PEDIATRIC SCREENING & PREVENTION


See also Preparticipation Evaluation, Safety Issues for Children, Sudden Infant Death Syndrome (SIDS), and Probiotics for Prevention of Respiratory Infections in Children, Screening for Lead Poisoning

I. Lab work:

  1. Newborn screening
  1. PKU incidence 1:10-20k; causes MR & eczema
  2. TSH for congenital hypothyroidism: 1:3-5k; 5MR, FTT, constipation
  3. CAH: 1:12k, ambig. genitalia in girls, salt wasting, shock
  4. Hb: 1:400 in afr-am pts; sickling crises, splenic sequestr., sepsis
  1. Screening for Iron Deficiency with Hb or HCT--Click link for recommendations
  1. UA
  1. 3 years or first visit if >3y
  2. PRN h/o UTI, enuresis, fam. h/o renal disease
  1. Cholesterol & lipids
  1. 9-12y if fam h/o dyslipidemias/CAD
  1. PPD--If risk, do at 12mos and 4-6y
  1. Lead levels to screen for lead poisoning
    1. Lead poisoning can cause cognitive and behavior problems and possibly neuromotor deficits
    2. Risk factors
      1. Living in or regularly visiting a building built before 1950 or was built before 1978 and is now or in the previous 6mos was being renovated or remdeled
      2. Sibling or playmater with current or past lead poisoning
      3. Household member with occupational or recreational exposure to lead
    3. As of 1998 (Peds 101:1072, 1998--AFP), AAP recommends screening children if > 27% of housing in the community was built before 1950 or if prevalence of lead poisoning in the community is unknown or if other risk factors are present. Screen at 9-12mos and again at 24mos
      1. If > 10mg/dl, confirm with repeat testing
      2. If > 70mg/dl, hospitalize for tx
      3. Other recommendations to be found in above reference

II. Other, Q Visit

  1. Denver Prescreening Developmental Questionnaire (& DDST PRN)
  2. Ht, Wt, VS. HC to 12 mos

III. At birth-NOTE this section is NOT complete!

  1. Pulse-oximetry in newborns (prior to hospital discharge)
    1. Note that many congenital cardiovascular abnormalities are not diagnosed prior to initial hospital discharge because they are masked by the patency of the ductus arteriosis (which usually closes around 72h of life).
    2. In a prospective study in 38,000 neonates, the approach below with echocardiography leading to a positive screen was associated with better sensitivity (82.8% vs. 62.5%; the summary didn't say what the gold standard was) and had a higher positive predictive value (20.7% vs. 1.3%) (BMJ 338a:3037, 2009-JW)
      1. Measure SaO2 in right hand ("preductal")
      2. Measure SaO2 in either foot ("postductal")
      3. Positive screen = 3 separate instances where ((both  measurements < 95%) or (> 3% difference between the two))
  2. Consider probiotics for prevention of Nectrotizing Enterocolitis (click link for details)
  3. Anterior fontanelle-At birth normally 0.6–3.6 cm (mean 2.1cm)
  4. Screening for Neonatal Hyperbilirubinemia
    1. AAP in 2004 recommended that every newborn undergo a clinical risk assessment or measurement of bilirubin (serum or transcutaneous) prior to hospital discharge.

IV. 1-2 Weeks of age:

  1. Repeat newborn exam, inc. pulses, hip click, metatarsus adductus, jaundice
  2. Clinitest (galactosemia), newborn screen (PKU, T4, CAH, Hb)
  3. Discuss feeding, car seat, crib safety, sleeping, crying, injury prevention inc. smoke detectors & lowering water-heater settings, family dynamics, pacifier use (to prevent SIDS)
  4. Start fluoride if breast-fed (if using bottled H2O or tap water that is not fluoridated)
  5. Adult family members? polio status
  6. Consider Fe supplementation if exclusively breastfed: In a randomized trial of full-term exclusively breastfed babies randomized to receive FeSO4 7.5mg QD vs. placebo from age 1-6mos, measures of psychomotor development and visual acuity were sig. better in Fe group; no sig. diffs. seen in mental development or physical growth (J. Peds. 143:582, 2003--JW)

V. 1 mo (optional)--Weight check, hip click, OFC, Hirschberg test for strabismus

VI. 2 mo

  1. Discuss same topics as above
  2. Review development: smiling, tears, vocalization, & head control
  3. Check for hip click, OFC, Hirschberg test for strabismus
  4. AP hip films if: breech, fam h/o CHD, or neonatal torticollis or metatarsus adductus (might indicate excessive intrauterine constraint). Repeat Hb screen if was abnl.
  5. Consider Fe supplementation if exclusively breastfed--Click HERE for details

VII. 4 mo:

  1. Can start cereal
  2. Anticipate URI's
  3. Discuss same topics as above, plus FB ingestion, teething
  4. Rolls front-back, grasps
  5. Sleep through night 5-9 hours
  6. Check for hip click, OFC, Hirschberg test for strabismus
  7. Consider Fe supplementation if exclusively breastfed--Click HERE for details

VIII. 6 mo:

  1. Start solids (starting earlier may cause food allergies)
  2. Discuss same topics as above, plus cover electrical outlets, Mr. Yuk packets, supervise in bathtub, fences for stairs
  3. Rolls both ways, sits with some support, blows "raspberries"
  4. Check for hip click, OFC, Hirschberg test for strabismus
  5. Consider Fe supplementation if exclusively breastfed--Click HERE for details

IX. 9 mo:

  1. Repeat previous discussions
  2. Separation anxiety
  3. Drink from cup
  4. Sits without support, "mama," "dada," responds to name, pulls to standing
  5. Repetitive movements e.g. head banging, rolling, rocking are normal, particularly at bedtime
  6. Check for hip click, OFC, Hirschberg test for strabismus

X. 12 mo:

  1. TB skin testing
  2. Torsional deformities of lower extremity (femoral anteversion, internal tibial torsion, metatarsus adductus)
  3. Walks, falls, 1-3 words, social games
  4. Repetitive movements e.g. head banging, rolling, rocking are normal,  particularly at bedtime
  5. Consider weaning from formula & breast milk
  6. Check for hip click, OFC, Hirschberg test for strabismus
  7. Anterior fontanelle-38% are closed at 12mos; 50% at 13.8 months. 

XI. 12-15 mo:

  1. Discipline, tantrums, 3-6 words, scribbles, recognizes self in mirrors
  2. Repetitive movements e.g. head banging, rolling, rocking are normal,  particularly at bedtime
  3. Hirschberg test for strabismus
  4. Anterior fontanelle-38% are closed at 12mos; 50% at 13.8 months. 

XII. 15-18 mo:

  1. Bedtime behavior problems; 4-10 words, feeds self; uses spoon
  2. Repetitive movements e.g. head banging, rolling, rocking are normal,  particularly at bedtime (usually disappear by 4yo)
  3. Cover/uncover test
  4. Expect temper tantrums (should usually last < 5min; should not involve highly aggressive or self-injurious behavior or > 5 tantrums/day)
  5. Anterior fontanelle-38% are closed at 12mos; 50% at 13.8 months. 

XIII. 2 years:

  1. Toilet training, can do stairs, climb on furniture, 50 words, answers "what's that?"
  2. Injury prevention: above plus don?t cross street alone
  3. Cover/uncover test
  4. Expect temper tantrums (should usually last < 5min; should not involve highly aggressive or self-injurious behavior or > 5 tantrums/day)

XIV. 3 years:

  1. Dental visit for screening
  2. Cover/uncover test
  3. Dresses self, washes & dries hands, 50% intelligible speech
  4. Vision screen--Visual acuity with Snellen letters or numbers, tumbling E, HOTV, or picture tests--Refer if < 4 of 6 correct at 20-foot line or 2-line difference between eyes (per Pediatrics 111:903, 2003--AFP)
  5. Expect temper tantrums (should usually last < 5min; should not involve highly aggressive or self-injurious behavior or > 5 tantrums/day)

XV. 4 years:

  1. Vision screen (see 3y)
  2. Hearing screen, BP, cover/uncover
  3. Climbs ladder, controls pencil, counts 1-10
  4. Injury prevention: car booster seat with lap/shoulder harness
  5. Expect temper tantrums (should usually last < 5min; should not involve highly aggressive or self-injurious behavior or > 5 tantrums/day); Tantrum frequency should have declined compared to early toddler years

XVI. 5 years:

  1. Vision screen (see 3y)
  2. Hearing screen, BP, cover/uncover
  3. School readiness, enuresis, seat belts
  4. Throws overhand, dresses alone, understands rules, knows nursery rhymes
  5. Tantrum frequency should have declined compared to early toddler years

XVII. 6, 7, 8 years:

  1. Vision and hearing screen, BP, cover/uncover
  2. School performance, bedtime, TV & video game rules, quality time w/child, privacy, chores
  3. Masturbation common
  4. Seat belts & bike safety

XVIII. 9, 10, 11, 12 years:

  1. Tanner staging, check for scoliosis
  2. Anticipate sports injuries
  3. Substance abuse (EtOH, tobacco, etc.)
  4. Self-esteem, independence, sexuality, obsession with appearance, peer rel?ships
  5. Sex
  6. Screen for type 2 DM if at high risk (overweight, family history, or signs of insulin resistance on Px such as acanthosis nigricans, hypertension, dyslipidemia, or signs of polycystic ovary syndrome in girls)

XIX. Adolescence:

  1. Consider ferritin, not just Hb, in girls: Prevalcence of Fe deficiency in adolescent girls in U.S. = 25%; 81 adolescent girls with nl Hb but Fe deficiency defined as ferritin < 13mg/l were randomized to FeSO4 650 BID vs. placebo x 8wks; both groups equivalent; FeSO4 group showed sig. better in tests of verbal learning and memory at end of tx period (no better on attention)
  2. Td
  3. Breast/testicular self-examination
  4. Acne
  5. Dr. Brent Oldham's "Six Golden Rules:"
  1. Always use seatbelts
  2. Never drive after drinking/drugging
  3. Don't smoke
  4. If you have sex, use a condom
  5. Low-fat diet
  6. Regular aerobic exercise
  1. Screening for Depression
    1. In 2009, USPSTF recommended screening all adolescents (12-18y) for major depression using the Patient Health Questionnaire for Adolescents (sens/spec 73%/91%) and Beck Depression Inventory-Primary Care version (sens/spec 94%/91%)

n.b. Hirschberg test: Shine light about 8in. from eyes into first one eye & then the other. Reflection should be in the same place in each eye, i.e. pointing the same way. If reflections are divergent, may indicate strabismus.

G & D: Often "find their growth curve" between 6 & 14 mos, going down in percentile; Should nevertheless always continue to gain weight; i.e. shouldn't plateau

Hearing screening