Children and Adolescents Screening

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.

American Academy of Family Physicians (AAFP) and US Preventive Services Task Force (USPSTF) --

Hemoglobin concentration screening should be performed between 6 and 12 months of age for infants in high-risk groups. The AAFP and USPSTF define high-risk groups as infants living in poverty; African Americans; American Indians; Alaska Natives; immigrants from developing countries; preterm and low-birth-weight infants; and infants whose principal intake is unfortified cow's milk.

American Academy of Pediatrics and Bright Futures --

Hemoglobin or hematocrit should be measured once during infancy (between 1 and 9 months) for all children and once during adolescence for all menstruating teenagers. Bright Futures recommends hemoglobin and hematocrit screening at age 6 months if certification for Women, Infants, and Children (WIC) is needed. Bright Futures also recommends annual hemoglobin and hematocrit screening for adolescent females (ages 11 to 21 years) if any of the following risk factors are present: moderate to heavy menses, chronic weight loss, nutritional deficit, or athletic activity.

Canadian Task Force on the Periodic Health Examination --

There is conflicting and insufficient evidence to recommend for or against inclusion or exclusion of routine hemoglobin measurements at 6 to 12 months of age in normal infants. However, there is fair evidence to recommend a routine measurement for high-risk infants (infants of families of low socioeconomic status, Chinese or aboriginal ethnic origin, low birth weight [<2500 grams], or fed only whole cow's milk during the first year of life).

Cut points for anemia should be adjusted upward for children and adolescents who live at high altitudes or smoke (See Tables 27.1 and 27.2).

Sickle Cell Anemia (New Hope for People With). FDA Office of Consumer Affairs. HFE 88 Rm 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

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.

American Academy of Pediatrics and Bright Futures --

Blood pressure should be measured in children at 3, 4, 5, 6, and 8 years of age, and annually beginning at 10 years of age.

American Medical Association --

During adolescence, blood pressure should be measured annually.

National Heart, Lung, and Blood Institute Task Force on Blood Pressure Control in Children --

Blood pressure should be measured annually beginning at 3 years of age.

US Preventive Services Task Force --

Measurement of blood pressure during office visits is recommended for children and adolescents. Beginning age and periodicity are not specified. This recommendation is based on the proven benefits of early detection of treatable causes of secondary hypertension.

Eat Right to Lower Your High Blood Pressure; High Blood Pressure: Treat it for Life; Check Your Healthy Heart IQ; High Blood Pressure and What You Can Do About It; Six Good Reasons to Control Your High Blood Pressure. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617. (703)524-7802. Internet address: http://www.brightfutures.org

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.

American Academy of Family Physicians and US Preventive Services Task Force --

Measure height and weight periodically.

American Academy of Pediatrics and Bright Futures --

Height, weight, and head circumference should be measured at birth, at 2 to 4 weeks, and at 1, 2, 4, 6, 9, 12, 15, 18, and 24 months of age. Height and weight should also be measured at 3, 4, 5, 6, and 8 years of age, and annually beginning at 10 years of age. Bright Futures also recommends scoliosis and sexual maturity ratings as part of a complete physical exam for adolescents (ages 10 to 21).

American Medical Association --

All adolescents should be screened annually for eating disorders and obesity by measuring weight and stature and by asking about body image and dieting patterns.

Canadian Task Force on the Periodic Health Examination --

There is fair evidence for the inclusion of serial measurements of height, weight, and head circumference in the periodic health examination of infants and children.

NOTE: Disagreement exists about the validity of using a single set of reference standards for all subpopulations of children in the United States. Although measurements should be assessed within the context of genetic and environmental factors, most authorities support use of the NCHS reference standards. Exceptions include children with genetic conditions such as Down's, Turner's, Marfan's, and fragile X syndromes, achondroplasia, sickle cell disease, and neurofibromatosis. Separate growth charts have been developed for some of these conditions. Growth charts also have been developed for use with infants born prematurely (See Selected References).

Health Diary: Myself, My Baby. This booklet contains information about pregnancy and early childhood development. To order, contact the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325.

The Child Health Record. This material includes growth charts and other record forms. Rx for Good Health Growth Chart. This 8-1/2" x 33" poster contains information on growth for children from birth to 10 years of age. Your Child's Growth: Developmental Milestones. Presents guidelines to gauge normal stages of development in children 3 months to 6 years of age. To order, contact the American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Your Growing Baby. This pamphlet includes information on growth. To order, contact Ross Laboratories, Dept L-1120, Columbus, OH 43260; (800)227-5767.

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.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

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.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to recommend for or against routine cholesterol screening of children and adolescents. Individual clinical judgment should be exercised to determine the need for screening.

National Heart, Lung, and Blood Institute's National Cholesterol Education Program Expert Panel on Blood Cholesterol Levels in Children and Adolescents; American Academy of Pediatrics; Bright Futures; and American Medical Association --

Universal screening of children and adolescents for cholesterol levels is not recommended. Children older than 2 years of age who have a parent with a total cholesterol level of 240 mg/dL or greater should be screened for both total serum cholesterol and HDL cholesterol levels. Children (older than age 2 years) and adolescents with a family history of premature cardiovascular disease (ie, a parent or grandparent who, at age 55 years or younger, had a documented myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death, or underwent diagnostic coronary arteriography and was found to have atherosclerosis, or underwent coronary artery bypass surgery or angioplasty) should be screened for lipoprotein levels after a 12-hour fast. In children whose family history is not obtainable, screening may be indicated, especially if risk factors for coronary artery disease are present (eg, high blood pressure, smoking, overweight, or excessive consumption of saturated fat and cholesterol).

US Preventive Services Task Force --

There is insufficient evidence to recommend screening of children and adolescents. For adolescents who have a family history of very high cholesterol, premature CHD in a first-degree relative (before age 50 years in men or age 60 years in women), or major nonlipid risk factors for CHD (eg, smoking, hypertension, diabetes), screening may be recommended on other grounds, because of the greater absolute risk attributable to high cholesterol levels in such persons and the potential long-term benefits of early lifestyle interventions in young persons with high cholesterol levels. Recommendations against screening of children may be made on other grounds, including the costs and inconvenience of screening and follow-up, greater potential for adverse effects of treatment, and the uncertain long-term benefits of small reductions in childhood cholesterol levels.

Step by Step: Eating to Lower Your High Blood Cholesterol; So You Have High Blood Cholesterol; Parents Guide: Cholesterol in Children -- Healthy Eating is a Family Affair. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Growing up Healthy: Fat, Cholesterol, and More. This brochure provides health and eating guidelines for children 2 to 6 years old. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

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.

American Academy of Pediatrics and Bright Futures --

Behavioral assessment should be a routine part of health supervision throughout childhood and adolescence. Adolescents and their parents should be asked about suicidal thoughts or threats.

American Medical Association --

Because of the pervasive nature of mood disorders, all adolescents should be screened annually for signs and symptoms of recurrent or severe depression. Special attention should be directed at adolescents who are performing poorly in school, who use alcohol or drugs, or who have had a deteriorating relationship with parents and peers. Physicians should also screen adolescents annually to identify those at risk for suicide. Parents or other adult care-givers of adolescents with suicidal intent should be counseled to remove weapons and potentially lethal medications from the home.

Canadian Task Force on the Periodic Health Examination --

Routine screening for depression is not recommended, but physicians should maintain a high level of clinical sensitivity. Evaluation of suicide risk is recommended for persons at high risk: those with a history of psychiatric illness, depression, or drug and alcohol abuse, especially those living in isolation; those with chronic terminal illness; Native and Aboriginal people, especially young males; those with a family history of suicide; and first-generation immigrant women.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against performance of routine screening tests for depression in asymptomatic patients in the primary care setting. Clinicians should, however, maintain an especially high index of suspicion for depressive symptoms in adolescents and young adults, persons with a family or personal history of depression, those with chronic illness, those who perceive or have experienced a recent loss, and those with sleep disorders, chronic pain, or multiple unexplained somatic complaints. There is also insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in asymptomatic persons. Clinicians should be alert to evidence of suicidal ideation when the history reveals risk factors for suicide, such as depression, alcohol or other drug abuse, other psychiatric disorders, prior attempted suicide, recent divorce, separation, unemployment, and recent bereavement.

Facts for Families: The Depressed Child; Teen Suicide; Children and Grief; Manic Depressive Illness in Teens. American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave, NW, Washington, DC 20016-3007; (202)966-7300; E-mail: 74003.264@compuserve.com

Surviving: Coping with Adolescent Depression and Suicide; Caring for Your Adolescent: Age 12 to 21; Divorce and Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60000-0927; (800)443-9016. Internet address: http://www.aap.org

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

The Classification of Child and Adolescent Mental Diagnosis in Primary Care. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Prevention in Child and Adolescent Psychiatry; Prevention of Mental Disorders, Alcohol and Other Drug Use in Children and Adolescents. American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave, NW, Washington, DC 20016-3007; (202)966-7300; E-mail 74003.264@compuserve.com

National Institute of Mental Health, 5600 Fishers Ln, Room 14C-02, Rockville, MD 20857; (800)421-4211. Internet address: http://www.nimh.nih.gov

National Mental Health Association, 1021 Prince St, Alexandria, VA 22314; (800)969-6642.

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.

American Academy of Pediatrics and Bright Futures

endorse the recommendation by the Joint Committee on Infant Hearing and alsorecommend that pure-tone audiometry be performed at 3, 4, 5, 10, 12, 15, and 18 years of age. Subjective assessment of hearing should be performed at other ages.

American Speech-Language-Hearing Association --

Annual pure-tone audiometry should be performed for children functioning at a developmental level of age 3 years to grade 3 and for any high-risk children, including those above grade 3.

Canadian Task Force on the Periodic Health Examination --

Repeated examination of hearing is recommended for young children, especially during the first year of life. Suggested guidelines for this examination include checking the startle or turning response to a novel noise produced outside the infant's field of vision at birth and 6 months of age and checking for the absence of babbling at 6 months of age. Screening using auditory brainstem responses or evoked otoacoustic emission by 3 months of age is not recommended pending further evaluation. Routine hearing assessment of asymptomatic preschoolers using history-taking, audiometry, tympanometry, or acoustic reflexometry is not recommended.

Joint Committee on Infant Hearing (American Speech-Language Hearing Association, American Academy of Pediatrics, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Audiology, American Academy of Pediatrics and the Directors of Speech and Hearing Programs in State Health and Welfare Agencies) and Bright Futures --

endorse the goal of universal detection of infants with hearing loss as early as possible using auditory brainstem response or otoacoustic emissions. All infants should be screened before 3 months of age.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine screening of asymptomatic neonates for congenital hearing loss using evoked otoacoustic emission (EOE) testing or auditory brainstem response (ABR). Routine hearing screening of asymptomatic children beyond age 3 years is not recommended. There is insufficient evidence to recommend for or against routinely screening asymptomatic adolescents for hearing impairment. However, screening of workers for noise-induced hearing loss should be performed in the context of existing worksite programs and occupational medicine guidelines.

American Academy of Pediatrics and American Speech-Language-Hearing Association (ASHA) --

Children with frequently recurring otitis media or middle ear effusion, or both, should have audiology screening and monitoring of communication skills development. ASHA recommends annual pure-tone audiometry testing for all children at high risk for hearing impairment.

Joint Committee on Infant Hearing (American Speech-Language Hearing Association, American Academy of Pediatrics, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Audiology, American Academy of Pediatrics and the Directors of Speech and Hearing Programs in State Health and Welfare Agencies) --

Neonates (birth to 28 days of age) with one or more of the neonatal risk criteria should have audiology screening, preferably before hospital discharge but no later than 3 months of age.

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.

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.

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.

US Preventive Services Task Force --

Screening for hearing impairment in high-risk infants can be recommended based on the relatively high prevalence of hearing impairment, parental anxiety, and the potential beneficial effect on language development from early treatment of infants with moderate or severe hearing loss. Refer to neonatal risk criteria listed above under Joint Committee on Infant Hearing. Clinicians examining any infant or young child should remain alert for symptoms or signs of hearing impairment, including parent/care-giver concern regarding hearing, speech, language, and/or developmental delay.

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.

Is My Baby's Hearing Normal? American Academy of Otolaryngology -- Head and Neck Surgery, Order Department, 1 Prince St, Alexandria, VA 22314; (703)836-4444.

Answers to Questions About Otitis Media, Hearing, and Language Development; How Does Your Child Hear and Talk?; Recognizing Communication Disorders. American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852. For general information, call: (800)638-8255. To order, call: (301)897-5700, ext 218; Internet address: http://www.asha.org

Middle Ear Fluid in Young Children: Parent Guide; Ear Infection in Children. The American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

National Institute on Deafness and Other Communication Disorders. Internet address: http://www.nih.gov/nidcd

American Speech-Language-Hearing Association.
Internet address: http://www.asha.org

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.

American Academy of Family Physicians --

Determination of lead levels is recommended for infants at 12 months of age who live in communities in which the prevalence of lead levels requiring intervention is high or undefined; live in or frequently visit a home built before 1950 with dilapidated paint or with recent or ongoing renovation or remodeling; have close contact with a person who has an elevated lead level; live near lead industry or heavy traffic; live with someone whose job or hobby involves lead exposure; use lead-based pottery; or take traditional remedies that contain lead.

American Academy of Pediatrics --

Pediatric-care providers should increase their efforts to screen children for lead exposure. Blood lead screening should be a part of routine health supervision of children and can best be addressed by increasing children's access to health care. Because lead is ubiquitous in the US environment, this screening should occur at about 9 to 12 months of age and, if possible, again at about 24 months of age. The Centers for Disease Control and Prevention has raised the possibility that there may be low-risk communities that do not require screening, but no explicit guidance has been developed for determining a community's risk. As more data are collected, it may become evident that there are locales where selective screening of children is more appropriate than routine screening.

Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to recommend for or against universal lead screening of children to detect mild or moderate lead exposure. Screening is recommended for children at high risk: children who live in or regularly visit homes built before 1960 with deteriorating paint or recent, ongoing, or planned renovation or remodeling; who have a sibling, housemate, or playmate known to have had lead poisoning; who live with an adult whose job or hobby involves exposure to lead; or who live near lead industries or busy highways.

Centers for Disease Control and Prevention (CDC) --

(NOTE: Revised guidelines are expected to be published in the fall of 1997. Revisions to the CDC guidelines were being considered at the time of this publication. Please consult Provider Resources below for information on how to obtain current recommendations.) CDC's draft guidelines recommend that state and local health officials make screening recommendations that are based on an assessment of local lead exposure sources and on blood lead screening data. Where risk is widespread, universal screening should be recommended; where risk is less or confined to small pockets, targeted screening should be recommended. Screening should be focused on children at 12 and at 24 months of age. A targeted screening recommendation would call for screening of children who meet criteria established by the health department. Likely criteria include: residence in a high-risk zip code or neighborhood, poverty, or response to a personal-risk questionnaire that is tailored to local conditions. An example of one such basic questionnaire is presented in Table 7.1. Health departments will be expected to tailor the questionnaire to make it appropriate to local sources of exposure.

US Preventive Services Task Force --

Screening for elevated lead levels by measuring blood lead at least once at about 12 months of age is recommended for all children at increased risk of lead exposure. All children with identifiable risk factors should be screened, as should children living in communities in which the prevalence of blood lead levels requiring individual intervention, including chelation therapy or residential lead hazard control, is high or undefined. If capillary blood is used, elevated lead levels should be confirmed by measurement of venous blood lead. The optimal frequency of screening for lead exposure in children, or for repeated testing of children previously found to have elevated blood lead levels, is unknown and is left to clinical discretion; consideration should be given to the degree of elevation, the interventions provided, and the natural history of lead exposure, including the typical peak in lead levels at 18 to 24 months of age. In communities where the prevalence of blood lead levels requiring individual intervention is low, a strategy of targeted screening, possibly using locale-specific questionnaires of known and acceptable sensitivity and specificity, can be used to identify high-risk children who should have blood lead testing. There is currently insufficient evidence to recommend an exact population prevalence below which targeted screening can be substituted for universal screening. Clinicians should seek guidance from their local or state health department.

Department of Housing and Urban Development, Office of Lead-Based Paint. Internet access: htp://www.hud.gov/lea

National Lead Information Center of the National Safety Council; (800)LEADFYI.

What Everyone Should Know About Lead Poisoning. To obtain individual copies, contact: Alliance to End Childhood Lead Poisoning, 600 Pennsylvania Ave SE, Suite 100, Washington, DC 20003. To obtain bulk copies, contact: Channing L. Bete Co, Inc, 200 State Rd, South Deerfield, MA 01373; (800)628-7733.

Protect your family from lead in your home. Centers for Disease Control and Prevention, Lead Poisoning Prevention Program, 1600 Clifton Rd NE, Atlanta, GA 30333; (770)488-7330.

Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control; The Strategic Plan for the Elimination of Lead Poisoning; Nutrition and Childhood Lead Poisoning Prevention. Centers for Disease Control and Prevention, Lead Poisoning Prevention Program, 1600 Clifton Rd NE, Atlanta, GA 30333; (770)488-7330.

Case Studies in Environmental Medicine: Lead Toxicity. Agency for Toxic Substances and Disease Registry, Division of Health Education, Mailstop E33, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-6205.

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
Most children with congenital hypothyroidism who are not identified and treated promptly suffer the irreversible mental retardation, growth failure, deafness, and neurologic abnormalities characteristic of the syndrome of cretinism. The incidence of this disorder is 1 per 3600 to 1per 5000 live births. Infants who receive adequate treatment with thyroxine within the first weeks of life have normal or near-normal intellectual performance at 4 to 7 years of age.

Phenylketonuria (PKU)
Phenylketonuria is an autosomal recessive aminoacidopathy that leads to severe, irreversible mental retardation (IQbelow 50) if it is not treated during infancy. The incidence of this disorder is 1 per 10,000 to 1 per 15,000 live births. Most children who undergo early screening, diagnosis, and optimal treatment with dietary restriction of phenylalanine will be in the normal range of intelligence.

Galactosemia
Galactosemia presents following milk feeding with vomiting, diarrhea, failure to thrive, and Escherichia coli septicemia (which is often fatal). Continued exposure to galactose results in liver disease (manifested by hepatomegaly, jaundice, and cirrhosis), cataracts, and irreversible mental retardation. The incidence of galactosemia is 1 per 60,000 to 1 per 80,000 live births. Treatment is directed to the elimination of dietary lactose by avoiding galactose in breast milk, cow's milk, and infant formulas. Treatment can lead to dramatic improvement in all clinical features except for central nervous system dysfunction.

Hemoglobinopathies
Sickle cell disease and other hemoglobinopathies, such as thalassemia and hemoglobin E, aremost common in persons of African, Mediterranean, Asian, Caribbean, and South andCentral American ancestry. Affected individuals may have overwhelming sepsis, chronic hemolytic anemia, episodic vascular occlusive crises, hyposplenism, periodic splenic sequestration, and bone marrow aplasia. Carriers (genetic heterozygotes) do not suffer significant morbidity. Early detection of sickle cell disease in newborns allows prophylactic use of penicillin to prevent septicemia and prompt clinical intervention for infection and sequestration crises.

American Academy of Pediatrics and Bright Futures --

Newborn screening should be performed according to each state's regulations.

National authorities have made recommendations for the following specific conditions:

American Academy of Family Physicians --

Neonatal screening for thyroid function abnormalities is recommended.

American Academy of Pediatrics (AAP), American Thyroid Association (ATA), Canadian Task Force on the Periodic Health Examination (CTFPHE), and US Preventive Services Task Force --

All neonates should be screened for congenital hypothyroidism between 2 and 6 days of life. Care should be taken to assure that infants born at home, ill at birth, or transferred between hospitals in the first week of life are screened before 7 days of life. According to the CTFPHE, it is better to obtain a specimen within 24 hours of birth than no specimen at all. According to the AAP and ATA, blood should be obtained from infants before discharge from the hospital or after 48 hours of age.

American Academy of Family Physicians --

Neonatal screening for PKU is recommended.

Canadian Task Force on the Periodic Health Examination (CTFPHE) and US Preventive Services Task Force (USPSTF) --

All infants should be screened for PKU before discharge from the nursery. Premature infants and those with illness should be tested at or near 7 days of age. Infants tested before 24 hours of age should receive a repeat screening. According to the CTFPHE, this should occur between 2 and 7 days of age; according to the USPSTF, this should occur by 2 weeks of age.

American Academy of Family Physicians --

Neonatal screening for hemoglobinopathies is recommended.

Canadian Task Force on the Periodic Health Examination and US Preventive Services Task Force (USPSTF) --

Neonatal screening for sickle hemoglobinopathies is recommended. Whether such screening should be universal or targeted to high-risk groups will depend on the proportion of high-risk individuals in the screening area. All screening must be accompanied by comprehensive counseling and treatment services. There is insufficient evidence to recommend for or against screening for hemoglobinopathies in adolescents and young adults in order to help them make informed reproductive decisions. According to the USPSTF, such screening may be justified on the basis of burden of suffering and patient preference.

Sickle Cell Disease Guideline Panel of the Agency for Health Care Policy and Research, US Public Health Service --

Universal screening for sickle cell disease should be conducted on all newborns. This recommendation has been endorsed by the American Academy of Pediatrics, the American Nurses Association, and the National Medical Association.

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.

Confirm 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.

Provide 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.

Sickle Cell Disease: Guide for Parents. Agency for Health Care Policy and Research Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295.

Sickle Cell Anemia (New Hope for People With). FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Understanding PKU. PKU Clinic, Children's Hospital Medical Center, 300 Longwood Ave, Boston, MA 02115; (617)355-6394.

Sickle Cell Disease: Clinical Practice Guideline; Sickle Cell Disease: Guideline Report; Sickle Cell Disease: Quick Reference Guide. Agency for Health Care Policy and Research Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295.

Blood Collection on Filter Paper for Neonatal Screening Programs -- Second Edition; Approved Standard. National Committee for Clinical Laboratory Standards (NCCLS), 940 W Valley Rd, Suite 1400, Wayne, PA 19087-1898. An educational videotape depicting the LA4-A2 collection procedure is also available.

Management and Therapy of Sickle Cell Disease. NIH publication No. 96-2117. NHLBI Information Center, PO Box 30105, Bethesda, MD 20814-0105.

New England Connection for PKU and Allied Disorders, 16 Angelina Ln, Mansfield, MA 02048. Various brochures on PKU, maple syrup urine disease, homocystinuria, tyrosinemia, urea cycle disorders, and organic acidemias are available; (508)261-1291.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Blood Collection on Filter Paper for Neonatal Screening ProgramsSecond Edition; Approved Standard.

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.

All major authorities, including American Academy of Pediatrics (AAP), American Academy of Family Physicians, American Medical Association, American Thoracic Society, Canadian Task Force on the Periodic Health Examination, Centers for Disease Control and Prevention, and US Preventive Service Task Force (USPSTF) --

Tuberculin testing should be performed on children and adolescents at high risk of disease. AAP has recommended annual TB testing for infants and children with HIV and incarcerated adolescents; testing every 2 to 3 years for children exposed to individuals in certain high-risk groups (HIV infected, homeless, residents of nursing homes, institutionalized adolescents or adults, users of illicit drugs, incarcerated adolescents or adults and migrant farm workers); and testing at ages 4 to 6 years and 11 to 16 years for children without specific risk factors who reside in high prevalence areas and for children whose parents immigrated from regions with a high prevalence of TB or with continued potential exposure by travel to the endemic areas and/or household contact with persons from the endemic areas with unknown skin test status. The USPSTF has stated that the frequency of skin testing is a matter of clinical discretion.

American Academy of Pediatrics (AAP), American Thoracic Society (ATS), and Centers for Disease Control and Prevention (CDC) --

Children with a positive Mantoux test and without active disease should receive prophylaxis with isoniazid. Certain children with a negative Mantoux test should be considered for isoniazid prophylaxis (See Basics of Prophylaxis: Indications). The AAP has also suggested prophylaxis for patients who are anergic and from a population with a high prevalence of TB. Recommendations for the duration of isoniazid prophylaxis vary among authorities. The ATS and CDC recommend a minimum of 6 months of prophylaxis; the AAP recommends a minimum of 9 months of prophylaxis. According to AAP recommendations, newborn prophylaxis may be discontinued at 3 months of age if a Mantoux test at that time is negative; if all known adult contacts have negative sputum samples and are compliant with anti-TB medications; and if a repeat Mantoux test is performed at 6 months of age. The ATS and CDC recommend maintaining newborn prophylaxis until a negative PPD test is obtained at 6 months of age. Patients who are HIV-positive or who have evidence of prior TB on chest radiograph should receive isoniazid prophylaxis for 12 months. In the latter case, a 4-month course of isoniazid combined with rifampin can also be used.

Advisory Committee on Immunization Practices (ACIP), Advisory Council for the Elimination of Tuberculosis, American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force (USPSTF) --

BCG vaccination should be considered for an infant or child who has a negative TB skin-test result if the following circumstances are present: the child is exposed continually to an untreated or ineffectively treated patient who has infectious pulmonary TB, and the child cannot be separated from the presence of the infectious patient or given long-term primary preventive therapy OR the child is exposed continually to a patient who had infectious pulmonary TB caused by M. tuberculosis strains resistant to isoniazid and rifampin, and the child cannot be separated from the presence of the infectious patient. The AAP and USPSTF also recommend consideration of BCG vaccination for infants and children in groups in which an excessive rate of new infections is present (eg, >1%) and the usual surveillance and treatment have failed or are not feasible (eg, in groups without a source of regular health care). In the United States, BCG vaccination is rarely indicated. Physicians considering the use of BCG vaccine for their patients are encouraged to consult the TB control programs in their area or the CDC's Division of Tuberculosis Elimination at (404)639-8120.

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.

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:

• Newborn prophylaxis: Infants whose mothers have active disease (even if noncontagious) and infants whose mothers have a positive Mantoux test but do not have active disease (preventive therapy can be discontinued after the entire family is demonstrated to have negative tuberculin skin tests)
• Children who are both anergic or HIV-positive and from populations where the prevalence of TB infection is higher than 10% (eg, injection drug users, homeless persons, migrant laborers, and individuals from Asia, Africa, or Latin America)
• Children who have had close contact within the past 3 months with a person with infectious TB.

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.

Continue isoniazid prophylaxis for 6 to 12 months. Recommendations regarding the duration of isoniazid prophylaxis vary (See Recommendations of Major Authorities: Prophylaxis).

Patients 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.

Recommendations differ slightly among authorities. (See Recommendations of Major Authorities.)

One 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.

> 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.

Until 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.

A 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.

BCG 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.

Perform 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:

• The vaccinated person is a contact of another person who has infectious TB, particularly if the infectious person has transmitted TB to others
• The vaccinated person was born or has resided in a country in which the prevalence of TB is high
• The vaccinated person is exposed continually to populations in which the prevalence of TB is high

Facts About the TB Skin Test; Facts About Tuberculosis. American Lung Association, 1740 Broadway, New York, NY 10019-4374; (212)315-8700.

TB: Get the Facts; Tuberculosis: Connection between TB and HIV. Centers for Disease Control and Prevention, Attn: Information Technology and Services, Mailstop E-06, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-1819.

Core Curriculum on Tuberculosis. Centers for Disease Control and Prevention; 1994. Centers for Disease Control and Prevention, Attn: Information Technology and Services, Mailstop E-06, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-1819.

Initial Therapy for TB in the Era of Multiple Drug Resistance; Mantoux Tuberculin Skin Testing (videotape). Centers for Disease Control and Prevention, Attn: Information Services Office, 1600 Clifton Rd NE, Atlanta GA 30333; (404)639-8135.

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.

American Academy of Family Physicians and US Preventive Services Task Force (USPSTF) --

Routine screening of males and most females for asymptomatic bacteriuria is not recommended; there is insufficient evidence for or against routine screening of diabetic women (including children and adolescents). The Canadian Task Force on the Periodic Health Examination and the USPSTF recommend against screening for asymptomatic bacteriuria with urinalysis in infants, children, and adolescents.

American Academy of Pediatrics --

Urinalysis should be performed once at 5 years of age. Also, dipstick leukocyte esterase testing to screen for sexually transmitted diseases should be performed once in adolescence, preferably at 14 years of age.

American Medical Association and Bright Futures --

Sexually active adolescent males should be screened yearly for gonorrhea and chlamydia by urinalysis with a dipstick leukocyte esterase test.

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617. (703)524-7802. Internet address: http://www.brightfutures.org

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.

American Academy of Family Physicians --

Children should be screened for amblyopia and strabismus at 3 to 4 years of age.

American Academy of Pediatrics and Bright Futures --

Visual acuity testing should first be performed at 3 years of age. If the child is uncooperative, retesting should occur 6 months later. Subsequent testing should occur at 4, 5, 10, 12, 15, and 18 years of age. Subjective assessment by history should occur at visits at all other ages. All infants should be examined by 6 months of age to evaluate fixation preference, alignment, and presence of any eye disease. Children should again be medically evaluated for these problems by 3 to 4 years of age.

American Academy of Ophthalmology (AAO), American Association for Pediatric Ophthalmology and Strabismus (AAPOS), and American Optometric Association (AOA) --

Eye and vision screening should be performed at birth and at approximately 6 months, 3 years, and 5 years of age. AAO has published recommendations regarding screening methods and indications for referral to be used by primary care clinicians in screening preschool children (Table 11.1). AAO and AAPOS recommend that screening after 5 years of age be carried out at routine school checks or after the appearance of symptoms. AOA recommends optometric examinations every 2 years throughout school years.

Canadian Task Force on the Periodic Health Examination --

Repeat examination of the eyes for strabismus is recommended during well-baby visits, especially during the first 6 months of life. There is fair evidence to include testing of visual acuity in the periodic health examination of preschool children.

US Preventive Services Task Force --

All children should have testing for amblyopia and strabismus once before entering school, preferably at 3 to 4 years of age. Stereoacuity testing may be more effective than visual acuity testing in detecting these conditions. There is insufficient evidence to recommend for or against routine screening for diminished visual acuity among asymptomatic school children. Recommendations against such screening can be made on other grounds, including the inconvenience and cost of routine screening and the fact that refractive errors can be readily corrected when they produce symptoms. Clinicians should be alert for signs of ocular misalignment when examining all newborns, infants, and children.

American Academy of Ophthalmology --

Asymptomatic children should have a comprehensive examination by an ophthalmologist if they are at high risk because of health and developmental problems that make screening by the primary care clinician difficult or inaccurate (eg, retinopathy of prematurity or diagnostic evaluation of a complex disease with ophthalmic manifestations); a family history of conditions that cause or are associated with eye or vision problems (eg, retinoblastoma, significant hyperopia, strabismus [particularly accommodative esotropia], amblyopia, congenital cataract, or glaucoma); multiple health problems, systemic disease, or use of medications that are known to be associated with eye disease and vision abnormalities (eg, neurodegenerative disease, juvenile rheumatoid arthritis, systemic steroid therapy, systemic syndromes with ocular manifestations, or developmental delay with visual system manifestations).

American Optometric Association --

The primary care clinician should remain alert for visual/ocular abnormalities associated with the following high-risk groups: infants who are premature, with low birth weight, or whose mothers have had rubella, venereal disease, AIDS-related infection or a history of substance abuse or other medical problems during pregnancy, and children failing to progress educationally or exhibiting reading and/or learning disabilities. The presence of high refractive error or a family history of eye disease, crossed eyes, or congenital eye disorders also places infants and children at risk. Infants at risk should be examined by a doctor of optometry by 6 months of age. Children at risk should be examined at 3 years of age and annually beginning at 6 years of age. All infants and children may be referred to an optometrist for a comprehensive eye and/or vision examination.

When screening for present or potential visual disorders, consider the following factors:

• Family history of vision or eye problems
• History of maternal, intrapartum, or neonatal conditions that may place the child at high risk for visual disorders (See High-Risk Children)
• Parental concerns about a child's visual functioning
• Worsening grades and other school difficulties

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.

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.

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.

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.

Hold a light or a small object in front of the infant. Normal eyes will be aligned in the same direction, without deviation.

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.

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.

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.

Counsel 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.

Amblyopia: Is it Affecting Your Child's Sight?;Cataracts in Children: Eye Safety and Children; Eyeglasses for Infants and Children; Home Eye Test for Strabismus. American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelop with your request.

Your Child's Eyes. American Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Answers to Your Questions About: Lazy Eye, Nearsightedness, Astigmatism, Eye Coordination, Color Deficiency, Crossed-Eyes; Signs of a Child's Vision Problems; Toys, Games and Your Child's Vision; Your Child's Eyes; Your Preschool Child's Eyes; Your School-Aged Child's Eyes. American Optometric Association, 243 N Lindbergh Blvd, St.Louis, MO 63141; (314)991-4100. Internet address: http://www.aoanet.org/

Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Policy Statement: Frequency of Ocular Examinations; National Eyecare Project (for those who do not have an eye doctor); Glaucoma 2001 Project (for people at risk for glaucoma). American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelope with your request.

Pediatric Eye and Vision Examination, Care of the Patient with Amblyopia, and other clinical practice guidelines. American Optometric Association, 243 N Lindbergh Blvd, St. Louis, MO 63141; (800)262-2210. Internet address: http://www.aoanet.org/