Clinical Summaries of Recommendations for Children and Adolescents

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The Guide to Clinical Preventive Services 2014: Recommendations of the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 May.

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The Guide to Clinical Preventive Services 2014: Recommendations of the U.S. Preventive Services Task Force.

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Clinical Summaries of Recommendations for Children and Adolescents

Blood Lead Levels in Children and Pregnant Women

Title	Screening for Elevated Blood Lead Levels in Children and Pregnant Women
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/.

^*Child Maltreatment

Title	Primary Care Interventions to Prevent Child Maltreatment
Population	Children and adolescents aged 0 to 18 years without signs or symptoms of maltreatment
Recommendation	No recommendation. Grade: I (Insufficient Evidence)

Risk Assessment	There are numerous risk factors associated with child maltreatment, including but not limited to: Young, single, or nonbiological parents Parental lack of understanding of childrenís needs, child development, or parenting skills Poor parent-child relationships/negative interactions Parental thoughts or emotions that support maltreatment behaviors Family dysfunction or violence Parental history of abuse or neglect in family of origin Substance abuse within the family Social isolation, poverty, or other socioeconomic disadvantages Parental stress and distress
Interventions	Although the evidence is insufficient to recommend specific preventive interventions, most child maltreatment prevention programs focus on home visitation. Home visitation programs usually comprise a combination of services provided by a nurse or paraprofessional in the family's home on a regularly scheduled basis; most programs are targeted to families with young children and often begin in the prenatal or postnatal period.
Balance of Benefits and Harms	The evidence on interventions in primary care to prevent child maltreatment among children without signs or symptoms of maltreatment is insufficient, and the balance of benefits and harms cannot be determined.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on screening for intimate partner violence and abuse of elderly and vulnerable adults. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

: 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/.

Congenital Hypothyroidism

Title	Screening for Congenital Hypothyroidism
Population	All newborn infants¹
Recommendation	Screen for congenital hypothyroidism. 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/recommendations.htm#pediatric

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

Developmental Dysplasia of the Hip

Title	Screening for Developmental Dysplasia of the Hip
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/.

: 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/.

Gonococcal Ophthalmia Neonatorum

Title	Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum
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.

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

Hearing Loss (Newborns)

Title	Universal Screening for Hearing Loss in Newborns
Population	All newborn infants
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.

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

^*High Blood Pressure (Children)

Title	Screening for Primary Hypertension in Children and Adolescents
Population	Children and adolescents without symptoms of hypertension
Recommendation	No recommendation. Grade: I (Insufficient Evidence)

Risk Assessment	The strongest risk factor for primary hypertension in children is elevated body mass index. Other risk factors include low birthweight, male sex, ethnicity, and a family history of hypertension.
Screening Tests	Blood pressure screening with sphygmomanometry in the clinical setting may identify children and adolescents with hypertension with reasonable sensitivity; however, false-positive results may occur with normalization of subsequent blood pressure measurements.
Treatment	Stage 1 hypertension in children is treated with lifestyle and pharmacological interventions; medications are not recommended as first-line therapy.
Balance of Benefits and Harms	The USPSTF found inadequate evidence on the diagnostic accuracy of screening for primary hypertension. The USPSTF also found inadequate evidence on the effectiveness of treatment and the harms of screening or treatment. Therefore, the USPSTF cannot determine the balance of benefits and harms of screening for hypertension in children and adolescents.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on screening for lipid disorders in children and adolescents. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

: 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/.

Hyperbilirubinemia in Infants

Title	Screening of Infants for Hyperbilirubinemia to Prevent Chronic Bilirubin Encephalopathy
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 encephalopathy 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.

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

^*Illicit and Prescription Drug Use in Children and Adolescents

Title	Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents
Population	Children and adolescents younger than age 18 years who have not already been diagnosed with a substance use disorder
Recommendation	No recommendation. Grade: I statement

Behavioral Interventions	While the evidence is insufficient to recommend specific interventions in the primary care setting, those that have been studied include face-to-face counseling, videos, print materials, and interactive computer-based tools. Studies on these interventions were limited and findings on whether interventions significantly improved health outcomes were inconsistent.
Balance of Benefits and Harms	The evidence regarding primary care-based behavioral interventions to prevent or reduce illicit drug and nonmedical pharmaceutical use in children and adolescents is insufficient, and the balance of benefits and harms cannot be determined.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on screening for and interventions to decrease the unhealthy use of other substances, including alcohol and tobacco. These recommendations are available at www.uspreventiveservicestaskforce.org.

: 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/.

Iron Deficiency Anemia (Screening)

Title	Part I: Screening for Iron Deficiency Anemia in Children and Pregnant Women
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	Individuals considered to be at high risk for iron deficiency include adult women, recent immigrants, and, among adolescent females, fad dieters, as well as those who are obese. Premature and low birth weight infants are also at increased risk for iron deficiency.
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/.

: 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/.

Iron Deficiency Anemia (Supplementation)

Title	Part II: Iron Supplementation for Children and Pregnant Women
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/.

: 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/.

Lipid Disorders in Children

Title	Screening for Lipid Disorders in Children
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 high blood pressure and obesity in children and adolescents. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

: 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/.

Major Depressive Disorder in Children and Adolescents

Title	Screening and Treatment for Major Depressive Disorder in Children and Adolescents
Population	Adolescents (12–18 years)	Children (7–11 years)
Recommendation	Screen when systems for diagnosis, treatment, and followup 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.

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

Obesity in Children and Adolescents

Title	Screening for Obesity in Children and Adolescents
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.

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

Phenylketonuria (PKU)

Title	Screening for Phenylketonuria
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

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

Sickle Cell Disease

Title	Screening for Sickle Cell Disease in Newborns
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.

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

Speech and Language Delay

Title	Screening for Speech and Language Delay in Preschool Children
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/.

: 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/.

^*Tobacco Use in Children and Adolescents

Title	Primary Care Interventions to Prevent Tobacco Use in Children and Adolescents
Population	School-aged children and adolescents
Recommendation	Provide interventions to prevent initiation of tobacco use. Grade: B

Risk Assessment	The strongest factors associated with smoking initiation in children and adolescents are parental smoking and parental nicotine dependence. Other factors include low levels of parental monitoring, easy access to cigarettes, perception that peers smoke, and exposure to tobacco promotions.
Behavioral Counseling Interventions	Behavioral counseling interventions, such as face-to-face or phone interaction with a health care provider, print materials, and computer applications, can reduce the risk for smoking initiation in school-aged children and adolescents. The type and intensity of effective behavioral interventions substantially varies.
Balance of Benefits and Harms	There is a moderate net benefit to providing primary care interventions to prevent tobacco use in school-aged children and adolescents.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women. These recommendations are available at www.uspreventiveservicestaskforce.org/.

: 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/.

Visual Impairment in Children Ages 1 to 5

Title	Screening for Visual Impairment in Children Ages 1 to 5
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

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

Footnotes

*: New recommendations released March 2012 to March 2014.

Bookshelf ID: NBK235850

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The Guide to Clinical Preventive Services 2014: Recommendations of the U.S. Preventive Services Task Force.

Clinical Summaries of Recommendations for Children and Adolescents

Blood Lead Levels in Children and Pregnant Women

^*Child Maltreatment

Congenital Hypothyroidism

Developmental Dysplasia of the Hip

Gonococcal Ophthalmia Neonatorum

Hearing Loss (Newborns)

^*High Blood Pressure (Children)

Hyperbilirubinemia in Infants

^*Illicit and Prescription Drug Use in Children and Adolescents

Iron Deficiency Anemia (Screening)

Iron Deficiency Anemia (Supplementation)

Lipid Disorders in Children

Major Depressive Disorder in Children and Adolescents

Obesity in Children and Adolescents

Phenylketonuria (PKU)

Sickle Cell Disease

Speech and Language Delay

^*Tobacco Use in Children and Adolescents

Visual Impairment in Children Ages 1 to 5

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