Section 3. Recommendations for Children and Adolescents

Guide to Clinical Preventive Services, 2012

All clinical summaries in this Guide are abridged recommendations. To see the full recommendation statements and recommendations published after March 2012, go to http://www.uspreventiveservicestaskforce.org.

Screening for Elevated Blood Lead Levels in Children and Pregnant Women

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Asymptomatic children ages 1 to 5 years who are at increased risk	Asymptomatic children ages 1 to 5 years who are at average risk	Asymptomatic pregnant women
Recommendation	No recommendation Grade: I (Insufficient Evidence)	Do not screen for elevated blood lead levels. Grade: D	Do not screen for elevated blood lead levels. Grade: D
Risk Assessment	Children younger than age 5 years 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; use of ethnic remedies, certain cosmetics, and exposure to lead-glazed pottery; occupational exposure; and recent immigration. Additional risk factors for pregnant women include alcohol use and smoking.
Screening Tests	Venous sampling accurately detects elevated blood lead levels. 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.
Interventions	Treatment options 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. Community-based interventions for the 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.
Balance of Benefits and Harms	There is not enough evidence to assess the balance between the 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 harms of screening for elevated blood lead levels in children at average risk outweigh the benefits.	Given the significant potential harms of treatment and residential lead hazard abatement, and no evidence of treatment benefit, the harms of screening for elevated blood lead levels in asymptomatic pregnant women outweigh the benefits.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

Screening for Congenital Hypothyroidism

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	All newborn infants¹
Recommendation	Screening for congenital hypothyroidism (CH) Grade: A
Screening Tests	Two methods of screening are used most frequently in the United States: Primary TSH with backup T4. Primary T4 with backup TSH. Screening for congenital hypothyroidism (CH) is mandated in all 50 states and the District of Columbia. Clinicians should become familiar with the tests used in their area and the limitations of the screening strategies employed.
Timing of Screening	Infants should be tested between 2 and 4 days of age. Infants discharged from hospitals before 48 hours of life should be tested immediately before discharge. Specimens obtained in the first 24-48 hours of age may be falsely elevated for TSH regardless of the screening method used.
Suggestions for Practice	Infants with abnormal screens should receive confirmatory testing and begin appropriate treatment with thyroid hormone replacement within 2 weeks after birth. Children with positive confirmatory testing in whom no permanent cause of CH is found should undergo a 30-day trial of reduced or discontinued thyroid hormone replacement therapy to determine if the hypothyroidism is permanent or transient. This trial of reduced or discontinued therapy should take place at some time after the child reaches 3 years of age.
Other Relevant Recommendations from the USPSTF	Additional USPSTF recommendations regarding screening tests for newborns can be accessed at: http://www.uspreventiveservicestaskforce.org/tfchildcat.htm

¹This recommendation applies to all infants born in the U.S. Premature, very low birth weight and ill infants may benefit from additional screening. These conditions are associated with decreased sensitivity and specificity of screening tests.

Screening for Developmental Dysplasia of the Hip

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Infants who do not have obvious hip dislocations or other abnormalities evident without screening
Recommendation	No recommendation Grade: I (Insufficient Evidence)
Risk Assessment	Risk factors for developmental dysplasia of the hip include female sex, family history, breech positioning, and in utero postural deformities. However, the majority of cases of developmental dysplasia of the hip have no identifiable risk factors.
Screening Tests	Screening tests for developmental dysplasia of the hip 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.
Interventions	Treatments for developmental dysplasia of the hip include both nonsurgical and surgical options. Nonsurgical treatment with abduction devices is used as early treatment and includes the commonly prescribed Pavlik method. Surgical intervention is used when the dysplasia is severe or diagnosed late, or after an unsuccessful trial of nonsurgical treatment. 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.
Balance of Benefits and Harms	The USPSTF was unable to assess the balance of benefits and harms of screening for developmental dysplasia of the hip due to insufficient evidence. There are concerns about the potential harms associated with treatment of infants identified by routine screening.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on screening for hyperbilirubinemia, phenylketonuria, sickle cell disease, congenital hypothyroidism, and hearing loss in newborns. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	All newborn infants
Recommendation	Provide prophylactic ocular topical medication for the prevention of gonococcal ophthalmia neonatorum. Grade: A
Risk Assessment	All newborns should receive prophylaxis. However, some newborns are at increased risk, including those with a maternal history of no prenatal care, sexually transmitted infections, or substance abuse.
Preventive Interventions	Preventive medications include 0.5% erythromycin ophthalmic ointment, 1.0% solution of silver nitrate, and 1.0% tetracycline ointment. All are considered equally effective; however, the latter two are no longer available in the United States.
Timing of Intervention	Within 24 hours after birth.
Other Relevant USPSTF Recommendations	Several recommendations on screening and counseling for infectious diseases and perinatal care can be found at: http://www.uspreventiveservicestaskforce.org.

Universal Screening for Hearing Loss in Newborns

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	All newborns
Recommendation	Screen for hearing loss in all newborn infants Grade: B
Risk Assessment	The prevalence of hearing loss in newborn infants with specific risk indicators is 10 to 20 times higher than in the general population of newborns. Risk indicators associated with permanent bilateral congenital hearing loss include: Neonatal intensive care unit admission for 2 or more days. Family history of hereditary childhood sensorineural hearing loss. Craniofacial abnormalities. Certain congenital syndromes and infections. Approximately 50% of newborns with permanent bilateral congenital hearing loss do not have any known risk indicators.
Screening Tests	Screening programs should be conducted using a one-step or two-step validated protocol. A frequently-used 2-step screening process involves otoacoustic emissions followed by auditory brain stem response in newborns who fail the first test. Infants with positive screening tests should receive appropriate audiologic evaluation and follow-up after discharge. Procedures for screening and follow-up should be in place for newborns delivered at home, birthing centers, or hospitals without hearing screening facilities.
Timing of Screening	All infants should have hearing screening before one month of age. Infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age.
Treatment	Early intervention services for hearing-impaired infants should meet the individualized needs of the infant and family, including acquisition of communication competence, social skills, emotional well-being, and positive self-esteem. Early intervention comprises evaluation for amplification or sensory devices, surgical and medical evaluation, and communication assessment and therapy. Cochlear implants are usually considered for children with severe-to-profound hearing loss only after inadequate response to hearing aids.
Other Relevant USPSTF Recommendations	Additional USPSTF recommendations regarding screening tests for newborns can be accessed at http://www.uspreventiveservicestaskforce.org/recommendations.htm#pediatric.

Screening of Infants for Hyperbilirubinemia To Prevent Chronic Bilirubin Encephalopathy

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Healthy newborn infants ≥35 weeks' gestational age
Recommendation	No recommendation Grade: I (Insufficient Evidence)
Risk Assessment	Risk factors for hyperbilirubinemia include family history of neonatal jaundice, exclusive breastfeeding, bruising, cephalohematoma, ethnicity (Asian, black), maternal age >25 years, male gender, G6PD deficiency, and gestational age <36 weeks. The specific contribution of these risk factors to chronic bilirubin encephalopathy in healthy children is not well understood.
Importance	Chronic bilirubin encephalopathy is a rare but devastating condition. Not all children with chronic bilirubin encepahalopathy have a history of hyperbilirubinemia.
Balance of Benefits and Harms	Evidence about the benefits and harms of screening is lacking. Therefore, the USPSTF could not determine the balance of benefits and harms of screening newborns for hyperbilirubinemia to prevent chronic bilirubin encephalopathy.
Considerations for Practice	In deciding whether to screen, clinicians should consider the following: Potential preventable burden. Bilirubin encephalopathy is a relatively rare disorder. Hyperbilirubinemia alone does not account for the neurologic condition of chronic bilirubin encephalopathy. There is no known screening test that will reliably identify all infants at risk of developing chronic bilirubin encephalopathy. Potential harms. Potential harms of screening are unmeasured but may be important. Evidence about the potential harms of phototherapy is lacking. Harms of treatment by exchange transfusion may include apnea, bradycardia, cyanosis, vasospasm, thrombosis, necrotizing enterocolitis, and, rarely, death. Current practice. Universal screening is widespread in the United States.
Screening Tests	Screening may consist of risk-factor assessment, measurement of bilirubin level either in serum or by transcutaneous estimation, or a combination of methods.
Interventions	Phototherapy is commonly used to treat hyperbilirubinemia. Exchange transfusion is used to treat extreme hyperbilirubinemia.
Relevant USPSTF Recommendations	USPSTF recommendations on screening newborns for hearing loss, congenital hypothyroidism, hemoglobinopathies, and phenylketonuria (PKU) can be found at http://www.uspreventiveservicestaskforce.org.

Part I: Screening for Iron Deficiency Anemia in Children and Pregnant Women

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Asymptomatic children ages 6 to 12 months	Asymptomatic pregnant women
Recommendation	No recommendation Grade: I (Insufficient Evidence)	Screen for iron deficiency anemia. Grade: B
Risk Assessment	Serum hemoglobin or hematocrit is the primary screening test for identifying anemia. Hemoglobin is sensitive for iron deficiency anemia; however, it is not sensitive for iron deficiency because mild deficiency states may not affect hemoglobin levels. Potential harms of screening include false-positive results, anxiety, and cost.
Screening Tests	Serum hemoglobin or hematocrit is the primary screening test for identifying anemia. Hemoglobin is sensitive for iron deficiency anemia; however, it is not sensitive for iron deficiency because mild deficiency states may not affect hemoglobin levels. Potential harms of screening include false-positive results, anxiety, and cost.
Interventions	Iron deficiency anemia is usually treated with oral iron preparations. The likelihood that iron deficiency anemia identified by screening will respond to treatment is unclear, because many families do not adhere to treatment and because the rate of spontaneous resolution is high.
Balance of Benefits and Harms	The USPSTF was unable to determine the balance between the benefits and harms of routine screening for iron deficiency anemia in asymptomatic children ages 6 to 12 months.	The benefits of routine screening for iron deficiency anemia in asymptomatic pregnant women outweigh the potential harms.
Other Relevant USPSTF Recommendations	The USPSTF has also made recommendations on screening for blood lead levels in children and pregnant women. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

Part II: Iron Supplementation for Children and Pregnant Women

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia	Asymptomatic children ages 6 to 12 months who are at average risk for iron deficiency anemia	Pregnant women who are not anemic
Recommendation	Provide routine iron supplementation Grade: B	No recommendation Grade: I (Insufficient Evidence)	No recommendation Grade: I (Insufficient Evidence)
Risk Assessment	A validated risk assessment tool to guide primary care physicians in identifying individuals who would benefit from iron supplementation has not been developed.
Preventive Medication	Iron supplementation, such as iron-fortified formula or iron supplements, may improve neurodevelopmental outcomes in children at increased risk for iron deficiency anemia. There is poor evidence that it improves neurodevelopmental or health outcomes in other populations. Oral iron supplementation increases the risk for unintentional overdose and gastrointestinal symptoms. Given appropriate protection against overdose, these harms are small.
Balance of Benefits and Harms	The moderate benefits of iron supplementation in asymptomatic children ages 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 ages 6 to 12 months who are at average risk for iron deficiency anemia.	The USPSTF was unable to determine the balance between the benefits and harms of iron supplementation in non-anemic pregnant women.
Other Relevant USPSTF Recommendations	The USPSTF has also made recommendations on folic acid supplementation in women planning or capable of pregnancy and vitamin D supplementation to prevent cancer and fractures. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

Screening for Lipid Disorders in Children

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Asymptomatic infants, children, adolescents, and young adults (age 20 years or younger)
Recommendation	No recommendation Grade: I (Insufficient Evidence)
Risk Assessment	Risk factors for dyslipidemia include overweight, diabetes, and a family history of common familial dyslipidemias (e.g., familial hypercholesterolemia).
Screening Tests	Serum lipid (total cholesterol, high-density and low-density lipoprotein cholesterol) levels are accurate screening tests for childhood dyslipidemia, although many children with multifactorial types of dyslipidemia will have normal lipid levels in adulthood. 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.
Interventions	The effectiveness of treatment interventions (diet, exercise, lipid-lowering agents) in improving health outcomes in children with dyslipidemia (including multifactorial dyslipidemia) remains a critical research gap. Potential harms of screening may include labeling of children whose dyslipidemia would not persist into adulthood or cause health problems. Adverse effects from lipid-lowering medications and low-fat diets, including potential long-term harms, have been inadequately evaluated in children.
Balance of Benefits and Harms	The USPSTF was unable to determine the balance between the potential benefits and harms of routinely screening children and adolescents for dyslipidemia.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on screening for lipid disorders in adults and screening for carotid artery stenosis, coronary heart disease, high blood pressure, and peripheral arterial disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

Screening and Treatment for Major Depressive Disorder in Children and Adolescents

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Adolescents (12-18 years)	Children (7-11 years)
Recommendation	Screen when systems for diagnosis, treatment, and follow-up are in place. Grade: B	No Recommendation Grade: I (Insufficient Evidence)
Risk Assessment	Risk factors for major depressive disorder (MDD) include parental depression, having comorbid mental health or chronic medical conditions, and having experienced a major negative life event.
Screening Tests	The following screening tests have been shown to do well in teens in primary care settings: Patient Health Questionnaire for Adolescents (PHQ-A). Beck Depression Inventory-Primary Care Version (BDI-PC).	Screening instruments perform less well in younger children.
Treatments	Among pharmacotherapies fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has been found efficacious. However, because of risk of suicidality, SSRIs should be considered only if clinical monitoring is possible. Various modes of psychotherapy, and pharmacotherapy combined with psychotherapy, have been found efficacious.	Evidence on the balance of benefits and harms of treatment of younger children is insufficient for a recommendation.

Screening for Obesity in Children and Adolescents

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Children and adolescents 6 to 18 years of age
Recommendation	Screen children aged 6 years and older for obesity. Offer or refer for intensive counseling and behavioral interventions. Grade: B
Screening Tests	BMI is calculated from the weight in kilograms divided by the square of the height in meters. Height and weight, from which BMI is calculated, are routinely measured during health maintenance visits. BMI percentile can be plotted on a chart or obtained from online calculators. Overweight = age- and gender-specific BMI at ≥85th to 94th percentile Obesity = age- and gender-specific BMI at ≥95th percentile
Timing of Screening	No evidence was found on appropriate screening intervals.
Interventions	Refer patients to comprehensive moderate- to high-intensity programs that include dietary, physical activity, and behavioral counseling components.
Balance of Benefits and Harms	Moderate- to high-intensity programs were found to yield modest weight changes. Limited evidence suggests that these improvements can be sustained over the year after treatment. Harms of screening were judged to be minimal.
Other Relevant USPSTF Recommendations	Recommendations on other pediatric and behavioral counseling topics can be found at http://www.uspreventiveservicestaskforce.org.

Screening for Phenylketonuria

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	All newborn infants
Recommendation	Screen for Phenykeltonuria (PKU). Grade: A
Screening Tests	Screening for PKU is mandated in all 50 states. Methods of screening vary. Three main methods are used to screen for PKU in the United States: Guthrie Bacterial Inhibition Assay (BIA) Automated fluorometric assay Tandem mass spectrometry
Timing of Screening	Infants who are tested within the first 24 hours after birth should receive a repeat screening test by 2 weeks of age. Optimal timing of screening for premature infants and infants with illnesses is at or near 7 days of age, but in all cases before discharge from the newborn nursery.
Treatment	It is essential that phenylalanine restrictions be instituted shortly after birth to prevent the neurodevelopmental effects of PKU.
Other Relevant USPSTF Recommendations	Additional USPSTF recommendations regarding screening tests for newborns can be accessed at: http://www.uspreventiveservicestaskforce.org/recommendations.htm#pediatric

Screening for Idiopathic Scoliosis in Adolescents

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Asymptomatic adolescents
Recommendation	Do not screen for idiopathic scoliosis. Grade: D
Screening Tests	There is no evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. Screening for idiopathic scoliosis is usually done by visual inspection of the spine to look for asymmetry of the shoulders, scapulae, and hips. If idiopathic scoliosis is suspected, radiography can be used to confirm the diagnosis and to quantify the degree of curvature.
Timing of Screening	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.
Interventions	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.
Balance of Benefits and Harms	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 harms of screening adolescents for idiopathic scoliosis exceed the potential benefits.
Other Relevant USPSTF Recommendations	The USPSTF has also made recommendations on screening for developmental dysplasia of the hip. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

Screening for Sickle Cell Disease in Newborns

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	All newborn infants
Recommendation	Screen for sickle cell disease Grade: A
Screening Tests	Screening for sickle cell disease in newborns is mandated in all 50 states and the District of Columbia. In most states, one of these tests is used for the initial screening: Thin-layer isoelectric focusing (IEF). High performance liquid chromatography (HPLC). Both IEF and HPLC have extremely high sensitivity and specificity for sickle cell anemia.
Timing of Screening	All newborns should undergo screening regardless of birth setting. Birth attendants should make arrangements for samples to be obtained. The first clinician to see the infant at an office visit should verify screening results. Confirmatory testing should occur no later than 2 months of age.
Treatment	Infants with sickle cell anemia should receive: Prophylactic penicillin starting by age 2 months. Pneumococcal immunizations at recommended intervals.
Other Relevant USPSTF Recommendations	Additional USPSTF recommendations regarding screening tests for newborns can be accessed at http://www.uspreventiveservicestaskforce.org/recommendations.htm#vision.

Screening for Speech and Language Delay in Preschool Children

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Children ages 5 years and younger who have not already been identified as at increased risk for speech and language delays
Recommendation	No Recommendation Grade: I (Insufficient Evidence)
Risk Assessment	The most consistently reported risk factors include a family history of speech and language delay, male sex, 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.
Screening Tests	There is insufficient evidence that brief, formal screening instruments that are suitable for use in primary care for assessing speech and language development can accurately identify children who would benefit from further evaluation and intervention.
Balance of Benefits and Harms	The USPSTF could not determine the balance of benefits and harms of using brief, formal screening instruments to screen for speech and language delay in the primary care setting.
Other Relevant USPSTF Recommendations	The USPSTF has also made recommendations on screening for hearing loss in newborns and vision impairment in children ages 1 to 5 years. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

Screening for Visual Impairment in Children Ages 1 to 5 Years

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population	Children ages 3 to 5 years	Children younger than 3 years of age
Recommendation	Provide vision screening Grade: B	No recommendation Grade: I (Insufficient Evidence)
Screening Tests	Various screening tests are used in primary care to identify visual impairment in children, including: Visual acuity test Stereoacuity test Cover-uncover test Hirschberg light reflex test Autorefraction Photoscreening
Timing of Screening	No evidence was found regarding appropriate screening intervals.
Interventions	Primary treatment for amblyopia includes the use of corrective lenses, patching, or atropine therapy of the non-affected eye. Treatment may also consist of a combination of interventions.
Balance of Benefits and Harms	There is adequate evidence that early treatment of amblyopia in children ages 3 to 5 years leads to improved visual outcomes. There is limited evidence on harms of screening, including psychosocial effects, in children ages 3 years and older. There is inadequate evidence that early treatment of amblyopia in children younger than 3 years of age leads to improved visual outcomes.
Suggestions for Practice Regarding the I Statement	In deciding whether to refer children younger than 3 years of age for screening, clinicians should consider: Potential preventable burden: screening later in the preschool years seems to be as effective as screening earlier Costs: initial high costs associated with autorefractors and photoscreeners Current practice: typical vision screening includes assessment of visual acuity, strabismus, and stereoacuity; children with positive findings should be referred for a comprehensive ophthalmologist exam

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Page last reviewed October 2011

Internet Citation: Section 3. Recommendations for Children and Adolescents: Guide to Clinical Preventive Services, 2012. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide2012/section3.html