Section 3. Recommendations for Children

All recommendation statements in this Guide are abridged. To see the full recommendation statements and recommendations published after 2005, go to http://www.ahrq.gov/clinic/uspstf/uspstopics.htm.

Prevention of Dental Caries in Preschool Children

This USPSTF recommendation was first published in: Am J Prev Med 2004;26(4)326-9. 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 Idiopathic Scoliosis in Adolescents

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. June 2004.  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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Newborn Hearing Screening

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. October 2001.  http://www.ahrq.gov/clinic/3rduspstf/newbornscreen/newhearrr.htm.

Clinical Considerations

• Currently, universal newborn hearing screening (UNHS) is required by law in more than 30 States and is performed routinely in some health care systems in other States. Selective screening of infants in the NICU and those with other risk factors for hearing loss (below) is conducted in many settings that do not follow a policy of universal screening. Clinicians should be aware of such screening policies in their practice environments.
• Risk factors for sensorineural hearing loss (SNHL) among newborns include:
  • NICU admission for 2 days or more.
  • Syndromes known to include hearing loss (e.g., Usher's syndrome, Waardenburg's syndrome).
  • Family history of childhood SNHL.
  • Congenital infections (e.g., toxoplasmosis, bacterial meningitis, syphilis, rubella, cytomegalovirus, herpes virus).
  • Craniofacial abnormalities (especially morphologic abnormalities of the pinna and ear canal).
• If a program for routine hearing screening of newborns is implemented, it should include systematic education to fully inform parents and clinicians about the potential benefits and harms of the testing protocol. Most infants with positive in-hospital screening tests will subsequently be found to have normal hearing, and clinicians should be prepared to provide reassurance and support to parents of infants who need followup audiologic evaluation.
• If any program for newborn hearing screening is implemented, screening should be conducted using a validated protocol, usually requiring 2 screening tests. Equipment used should be well maintained, staff should be thoroughly trained, and quality control programs to reduce avoidable false-positive tests should be in place. Programs should develop protocols to ensure that infants with positive screening tests receive appropriate audiologic evaluation and followup after discharge.

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Screening and Interventions for Overweight in Children and Adolescents

This recommendation was first published in: Pediatrics. 2005;116(1):205-209. 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 fatfree 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 Visual Impairment in Children Younger Than Age 5 Years

This USPSTF recommendation was first published in: Ann Fam Med 2004;2:263-6. 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.

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