Guide to Clinical Preventive Services, 2008

Section 3. Recommendations for Children

ll recommendation statements in this Guide are abridged. To see the full recommendation statements and recommendations published after March 2008, go to http://www.preventiveservices.ahrq.gov. 

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Screening for Elevated Blood Lead Levels in Children and Pregnant Women

Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. Grade: I Statement. The USPSTF recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk. Grade: D Recommendation. The USPSTF recommends against routine screening for elevated blood lead levels in asymptomatic pregnant women. Grade: D Recommendation.

This USPSTF recommendation was first published in: Pediatrics 2006;118:e2514-2518.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspslead.htm

Clinical Considerations

• This USPSTF recommendation addresses screening for elevated blood levels in children aged 1 to 5 years who are both at average and increased risk, and in asymptomatic pregnant women.
• The highest mean blood lead levels in the U.S. occur in children aged 1-5 years (geometric mean 1.9 µg/dL). Children under 5 years of age are at greater risk for elevated blood lead levels and lead toxicity because of increased hand-to-mouth activity, increased lead absorption from the gastrointestinal tract, and the greater vulnerability of the developing central nervous system. Risk factors for increased blood lead levels in children and adults include: minority race/ethnicity; urban residence; low income; low educational attainment; older (pre-1950) housing; recent or ongoing home renovation or remodeling; pica exposure; use of ethnic remedies, certain cosmetics, and exposure to lead-glazed pottery; occupational and paraoccupational exposures; and recent immigration. Additional risk factors for pregnant women include alcohol use, smoking, pica, and recent immigration status.
• Blood lead levels in childhood, after peaking at about 2 years of age, decrease during short- and long-term followup without intervention. Most lead is stored in bone. High bone lead levels can be present with normal blood lead levels, so that blood lead levels often do not reflect the total amount of lead in the body. This could explain the lack of effect of blood lead level-lowering measures on reducing neurotoxic effects.
• Screening tests for elevated blood lead levels include free erythrocyte (or zinc) protoporphyrin levels and capillary or venous blood lead levels. Erythrocyte (or zinc) protoporphyrin is insensitive to modest elevations in blood lead levels and lacks specificity. Blood lead concentration is more sensitive than erythrocyte protoporphyrin for detecting modest lead exposure, but its accuracy, precision, and reliability can be affected by environmental lead contamination. Therefore, venous blood lead level testing is preferred to capillary sampling. Screening questionnaires may be of value in identifying children at risk for elevated blood lead levels but should be tailored for and validated in specific communities for clinical use.
• Treatment options in use for elevated blood lead levels include residential lead hazard-control efforts (i.e., counseling and education, dust or paint removal, and soil abatement), chelation, and nutritional interventions. In most settings, education and counseling is offered for children with blood lead levels from 10 to 20 µg/dL. Some experts have also recommended nutritional counseling for children with blood lead levels in this range. Residential lead hazard control is usually offered to children with blood lead levels >20 µg/dL, while chelation therapy is offered to children with blood lead levels >45 µg/dL.
• Community-based interventions for the primary prevention of lead exposure are likely to be more effective, and may be more cost-effective, than office-based screening, treatment, and counseling. Relocating children who do not yet have elevated blood lead levels but who live in settings with high lead exposure may be especially helpful. Community, regional, and national environmental lead hazard reduction efforts, such as reducing lead in industrial emissions, gasoline, and cans, have proven highly effective in reducing population blood lead levels.

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Prevention of Dental Caries in Preschool Children

Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. Grade: B Recommendation. The USPSTF concludes that the evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease. Grade: I Statement.

This USPSTF recommendation was first published in: Am J Prev Med 2004;26(4)326-9.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/dentalchild/dentchrs.htm.

Clinical Considerations

• Dental disease is prevalent among young children, particularly those from lower socioeconomic populations; however, few preschool-aged children ever visit a dentist. Primary care clinicians are often the first and only health professionals whom children visit. Therefore, they are in a unique position to address dental disease in these children.
• Fluoride varnishes, professionally applied topical fluorides approved to prevent dental caries in young children, are adjuncts to oral supplementation. Their advantages over other topical fluoride agents (mouth-rinse and gel) include ease of use, patient acceptance, and reduced potential for toxicity.
• Dental fluorosis (rather than skeletal fluorosis) is the most common harm of either oral fluoride or fluoride toothpaste use in children younger than 2 years in the United States. Dental fluorosis is typically very mild and only of aesthetic importance. The recommended dosage of fluoride supplementation was reduced by the American Dental Association in 1994, which is likely to decrease the prevalence and severity of dental fluorosis.
  The current dosage recommendations are based on the fluoride level of the local community's water supply and are available online at www.ada.org. The primary care clinician's knowledge of the fluoride level of his or her patients' primary water supply ensures appropriate fluoride supplementation and minimizes risk for fluorosis.

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Screening for Developmental Dysplasia of the Hip

Summary of Recommendation The USPSTF concludes that evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. Grade: I Statement.

This USPSTF recommendation was first published in Pediatrics 2006;117:898-902.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspshipd.htm

Clinical Considerations

• This USPSTF screening recommendation applies only to infants who do not have obvious hip dislocations or other abnormalities evident without screening. DDH represents a spectrum of anatomic abnormalities in which the femoral head and the acetabulum are aligned improperly or grow abnormally. DDH can lead to premature degenerative joint disease, impaired walking, and pain. Risk factors for DDH include female gender, family history of DDH, breech positioning, and in utero postural deformities. However, the majority of cases of DDH have no identifiable risk factors.
• Screening tests for DDH have limited accuracy. The most common methods of screening are serial physical examinations of the hip and lower extremities, using the Barlow and Ortolani procedures, and ultrasonography. The Barlow examination is performed by adducting a flexed hip with gentle posterior force to identify a dislocatable hip. The Ortolani examination is performed by abducting a flexed hip with gentle anterior force to relocate a dislocated hip. Data assessing the relative value of limited hip abduction as a screening tool are sparse and suggest the test is of little value in early infancy and is of somewhat greater value as infants age.
• Treatments for DDH include both nonsurgical and surgical options. Nonsurgical treatment with abduction devices is used in early treatment and includes the commonly prescribed Pavlik method. Surgical intervention is used when DDH is severe or diagnosed late or after an unsuccessful trial of nonsurgical treatments. Evidence of the effectiveness of interventions is inconclusive because of a high rate of spontaneous resolution, absence of comparative studies of intervention versus nonintervention groups, and variations in surgical indications and protocols. Avascular necrosis of the hip is the most common and most severe potential harm of both surgical and nonsurgical interventions and can result in growth arrest of the hip and eventual joint destruction with significant disability.

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Screening for Idiopathic Scoliosis in Adolescents

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis. Grade: D Recommendation.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. June 2004.
To read the recommendation, go to:  http://www.ahrq.gov/clinic/3rduspstf/scoliosis/scoliors.htm.

Clinical Considerations

• Screening adolescents for idiopathic scoliosis is usually done by visual inspection of the spine to look for asymmetry of the shoulders, scapulae, and hips. A scoliometer can be used to measure the curve. If idiopathic scoliosis is suspected, radiography can be used to confirm the diagnosis and to quantify the degree of curvature.
• The health outcomes of adolescents with idiopathic scoliosis differ from those of adolescents with secondary scoliosis (i.e., congenital, neuromuscular, or early onset idiopathic scoliosis). Idiopathic scoliosis with onset in adolescence may have a milder clinical course.¹
• Conservative interventions to treat curves detected through screening include spinal orthoses (braces) and exercise therapy, but they may not significantly improve back pain or the quality of life for adolescents diagnosed with idiopathic scoliosis.
• The potential harms of screening and treating adolescents for idiopathic scoliosis include unnecessary followup visits and evaluations due to false positive test results and psychological adverse effects, especially related to brace wear. Although routine screening of adolescents for idiopathic scoliosis is not recommended, clinicians should be prepared to evaluate idiopathic scoliosis when it is discovered incidentally or when the adolescent or parent expresses concern about scoliosis.

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Screening for Lipid Disorders in Children

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders in infants, children, adolescents, or young adults (up to age 20). Grade: I Statement.

This USPSTF recommendation was first published in: Pediatrics. 2007;120:e215-e219.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspschlip.htm.

Clinical Considerations

• Dyslipidemias are abnormalities of lipoprotein metabolism and include elevations in TC, LDL-C, or triglycerides or deficiencies of HDL-C. These disorders can be acquired or familial; monogenic dyslipidemias are related to genetic conditions such as familial hypercholesterolemia in some individuals. Multifactorial dyslipidemias are due to risk factors including environmental factors (obesity, diet) or currently unidentified genetic factors. This recommendation applies to all asymptomatic individuals from birth to age 20.
• Because normal lipid levels have been strongly associated with the risk of coronary heart disease (CHD) events in adulthood, and early identification and lipid-lowering intervention in certain populations of adults can prevent CHD events, much attention has been directed at screening individuals for dyslipidemia at young ages (e.g., childhood). Among children and adolescents, 3 groups may be identified through screening:
  1. Children with undiagnosed monogenic dyslipidemias such as familial hypercholesterolemia.
  2. Those with undiagnosed secondary causes of dyslipidemia.
  3. Those with multi-factorial dyslipidemia (polygenetic or related to risk-factors). However, the clinical health benefits shown in adults identified and treated for dyslipidemia have not been studied in children, making the role of screening children uncertain.
• Children and adolescents with diabetes may be at especially high risk for dyslipidemia and cardiovascular events. Screening children and adolescents with diabetes for dyslipidemia has been recommended by other groups as a part of appropriate care for these children.
  
• The use of family history as a screening tool for dyslipidemia has variable accuracy largely because definitions of a positive family history and lipid threshold values vary substantially. Screening using family history as defined by the National Cholesterol Education Program (NCEP) and the American Academy of Pediatrics (AAP) has been shown to have high rates of false negative results.

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Newborn Hearing Screening

NOTE: The USPSTF revised its recommendation on this topic during publication of The Guide to Clinical Preventive Services 2008. For the most recent recommendation, please visit our Web site at http://www.preventiveservices.ahrq.gov or the USPSTF’s Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov. You can search the ePSS for recommendations by patient age, sex, and pregnancy status, and you can download the recommendations as well as receive automatic updates to your PDA.

This USPSTF recommendation was first published in: Pediatrics 2008;122:143–148.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspsnbhr.htm.

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Screening and Interventions for Overweight in Children and Adolescents

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes. Grade: I Statement.

This recommendation was first published in: Pediatrics 2005;116(1):205-9.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf05/choverwt/choverrs.htm.

Clinical Considerations

• It is important to measure and monitor growth over time in all children as an indicator of health and development. The number of children and adolescents who are overweight has more than doubled since the early 1970s, with the prevalence of overweight (BMI > 95th percentile for age and sex) for children aged 6 to 19 years now at approximately 15 percent. The conclusion that there is insufficient evidence to recommend for or against screening for overweight in children and adolescents reflects the paucity of good-quality evidence on the effectiveness of interventions for this problem in the clinical setting. There is little evidence for effective, family-based or individual approaches for the treatment of overweight in children and adolescents in primary care settings. The Centers for Disease Control and Prevention's (CDC's) Guide to Community Preventive Services has identified effective population-based interventions that have been shown to increase physical activity, which may help reduce childhood overweight.
• BMI (calculated as weight in kilograms divided by height in meters squared) percentile for age and sex is the preferred measure for detecting overweight in children and adolescents because of its feasibility, reliability, and tracking with adult obesity measures. BMI values are CDC population-based references for comparison of growth distribution to those of a larger population. Being at risk for overweight is defined as a BMI between the 85th and 94th percentile for age and sex, and overweight as a BMI at or above the 95th percentile for age and sex. Disadvantages of using BMI include the inability to distinguish increased fat mass from increased fat-free mass, and reference populations derived largely from non-Hispanic whites, potentially limiting its applicability to non-white populations. Indirect measures of body fat, such as skinfold thickness, bio-electrical impedance analysis, and waist-hip circumference, have potential for clinical practice, treatment, research, and longitudinal tracking, although there are limitations in measurement validity, reliability, and comparability between measures.
• Childhood overweight is associated with a higher prevalence of intermediate metabolic consequences and risk factors for adverse health outcomes, such as insulin resistance, elevated blood lipids, increased blood pressure, and impaired glucose tolerance. Severe childhood overweight is associated with immediate morbidity from conditions such as slipped capital femoral epiphysis, steatohepatitis, and sleep apnea. Medical conditions new to this age group, such as type 2 diabetes mellitus, represent "adult" morbidities that are now seen more frequently among overweight adolescents. For most overweight children, however, medical complications do not become clinically apparent for decades.

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Screening for Sickle Cell Disease

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) recommends recommends screening for sickle cell disease in newborns. Grade: A Recommendation.

This USPSTF recommendation was first published by Agency for Healthcare Research and Quality, Rockville, MD. September 2007.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspshemo.htm

Clinical Considerations

• Screening for sickle cell disease in newborns is mandated in all 50 States and the District of Columbia. Most States use either thin-layer isoelectric focusing (IEF) or high performance liquid chromatography (HPLC) as the initial screening test. Both methods have extremely high sensitivity and specificity for sickle cell anemia. Specimens must be drawn prior to any blood transfusion due to the potential for a false negative result as a result of the transfusion. Extremely premature infants may have false positive results when adult hemoglobin is undetectable.³
  
• All newborns should undergo testing regardless of birth setting. In general, birth attendants should make arrangements for samples to be obtained, and the first physician to see the child at an office visit should verify screening results. Confirmatory testing should occur no later than 2 months of age.
• Children with sickle cell anemia should begin prophylactic penicillin by 2 months of age and receive pneumococcal immunizations at recommended intervals.

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Screening for Speech and Language Delay in Preschool Children

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age. Grade: I Statement.

This USPSTF recommendation was first published in Pediatrics 2006;117(2):497-501.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspschdv.htm

Clinical Considerations

• It is the responsibility of primary care clinicians to seek and address parents' concerns and children's obvious speech and language delays despite the lack of evidence to support screening with brief formal instruments. Speech and language development is considered a useful early indicator of a child's overall development and cognitive ability, and clinical and parental concerns are important modes of identifying children with speech and language delay. Early identification of children with developmental delay (lateness in achieving milestones) or developmental disabilities (chronic conditions that result from mental or physical impairments), such as marked hearing deficits, may lead to intervention and family assistance at a young age when chances for improvement may be best.
• Specific groups of children who already have been identified as at higher than average risk for speech and language delay, including children with other medical problems such as hearing deficits or craniofacial abnormalities, are not considered in this recommendation. The results of studies of other risk factors are inconsistent, so the USPSTF was unable to develop a list of specific risk factors to guide primary care providers in selective screening. The most consistently reported risk factors, however, include a family history of speech and language delay, male gender, and perinatal factors, such as prematurity and low birth-weight. Other risk factors reported less consistently include levels of parental education, specific childhood illnesses, birth order, and larger family size.

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Screening for Visual Impairment in Children Younger Than Age 5 Years

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) recommends screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years. Grade: B Recommendation.

This USPSTF recommendation was first published in: Ann Fam Med 2004;2:263-6.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/visionscr/vischrs.htm

Clinical Considerations

• The most common causes of visual impairment in children are:
  1. Amblyopia and its risk factors.
  2. Refractive error not associated with amblyopia.
• Amblyopia refers to reduced visual acuity without a detectable organic lesion of the eye and is usually associated with amblyogenic risk factors that interfere with normal binocular vision, such as strabismus (ocular misalignment), anisometropia (a large difference in refractive power between the 2 eyes), cataract (lens opacity), and ptosis (eyelid drooping). Refractive error not associated with amblyopia principally includes myopia (nearsightedness) and hyperopia (farsightedness); both remain correctable regardless of the age at detection.
• Various tests are used widely in the United States to identify visual defects in children, and the choice of tests is influenced by the child's age. During the first year of life, strabismus can be assessed by the cover test and the Hirschberg light reflex test.
  
• Screening children younger than age 3 years for visual acuity is more challenging than screening older children and typically requires testing by specially trained personnel. Newer automated techniques can be used to test these children. Photoscreening can detect amblyogenic risk factors such as strabismus, significant refractive error, and media opacities; however, photoscreening cannot detect amblyopia.
• Traditional vision testing requires a cooperative, verbal child and cannot be performed reliably until ages 3 to 4 years. In children older than age 3 years, stereopsis (the ability of both eyes to function together) can be assessed with the Random Dot E test or Titmus Fly Stereotest; visual acuity can be assessed by tests such as the HOTV chart, Lea symbols, or the tumbling E. Some of these tests have better test characteristics than others.
• Based on their review of current evidence, the USPSTF was unable to determine the optimal screening tests, periodicity of screening, or technical proficiency required of the screening clinician. Based on expert opinion, the American Academy of Pediatrics (AAP) recommends the following vision screening be performed at all well-child visits for children starting in the newborn period to 3 years:
  • Ocular history.
  • Vision assessment.
  • External inspection of the eyes and lids.
  • Ocular motility assessment.
  • Pupil examination.
  • Red reflex examination.
  For children aged 3 to 5 years, the AAP recommends the aforementioned screening in addition to age-appropriate visual acuity measurement (using HOTV or tumbling E tests) and ophthalmoscopy.²
• The USPSTF found that early detection and treatment of amblyopia and amblyogenic risk factors can improve visual acuity. These treatments include:
  • Surgery for strabismus and cataracts.
  • Use of glasses, contact lenses, or refractive surgery treatments to correct refractive error.
  • Visual training, patching, or atropine therapy of the nonamblyopic eye to treat amblyopia.
• These recommendations do not address screening for other anatomic or pathologic entities, such as macro cornea, cataracts, retinal abnormalities, or neonatal neuroblastoma, nor do they address newer screening technologies currently under investigation.

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References

1. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA 2003;289(5):559-67
2. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Section on Ophthalmology, American Association of Certified Orthoptists, American Association of Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians: policy statement. Pediatrics 2003;111(4):902-7.
3. National Institutes of Health. The Management of Sickle Cell Disease, 4th Ed. Revised June 2002. NIH National Heart, Lung, and Blood Institute. NIH Publication No. 02-2117. Available at: http://www.nhlbi.nih.gov/health/prof/blood/sickle/sc_mngt.pdf. Accessed August 2, 2007.

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