Preventive Service



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|US Preventive Services Task Force Recommendations for Children |

|March, 2014 |

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|Recommendation Key |

|Recommended |Insufficient Evidence/No recommendationi |Recommend Against |

|(A or B Grade) |(I or C Grade) |(D Grade) |

| |

|Preventive Service |General Population |High Risk Population |

| Screening | | |

| Body Measurement | | |

| Blood Pressure1 |Insufficient evidence |No specific recommendation |

| Height/Weight/BMI2 |>6 years |No specific recommendation |

| |Obesity—insufficient evidence |No specific recommendation |

| Hip Dysplasia (infant exam or US)3 |Insufficient evidence |No specific recommendation |

| Idiopathic Scoliosis (adolescent exam)4 |Recommend against |No specific recommendation |

| Metabolic | | |

| Lipids5 |Insufficient evidence |No specific recommendation |

| Lead6 |Recommend against |Insufficient evidence |

| Anemia (infants)7 |Insufficient evidence |Premature or low birth weight infants |

| Hyperbilirubinemia (infants)8 |Insufficient evidence |No specific recommendation |

| Newborn (PKU, thyroid, hemoglobinopathy)9 |At birth |At birth |

| Cancer | | |

| Testicular (exam, self-exam)10 |Recommend against |No specific recommendation |

| Sensory | | |

| Hearing11 |Newborn |Newborn |

| |> 3 years—recommend against |Insufficient evidence |

| Vision (strabismus, amblyobia, acuity)12 |3-5 years at least once |No specific recommendation |

| |25 hours of contact with the child and/or the family over a 6-month period and showed results including improved weight status, defined as an absolute and/or relative decrease in the BMI 12 months after the beginning of the intervention. Most participants were obese, and it is not known whether these results can be applied to children who are overweight but not obese. In addition, evidence was limited on the long-term sustainability of BMI changes achieved through behavioral interventions and on the trajectory of weight gain in children and adolescents. Interventions generally took place in referral settings, and the results can only be generalized to children who follow through on treatment. Low-intensity interventions, defined as ≤25 contact hours over a 6-month period, did not result in significant improvement in weight status. Interventions that combined pharmacologic agents (sibutramine or orlistat) with behavioral interventions resulted in modest short-term improvement in weight status in children aged 12 years and older. There were no long-term data on the maintenance of improvement after discontinuation of medications. The magnitude of the harms of these drugs in children could not be estimated with certainty. Adverse effects included elevated heart rate, elevated blood pressure, and adverse gastrointestinal effects. Sibutramine, a centrally acting appetite suppressant, has been approved by the US Food and Drug Administration (FDA) for use in adolescents aged 16 years and older. Orlistat, a lipase inhibitor, has been approved by the FDA for use in adolescents aged 12 years and older. Neither sibutramine nor orlistat has been approved for use in pediatric populations younger than 12 years. (2010)

3 Hip Dysplasia. The pathophysiology and natural history of developmental dysplasia of the hip (DDH) are poorly understood.  There is evidence that screening leads to earlier identification; however, 60% to 80% of the hips of newborns identified as abnormal or as suspicious for DDH by physical examination and >90% of those identified by ultrasound in the newborn period resolve spontaneously, requiring no intervention. There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening. (2006)

4 Idiopathic Scoliosis. The USPSTF did not find good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The accuracy of the most common screening test—the forward bending test with or without a scoliometer—in identifying adolescents with idiopathic scoliosis is variable, and there is evidence of poor followup of adolescents with idiopathic scoliosis who are identified in community screening programs. The USPSTF found fair evidence that treatment of idiopathic scoliosis during adolescence leads to health benefits (decreased pain and disability) in only a small proportion of people. Most cases detected through screening will not progress to a clinically significant form of scoliosis. Scoliosis needing aggressive treatment, such as surgery, is likely to be detected without screening. The USPSTF found fair evidence that treatment of adolescents with idiopathic scoliosis detected through screening leads to moderate harms, including unnecessary brace wear and unnecessary referral for specialty care. As a result, the USPSTF concluded that the harms of screening adolescents for idiopathic scoliosis exceed the potential benefits. (2004)

5 Lipids. There is insufficient evidence to recommend routine screening in children, adolescents, or young adults. For adolescents and young adults who have a family history of very high cholesterol, premature CHD in a first-degree relative (before age 50 in men or age 60 in women), or major risk factors for CHD screening may be recommended on other grounds: the greater absolute risk attributable to high cholesterol in such persons, and the potential long-term benefits of early lifestyle interventions in young persons with high cholesterol. Recommendations against routine screening in 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. (1996)

6 Lead. Blood lead levels in children have declined dramatically in the United States over the past two decades. However, segments of the population remain at increased risk for higher blood lead levels. Even relatively low blood lead levels are associated with neurotoxic effects in children. Severely elevated blood lead levels in symptomatic pregnant women are associated with poor health outcomes; however, lead levels in this range are rare in the U.S. population. There is good evidence that venous sampling accurately detects elevated blood lead levels and fair evidence that validated questionnaires are modestly useful in identifying children at increased risk for elevated blood lead levels. The USPSTF found good quality evidence that interventions do not result in sustained decreases in blood lead levels and found insufficient evidence (no studies) evaluating residential lead hazard control efforts (i.e., dust or paint removal, soil abatement, counseling, or education) or nutritional interventions for improving neurodevelopmental outcomes in children with mild to moderately elevated blood lead levels. The USPSTF found no evidence examining the effectiveness of screening or interventions in improving health outcomes in asymptomatic pregnant women. Given the low prevalence of elevated blood lead levels in children at average risk and asymptomatic pregnant women, the magnitude of potential benefit cannot be greater than small. A theoretical benefit of screening is that identification may prevent lead poisoning of other individuals in a shared environment, but the magnitude of this theoretical benefit is uncertain. There is good quality evidence that chelation treatment in asymptomatic children does not improve neurodevelopmental outcomes and is associated with a slight diminution in cognitive performance. Chelation therapy may result in transient renal, hepatic, and other toxicity, mild gastrointestinal symptoms, sensitivity reactions, and rare life-threatening reactions. Residential lead-based paint and dust hazard control treatments may lead to acutely increased blood lead levels from improper removal techniques. Potential harms of screening are false-positive results, anxiety, inconvenience, work or school absenteeism, and financial costs associated with repeated testing. Although the exact magnitude of these known and potential harms is uncertain, the overall magnitude is at least small. No studies have directly addressed the harms of screening and interventions for pregnant women. Although there is little specific evidence concerning the potential harms of interventions for pregnant women with elevated blood lead levels, the magnitude of harms from such interventions is also at least small. The USPSTF concluded that the evidence is insufficient to assess the balance between potential benefits and harms of routine screening for elevated blood lead levels in children at increased risk. Given the significant potential harms of treatment and residential lead hazard abatement, and no evidence of treatment benefit, the USPSTF concluded that the harms of screening for elevated blood lead levels in children at average risk and in asymptomatic pregnant women outweigh the benefits.(2006)

7 Anemia. Iron deficiency anemia is associated with psychomotor and cognitive abnormalities in children.  The prevalence of iron-deficiency anemia has remained stable over the last decade in the general U.S. population and continues to be greatest among minority and poor children.  A validated risk assessment tool to guide primary care physicians in identifying individuals who would benefit from iron supplementation has not been developed. The USPSTF found fair evidence that iron supplementation (e.g., iron–fortified formula or iron supplements) may improve neurodevelopmental outcomes in children at increased risk for iron deficiency anemia. The USPSTF found poor evidence (poor quality and conflicting studies) that iron–fortified formula or supplementation improves neurodevelopmental outcomes in children aged 6 to 12 months if they are not at increased risk for iron deficiency anemia. The USPSTF found fair evidence that oral iron supplementation increases the risk for unintentional overdose and gastrointestinal symptoms. Given appropriate protection against overdose, these harms are small. The moderate benefits of iron supplementation in asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia outweigh the potential harms. The USPSTF was unable to determine the balance between the benefits and harms of iron supplementation in children aged 6 to 12 months who are at average risk for iron deficiency anemia. (2006)

8 Hyperbilirubinemia. The exact incidence of chronic bilirubin encephalopathy is not known but is very low; in 1 study, 90 cases were documented in term and near-term infants in 21 states over a period of 17 years. In a recent prospective study in the United Kingdom and Ireland, the incidence of chronic bilirubin encephalopathy was estimated at 0.9 per 100 000 live births. Efforts have been made by clinicians to eliminate this rare but devastating condition by instituting system-level measures to screen for hyperbilirubinemia and by aggressively managing high bilirubin levels. There is adequate evidence that screening using risk factors and/or hour-specific bilirubin measurement can identify infants at risk of developing hyperbilirubinemia. However, not all children with chronic bilirubin encephalopathy have a history of hyperbilirubinemia, and there is no known screening test that will reliably identify all infants who are at risk of developing chronic bilirubin encephalopathy. Early treatment can decrease the number of infants with elevated serum bilirubin levels. However, the USPSTF found inadequate evidence that treating elevated bilirubin levels in term or near-term infants to prevent severe hyperbilirubinemia resulted in the prevention of chronic bilirubin encephalopathy. Hyperbilirubinemia is commonly treated with phototherapy, and severe hyperbilirubinemia may be treated with exchange blood transfusion. The USPSTF found inadequate evidence regarding the harms of phototherapy. Potential harms of phototherapy include weight loss, gastrointestinal problems, interruption of breastfeeding and disruption of the maternal-infant relationship, and possibly growth of melanocytic nevi. Significant morbidity (apnea, bradycardia, cyanosis, vasospasm, thrombosis, necrotizing enterocolitis) occurs in as many as 5% of patients who undergo exchange transfusion. The USPSTF concluded that evidence about the benefits and harms of screening is lacking. Thus, the USPSTF could not determine the balance of benefits and harms of screening newborn infants to prevent chronic bilirubin encephalopathy. (2009)

9 Newborn (PKU, thyroid, hemoglobinopathies). Screening for phenylketonuria by measurement of phenylalanine level on a dried-blood spot specimen, collected by heelstick and adsorbed onto filter paper, is recommended for all newborns before discharge from the nursery. Infants who are tested in the first 24 hours of age should receive a repeat screening test by 2 weeks of age. Premature infants and those with illnesses optimally should be tested at or near 7 days of age, but in all cases before newborn nursery discharge. All parents should be adequately informed regarding the indications for testing and the interpretation of PKU test results, including the probabilities of false-positive and false-negative findings. Screening for congenital hypothyroidism with thyroid function tests performed on dried-blood spot specimens is recommended for all newborns, optimally between days 2 and 6, but in all cases before newborn nursery discharge. Blood specimens should be collected by heelstick, adsorbed onto filter paper, and air dried using standard technique. The choice of which thyroid function test or tests to perform is generally determined by individual state requirements. Testing procedures and follow-up treatment for abnormal results should follow current guidelines. Care should be taken to ensure that those born at home, ill at birth, or transferred between hospitals in the first week of life are appropriately screened before 7 days of age. Normal newborn screening results should not preclude appropriate evaluation of infants presenting with clinical symptoms and signs suggestive of hypothyroidism. Screening newborn infants for hemoglobinopathies with hemoglobin electrophoresis or other tests of comparable accuracy on umbilical cord or heelstick blood specimens is recommended. In geographic areas with a very low incidence of hemoglobin disorders, selective screening of newborns may be more efficient than universal screening. (1996)

10 Testicular Cancer. The USPSTF found no new evidence that screening with clinical examination or testicular self-examination is effective in reducing mortality from testicular cancer. Even in the absence of screening, the current treatment interventions provide very favorable health outcomes. Given the low prevalence of testicular cancer, limited accuracy of screening tests, and no evidence for the incremental benefits of screening, the USPSTF concluded that the harms of screening exceed any potential benefits. (2004)

11 Hearing. Children with hearing loss have increased difficulties with verbal and nonverbal communication skills, increased behavioral problems, decreased psychosocial well-being, and lower educational attainment compared with children with normal hearing. Because half of the children with hearing loss have no identifiable risk factors, universal screening (instead of targeted screening) has been proposed to detect children with permanent congenital hearing loss (PCHL). There is good evidence that newborn hearing screening testing is highly accurate and leads to earlier identification and treatment of infants with hearing loss. Good-quality evidence shows that early detection improves language outcomes. There is limited evidence about the harms of screening, with conflicting research findings regarding anxiety associated with false-positive test results. There is limited information about the harms of treatment. Complications of cochlear implant surgery include increased risk of meningitis; however, the overall risks of complications of screening and treatment are estimated to be small. The USPSTF concluded that there is moderate certainty that the net benefit of screening all newborn infants for hearing loss is moderate. (2008) Routine hearing screening of asymptomatic children beyond age 3 years is not recommended. It is recognized, however, that such testing often occurs outside the clinical setting. When this occurs, abnormal test results should be confirmed by repeat testing at appropriate intervals, and all confirmed cases identified through screening referred for ongoing audiologic assessment, selection of hearing aids, family counseling, psycho-educational management, and periodic medical evaluation. (1996)

12 Vision. Approximately 2% to 4% of preschool-aged children have amblyopia, an alteration in the visual neural pathway in the developing brain that can lead to permanent vision loss in the affected eye. Amblyopia usually occurs unilaterally but can occur bilaterally. Identification of vision impairment before school entry could help identify children who may benefit from early interventions to correct or to improve vision. The USPSTF found adequate evidence that vision screening tools have reasonable accuracy in detecting visual impairment, including refractive errors, strabismus, and amblyopia. The USPSTF found adequate evidence that early treatment for amblyopia, including the use of cycloplegic agents, patching, and eyeglasses, for children 3 to 5 years of age leads to improved visual outcomes. The USPSTF found inadequate evidence that early treatment of amblyopia for children ................
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