE. . Vision/eye screening: Test twice and refer once. Pediatr Annals. 1990. 19: 359-367. US Preventive Services Task Force. . Screening for visual impairment. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services, 1996: chap 33. Tables Table 11.1. Eye and Vision Examination Recommendations for Primary Care Clinicians
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