Clinician's Handbook of Preventive Services, 2nd Edition. PPIP

Organization

The Clinician's Handbook has been organized to facilitate quick reference. The main text is divided into two sections: preventive services for children/adolescents (up to age 18 years) and preventive services for adults/older adults. The overview chapters provide background information on topics such as: the basic epidemiologic principles of prevention, occupational and environmental considerations, and the implementation of a preventive care protocol. In addition, several appendices provide supplementary information including timelines and risk factor tables (Appendix A); general information on immunizations, including information on reporting adverse effects (Appendix B); notifiable diseases (Appendix C); and a list of major authorities cited (Appendix D).

The Children and Adolescents and Adults and Older Adults sections are divided into three subsections: (1) screening guidelines, (2) immunization and prophylaxis recommendations, and (3) counseling information.

Chapters are broken down into six subsections. Each chapter is organized in the following format:

1. A brief introduction describing the burden of suffering of the disease, risk factors, and the effectiveness of the preventive intervention.

2. A summary of the recommendations of major authorities.

3. Technical information describing how to perform each preventive service.

4. A resource list for patients--pamphlets, books, videotapes, and other materials that can be provided to patients for reinforcement of health messages.

5. A resource list for providers--information for supplemental reading on each topic.

6. Selected (bibliographic) references--references used in the chapter.

Content

The criterion for inclusion of a preventive service in the Clinician's Handbook is a recommendation for its routine use in the care of asymptomatic persons by a major US authority such as: a Federal health agency (eg, Centers for Disease Control and Prevention, National Institutes of Health), a non-Federal expert panel (eg, US Preventive Services Task Force), a national professional organization (eg, American Academy of Family Physicians, American Academy of Pediatrics), or a national voluntary health organization (eg, American Cancer Society, American Heart Association). Recommendations of the Canadian Task Force on the Periodic Health Examination have also been included.

Because the Clinician's Handbook focuses on preventive care for the general population without special risk factors, the following types of preventive care have not been included: tertiary prevention (treatment to prevent progression of known disease), prenatal and perinatal care, and preventive care for certain high-risk groups. Preventive services not recommended by at least one major authority have been excluded. However, the exclusion of a medical procedure does not suggest that it is ineffective in diagnosing and treating disease. The clinician should exercise judgement on a case-by-case basis with respect to preventive services not addressed in the Clinician's Handbook.

Every effort has been made to ensure that recommendations of major authorities listed in each chapter accurately represent the current positions of these authorities. Recommendations are listed alphabetically by organization. Similar recommendations are often grouped together to facilitate comparisons by the reader. Appearance in the Clinician's Handbook does not imply that either the US Department of Health and Human Services or the Public Health Service endorses a specific authority or its recommendations; clinicians are encouraged to consult the references provided to evaluate the scientific basis for each organization's recommendations. Similarly, the citation of a group's recommendations does not imply that the group has endorsed the Clinician's Handbook or its contents.

The "Basics" of providing services sections were derived from a compilation of sources, including expert opinion. In many instances, the recommendations of major authorities, as well as expert researchers, were combined.

The items listed in the "Patient and Provider Resource" sections of the chapters have been selected after an extensive review of materials solicited from government agencies and professional and voluntary organizations. However, this list is not exhaustive and there are undoubtedly other, equally useful publications that have not been included. The materials listed provide a starting point for clinicians to build a library of high-quality literature and resources for themselves and their patients. The individual clinician must determine the appropriateness of each material in any specific case.

The publications listed in the "Selected References" sections were chosen because of their use in preparing the chapters and their potential usefulness to the clinician. These lists are not intended to be a comprehensive bibliography of the literature, but provide a core set of references for the reader.

No single set of preventive services is appropriate for all patients in all settings. The Clinician's Handbook is designed to facilitate the design and implementation of a preventive care program for practices of all sizes and types. Chapter ii discusses the principles of prevention, such as general principles of screening, immunizations, and counseling. This information, when combined with the more specific recommendations of authorities, relevant patient risk factors given in each chapter, and the summary risk-factor tables in Appendix A, should help clinicians select a set of preventive services appropriate for their patients and practice. Chapter iv provides practical information on establishing and implementing a preventive care protocol.

A goal of the Clinician's Handbook is to describe areas of consensus among the recommendations of major authorities regarding clinical preventive services. Important clinical differences in recommendations are reflected. However, the differences in the processes by which authorities arrived at their recommendations are not described. Some recommendations of major authorities are based strictly on expert opinion and others incorporate evidence-based approaches. Names and addresses of all major authorities cited are listed in Appendix D and readers are encouraged to contact the organization to ascertain how guidelines were formulated.

Sources

The data for the Clinician's Handbook were obtained from scientific literature identified by searching computerized data bases and reference lists of primary sources; policy statements and position papers issued by government agencies, professional groups, and voluntary associations; educational brochures, booklets, and other materials from government agencies, professional groups, and voluntary associations; and consultation with experts.

Review

The chapters of this book have been reviewed for scientific accuracy by experts in the following divisions in the Department of Health and Human Services:

• Administration for Children and Families

• Agency for Health Care Policy and Research

• Administration on Aging

• Centers for Disease Control and Prevention

• Food and Drug Administration

• Health Care Financing Administration

• Health Resources and Services Administration

• Indian Health Service

• National Institutes of Health

• Office of HIV/AIDS Policy

• Office of Minority Health

• Office of Population Affairs

• Office of the Surgeon General

• Office on Women's Health

• Substance Abuse and Mental Health Services Administration

Acknowledgments

Preparation of this Clinician's Handbook of Preventive Services was coordinated by staff in the Office of Disease Prevention and Health Promotion, Office of Public Health and Science, US Department of Health and Human Services, under the general supervision of Claude Earl Fox, III, MD, MPH, Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion).

Principal staff responsible for the preparation of this edition were:

• Rika Maeshiro, MD, MPH, Co-Editor

• Lynn M. Soban, MPH, RN, Project Coordinator and Co-Editor

Other staff members of the Office of Disease Prevention and Health Promotion who contributed to the preparation of this edition were:

• David R. Baker

• Kate-Louise Gottfried, JD, MSPH

• Kathryn McMurry, MS

• Linda D. Meyers, PhD

• Janice T. Radak

• Mark Smolinski, MD, MPH

Valuable research and writing contributions were made by the following preventive medicine residents during rotations at the Office of Disease Prevention and Health Promotion:

Special thanks to the following individuals and organizations for their contributions:

• Larry L. Dickey, MD, MPH, Office of Clinical Preventive Medicine, California Department of Health Services, who updated the Recommendations of Major Authorities;

• Bradley Evanoff, MD, MPH, Assistant Professor, Section of Occupational and Environmental Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, who prepared the chapter on Occupational and Environmental Exposures;

• Crystal Wilkinson, MSN, RN, CNS, Texas Department of Health, who prepared the chapter on Implementing a Preventive Care Protocol;

• The American Society of Clinical Pathologists for their contributions to the chapter on Papanicolaou Smear Screening.

Other contributors included:

• Jacqelyn B. Admire, MSPH

• Patti Auer, RN, MSN

• Susan Bradford

• Cheri Hahn, MS, RN

• Melissa Koenig

• Tammy L. Lin, MD

• Rosemarie Perrin

• Kristine Samson

• Yu Ning Wong

General Clinical Preventive Services

The primary and secondary clinical preventive services presented in the Clinician's Handbook target asymptomatic persons based on individual risk profiles. The basic epidemiologic principles used to develop preventive services guidelines also provide the context in which to consider these general recommendations and their relevance to particular populations, communities, and patients. The following questions have been adapted from Woolf (1996) for clinicians to consider when prioritizing their assessment of risk factors that can increase a patient's potential for future disease. These questions can be applied to all clinical preventive services:

• How important is the target condition?

• How important is the risk factor?

• Is the preventive service effective?

• How accurately can the risk factor or target condition be identified?

Is the preventive service effective?

Table ii.1. US Preventive Services Task Force Rating (more...)

Table ii.1. US Preventive Services Task Force Rating System of Quality of Scientific Evidence

I:	Evidence obtained from at least one properly designed randomized controlled trial
II-1:	Evidence obtained from well-designed controlled trials without randomization
II-2:	Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group
II-3:	Evidence obtained from multiple time series with or without the intervention, or dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s)
III:	Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

From: US Preventive Services Task Force. Task Force Ratings. Guide to Clinical Preventive Services. Washington, DC: US Department of Health and Human Services; 1996:862.

The strongest quality of scientific evidence to evaluate the effects of preventive services comes from well designed intervention studies and observational studies that link risk modification with improved outcomes. Many major authorities rely on scientific evidence to guide their recommendations. The US Preventive Services Task Force (USPSTF), a body of preventive care experts convened by the US Public Health Service, has developed a system for rating the quality of scientific evidence used in its deliberations. The USPSTF rating system for grading scientific evidence is given in Table ii.1.

Even with good evidence that an intervention is efficacious (the intervention results in true effects under ideal conditions), the intervention may be less effective in a routine practice setting. Potential benefits of a preventive intervention must be weighed against potential harms, costs, and implementation considerations.

Recently, outcome measures have been developed incorporating quality-of-life measures that attempt to capture functional status and preference as outcomes of clinical interventions, including preventive services. Quality-adjusted life-years and disability-adjusted life-years are measures that attempt to standardize quantitative and qualitative information into summary measures that can be used to compare various conditions and outcomes for different prevention strategies.

Unfortunately, for most of medical practice, there is insufficient evidence that a service is or is not effective in improving process or outcome measures. Therefore, decision-makers at the policy and at the clinical level often need to consider factors other than scientific evidence in determining whether to offer a preventive service. Particularly for asymptomatic patients, thresholds for performing preventive services differ depending on their potential for harm in the absence of strong evidence of benefit. Frame and Carlson (1975) summarized the circumstances that must exist for screening tests to be useful:

• The condition must have a significant effect on the quality and quantity of life.

• Acceptable methods of treatment must be available.

• The condition must have an asymptomatic period during which detection and treatment significantly reduce morbidity or mortality.

• Treatment in the asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptoms appear.

• Tests that are acceptable to patients must be available, at a reasonable cost, to detect the condition in the asymptomatic period.

• The incidence of the condition must be sufficient to justify the cost of the screening.

"The clinician and patient should share decision-making." ²

Clinicians are responsible for providing patients with the best available information about potential benefits and harms of the preventive service, translating what is known and not known about the likelihood of various outcomes, and explaining the probable consequences of different decisions. Patient preferences, which are important in all clinical decisions, are paramount to consider when contemplating preventive services of uncertain benefit.

Counseling

The most prominent identifiable contributors to premature death in the United States are tobacco, diet and physical activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and illicit use of drugs (McGinnis 1993). Because behavioral choice is critical to most of these risk factors, the USPSTF has suggested that clinician counseling that leads to improved personal health practices may be more valuable to patients than conventional clinical activities such as diagnostic testing. The following are general guidelines to consider when providing clinical counseling:

Table ii.2. US Preventive Services Task Force Patient Education/Counseling (more...)

Table ii.2. US Preventive Services Task Force Patient Education/Counseling Strategies

1.	Frame the teaching to match the patient's perceptions.
2.	Fully inform patients of the purposes and expected effects of interventions and when to expect these effects.
3.	Suggest small changes rather than large ones.
4.	Be specific.
5.	It is sometimes easier to add new behaviors than to eliminate established behaviors.
6.	Link new behaviors to old behaviors.
7.	Use the power of the profession.
8.	Get explicit commitments from the patient.
9.	Use a combination of strategies.
10.	Involve office staff.
11.	Refer.
12.	Monitor progress through follow-up contact.

From: US Preventive Services Task Force. Patient Education/Counseling Strategies. In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap iv.

1. Counseling should be culturally appropriate. Present information and services in a style and format that are sensitive to the culture, values, and traditions of the patient and at a level of comprehension consistent with the age and learning skills of the patient. Use a dialect and terminology consistent with the patient's language and communication style.

2. Clinicians often cite lack of time and poor reimbursement for counseling as key barriers to patient counseling. Several measures may be taken to improve delivery of counseling.

   • Create an office or clinic environment that promotes preventive care.

   • Use a variety of resources to reinforce healthy behaviors. Display pamphlets, posters, and other materials conspicuously so that they are readily available. Patient education resources are listed at the end of each chapter of this book.

   • Use short patient questionnaires to quickly assess patient needs for counseling. Examples of such questionnaires are included in this book. Some are brief enough that they may be incorporated into patient intake questionnaires and history forms.

   • Focus interventions by assessing patients' readiness to change health-related behaviors. Research indicates that patients who are in the early stages of behavior change may benefit most from information but probably not from more intensive interventions. Patients who are ready to change may benefit from more directed, task-oriented counseling and behavior modification. Finally, those who have successfully changed behavior need support and follow-up.

   • Use a team approach to provide counseling.

   • Be familiar with community resources to which patients may be referred for types of counseling that cannot be provided in the practice.

   • Provide repeated messages to patients. Even brief interventions, such as simple advice to stop smoking, may have a beneficial effect.

3. The USPSTF describes 12 strategies for patient education and counseling with which clinicians should be familiar (Table ii.2).

Putting Prevention into Perspective

Preventive services impact the health status of individuals and populations. However, many health patterns in populations are related to an uneven distribution of societal resources. These resources encompass social, economic, and political advantages such as knowledge, money, and social connections that influence people's ability to avoid risks and to minimize the consequences of disease once it occurs. The broad influence of these resources is associated with multiple risk factors and disease outcomes. Interventions such as school-based curricula, community programs, and regulatory and legislative initiatives may be effective in addressing these more global issues. Being aware of community programs, encouraging patient participation and involvement, acting as a consultant for communities implementing programs or introducing legislation, and serving as an advocate to initiate and maintain effective community interventions are suggested roles for the interested clinician. An appreciation of the link between specific risk factors and general societal factors that influence health patterns may enhance the clinicians' contribution to prevention efforts.

Dr. William H. Welch,
Founder, Johns Hopkins School of Hygiene and Public Health

Summary

The concepts of prevention, as discussed in the earlier part of this section, are used to prioritize prevention strategies. These concepts include: measures of frequency and severity of the health condition; magnitude of risk associated with risk factors; accuracy of screening tests; and the strength of evidence in support and magnitude of an intervention's effectiveness. These concepts were used by some of the major authorities to direct their guideline process and to support their preventive services recommendations. These recommendations can assist the clinician in prioritizing prevention strategies for individual patients and practice population.

Preventive services for individuals may comprise a "core set" of preventive services that apply broadly to most individuals from the "average-risk" population. The average-risk approach used in the Clinician's Handbook stratifies individuals based on age and gender. In addition, a more targeted strategy can be offered to individuals at a relative "high-risk" based on their risk profile. The average-risk and high-risk strategies are complementary. Appendix A, which consists of risk tables and time lines for preventive care, illustrates the link between the two strategies. The purpose of and relationship between the risk tables and time lines are discussed further in the introduction to Appendix A.

Selected References

Key Concepts

The Role of Primary Prevention in Occupational and Environmental Health

Primary prevention of occupational diseases can be achieved only through the reduction or elimination of exposures to chemical, physical, or biological hazards. Clinicians must recognize these exposures to participate meaningfully in preventive efforts. As noted below, the basic occupational history is the cornerstone of preventive efforts and needs to be obtained from each patient. Reduction of exposures can be achieved through the hierarchy of controls, listed here in descending order of importance and desirability:

• 1

  Elimination of the exposure, usually through substitution of a different agent or process

• 2

  Engineering controls such as noise reduction or improved ventilation

• 3

  Administrative controls such as job rotation

• 4

  Personal Protective Equipment such as respirators or hearing protection

Clinicians should inquire about exposure reduction strategies used in their patients' workplaces. When appropriate, clinicians need to urge employers and employee representatives to adopt better control measures. Clinicians need to encourage their patients to wear personal protective equipment when warranted by job exposures that are not otherwise adequately controlled.

The initial step for achieving better recognition of occupational and environmental exposures is for all clinicians to take a basic occupational history from their patients. This history should include:

• the patient's past and current job titles and industries

• a description of past and current work duties

• any known exposures to chemical, physical, or biological hazards

• the presence of any symptoms in relation to work

Table iii.1. Essential Elements of the Occupational (more...)

Table iii.1. Essential Elements of the Occupational History and Questionnaire

Current or most recent work and exposure history

* Job title; type of industry; name of employer

* Year work started and year work finished (if not currently employed)

* Description of job (what is a typical workday), especially the parts of the job the patient believes may be potentially hazardous

* Current work hours and any shift changes

* Current exposures to dust, fumes, radiation, chemicals, biologic hazards, or physical hazards

* Protective equipment used (clothes, safety glasses, hearing protections, respirator, or gloves)

* Other employees at the workplace who have similar health problems

Earlier employment history

* Job chronology, working backward from the current or most recent jobs

The same information as above for each job previously held

Major types of exposure associated with clinical illness

* Gases

* Corrosive substances (acids, alkalis)

* Dyes and stains

* Dusts and powders

* Asbestos, other fibers

* Infectious agents

* Insecticides and pesticides

* Metals and metal fumes

* Organic dusts (cotton, wood, biologic matter)

* Plastics

* Solvents

* Petrochemicals (coal, tar, asphalt, petroleum distillates)

* Physical factors (noise, lifting, thermal stress, vibration, repetitive motion)

* Emotional factors (stress)

* Radiation (electromagnetic fields, x-ray radiation, ultraviolet radiation)

Source: Newman, LS. Occupational illness. N Engl J Med. 1995;333:1128-1134. Reproduced with permission of the Massachusetts Medical Society, copyright 1997. All rights reserved.

Because workplace exposures can have additive or synergistic effects with other exposures, clinicians also need to take into account patient activities outside of work. For example, workers in noisy occupations should be counseled about the additive effects of noise exposure from work and from such avocational pursuits as shooting and the use of power tools. Counseling patients about exacerbation of occupational illness through nonemployment-related activities is not a substitute for primary prevention focused at reducing work site exposures, but does represent an additional step that clinicians can take to reduce the overall burden of occupational disease among their patients.

In addition to potentially hazardous exposures, symptoms or health conditions that have a significant likelihood of being related to occupational exposures also require a more detailed occupational history. Several such sentinel health conditions are discussed below. They do not comprise a comprehensive listing of work-related disorders, but represent some of the disorders which have been targeted by NIOSH and other authorities. Other conditions besides the ones detailed below in which occupational exposures should be evaluated include peripheral neuropathy, encephalopathy, hepatitis, nephropathy, and cancers of the skin, lung, and bladder.

The Role of Secondary Prevention in Occupational and Environmental Health

There is little data regarding the effectiveness of secondary prevention activities in preventing occupational diseases. For a number of specific exposures, there is federal or state mandated screening; many employers also conduct regular screening for some employee groups. Screening procedures are dependent on the specific exposures incurred by workers. Examples of screening programs include:

• periodic chest X-rays for workers exposed to asbestos

• spirometry for workers exposed to agents known to cause asthma or COPD

• periodic blood or urine testing for lead and cadmium in exposed workers

• urine cytology for workers exposed to bladder carcinogens

Probably the most widespread periodic screening is regular audiometry for workers in noisy occupations. In theory, such a program can detect early hearing loss and help to prevent further noise-induced hearing loss. However, few data exist to document the effectiveness of this and other screening programs in practice.

In summary, health care providers need to be involved in the prevention of occupational and environmental illness. Although most clinicians will find themselves limited in their ability to influence primary preventive measures at their patients' work sites or other public settings, some degree of primary prevention for the patient, patient's co-workers, and patient's family may be achieved by attending to details of the occupational history and counseling accordingly based on the potential hazardous exposures revealed, and/or by notifying the appropriate agencies when potentially hazardous conditions are suspected to exist at an employment site. Secondary prevention of occupational and environmental illness through periodic screenings targeted toward a patient's specific work and exposure history can also involve the primary care provider, although the effectiveness of such screening measures needs to be further elucidated through appropriate research.

Sources for Further Information

Agency for Toxic Substances and Disease Registry (ATSDR), 1600 Clifton Rd, NE, Atlanta GA 30333. Telephone: (404)639-6000 (Division of Toxicology); (404)639-6206 (Division of Health Education). Internet address: http://atsdr1.atsdr.cdc.gov:8080/atsdrhome.html/. Part of the US Public Health Service (USPHS), the ATSDR provides toxicologic profiles and clinically useful case studies in environmental medicine.

American College of Occupational and Environmental Medicine (ACOEM), 55 W. Seegers Rd., Arlington Heights, IL 60005-3919. Telephone: (847)228-6850. Internet address: http://www.acoem.org/. The ACOEM lists physicians who are board-certified in occupational-environmental medicine and members of the college; it also conducts educational programs on occupational health, impairment, and the worker's compensation system.

Association of Occupational and Environmental Clinics (AOEC), 1010 Vermont Ave., Suite 513, Washington, DC 20005. Telephone: (202)347-4976. Internet address: http://152.3.65.120/oem/aoec.htm. The AOEC is a network of academically based occupational-environmental medicine clinics throughout the United States. Member clinics provide professional training, community education about toxic substances, exposure and risk assessment, clinical evaluation, and consultation. Clinicians can contact the AOEC for clinical referrals to assist in the diagnosis, management, therapy, and prevention of occupational disorders.

Environmental Protection Agency (EPA), 401 M Street, SW, Washington, DC 20460. Telephone: (202)260-5922. Internet address: http://www.epa.gov/epahome/. The EPA is an independent United States federal agency whose stated mission is to protect public health and to safeguard and improve the natural environment upon which human life depends. EPA's goals include ensuring that federal environmental laws are implemented and enforced fairly and effectively and that environmental protection is an integral consideration in US policy. Their web site provides numerous sources on a wide array of environmental and health-related issues.

National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention, Mail Stop F-29, 4770 Buford Highway, NE, Atlanta, GA 30341-3724. Telephone: (770)488-7030. Internet address: http://www.cdc.gov/nceh/ncehhome.htm. The NCEH is a division of the Department of Health and Human Services within the Centers for Disease Control and Prevention. Its mission is to promote health and quality of life by preventing and controlling disease, birth defects, disability, and death resulting from interactions between people and their environment. Some of its activities include: public health surveillance; applied research; dissemination of standards, guidelines, and recommendations; and technical and financial assistance to state and local health agencies.

National Institute of Environmental Health Sciences (NIEHS), P.O. Box 12233, Research Triangle Park, ND 27709. Telephone: (909)541-3345. Internet address: http://www.niehs.nih.gov/. A division of the Department of Health and Human Services within the National Institutes of Health, the NIEHS has as its stated mission to reduce the burden of human illness and dysfunction from environmental causes by understanding the interaction between environmental factors, individual susceptibility, and age. It engages in multidisciplinary biomedical research programs, prevention and intervention efforts, and communication strategies that encompass training, education, technology transfer, and community outreach.

National Institute for Occupational Safety and Health (NIOSH), Robert A. Taft Laboratories, 4676 Columbia Pkwy, Cincinnati, OH 45226-1998. Telephone: (800)356-4674. Internet address: http://www.cdc.gov/niosh/Homepage.html. A division of the Department of Health and Human Services within the Centers for Disease Control and Prevention, NIOSH provides information about substance toxicity and workplace hazards. The health-hazard evaluation program can investigate work sites at which physicians, employees, or employers suspect work-related illness and injury to have occurred. NIOSH offers training in occupational safety and health and funds continuing-medical-education courses.

Occupational Safety and Health Administration (OSHA), Department of Labor, 200 Constitution Ave., NW, Washington, DC 20210. Telephone: (202)219-8148 (general information); (202)219-9308 (compliance officer); (202)219-4667 (publications). Fax: (900) 555-3400 (OSHA FAX). Internet address: http://www.osha.gov/. OSHA sets US standards for health and safety in the workplace, investigates compliance, and issues citations. The publications-distribution office has articles about many occupational diseases. OSHA FAX is a fax-on-demand data-base service providing documents for a nominal telephone charge.

Selected References

Assess the Need for a New System

If preventive care services are being provided, assess how well your current system works. The services provided by some practices may not require significant changes. Determining the current status of a preventive care delivery system is important before implementing big changes. The best way to assess the need for a new system is to examine clinical records. A baseline chart audit can help determine if changes are needed and can also establish a baseline for demonstrating future improvements.

Assess Readiness to Make a Systems Change

As is true about any process that requires change, assessing readiness to change is beneficial. Two commonly cited barriers to implementing preventive care in clinical practice are clinicians' attitudes about prevention and problems within office systems (eg, lack of time, staff, and resources). The effect of these barriers can be minimized if they are viewed in the context of "readiness" for change. The following questions should be addressed as part of readiness assessment:

• 1

  Is prevention an important aspect of the care provided by this organization?

• 2

  Is increasing the quality and consistency of preventive services a priority?

• 3

  Are adequate resources available to incorporate preventive care services?

• 4

  Is change feasible (in terms of time, capacity, and cost)?

• 5

  Is the staff committed to changing the system?

• 6

  Will the administration and key stakeholders support change?

If the answer to the majority of the questions is "yes," implementation of a preventive care system can begin. If the majority of answers is "no," attention should focus on resolving the issues associated with the questions before attempting to make a change. Use of this simple questionnaire will save significant time and energy by identifying potential barriers that need to be addressed and potential facilitators of the process and allowing time to plan for successful implementation based on information collected.

Enlist Staff Support

Communication and teamwork are critical factors to successful implementation. Involving the staff is critical to ensuring that preventive services are a routine part of office practice. Include everyone who will be impacted by the changes in the planning and implementation process. Clearly define the role of all staff members and include them in the planning and problem-solving. You may discover untapped resources by encouraging staff members to creatively consider their roles in prevention delivery.

Designate a Facilitator

Recent research indicates that appointing a facilitator to introduce the tools and the process for change increases the chance of successful implementation. The responsibilities of a facilitator include:

• planning and setting goals for the implementation process

• coordinating implementation activities

• ensuring good communication between all involved staff members

• helping to establish a quality-improvement process to track progress

• giving feedback on performance and encouraging progress

• facilitating creative problem-solving

Perform a Chart Audit

1. Select a small sample of records from a specific patient population (eg, adults, children, males, females).

2. Determine which preventive care elements are to be assessed (eg, Pap testing, cholesterol screening, smoking counseling) and which guidelines to use. (Recommendations of Major Authorities in individual chapters.)

3. Use information from the health history forms, problem lists, or progress notes from the most recent visit to determine whether the client has had:

   • health-risk behavior assessed or identified in the past year

   • appropriate screening exams for age, sex, and risk in the appropriate time frame

   • documented counseling for health risk factors

4. Determine what percentage of the sample population received age- and gender-appropriate preventive care services in a timely manner.

Table iv.1. Sample Chart Audit Tool

Table iv.1. Sample Chart Audit Tool

Preventive Care Guideline Parameters	Documentation	Treatment or Education Provided
Cholesterol	Current date:	Counseling done	yes	no
Women q 5 yrs (45-65 y.o.)	_____________	Prescription given	yes	no
Men q 5 yrs (35-65 y.o.)	Date of last:	Referred to outside program/class	yes	no
	_____________
	Result:________
Smoking Behavior	Smoker ___	Counseling done	yes	no
Assess every visit	Non-Smoker ___	Prescription given	yes	no
	Not assessed ___	Referred to outside program/class	yes	no
DTaP/DTP Immunization	Age at last visit: _______________
Children <6 y.o.	Has child received:
5 doses	1st dose (2 mos)	yes	no	n/a
	2nd dose (4 mos)	yes	no	n/a
	3rd dose (6 mos)	yes	no	n/a
	4th dose (15-18 mos)	yes	no	n/a
	5th dose (4-6 yrs)	yes	no	n/a

Establish Preventive Care Protocols

Develop a protocol of preventive care that meets the particular needs of your specific practice and its patients. The Clinician's Handbook is designed to facilitate this process. Recommendations of major authorities, emphasizing age and periodicity for preventive screening, appear at the beginning of each chapter. By reviewing these recommendations, clinicians can decide which guidelines to select or can set their own standards based on current recommendations. A set of standards, even if minimal, needs to be identified and adopted as a policy. Concentrate efforts on selecting preventive services that truly can be provided in light of limited time, available staff, and other resources. Periodically examine the selected standards, updating them as needed based on current research and the changing needs of the patient population.

Once policy is set, familiarize the entire staff with the criteria and incorporate the standards into a preventive care flow sheet for tracking purposes. The flow sheet permits quick determination of a particular patient's need for preventive care services and allows the provider to deliver preventive care at all patient visits. If time limitations prevent delivery of such services during a visit, the patient may be informed of what care is needed, and a plan to obtain it can be established (eg, referral, follow-up appointment). After protocols for preventive care service are identified, the next step is to establish systems that ensure consistent, efficient delivery of these services.

Analyze Service Delivery and Patient Flow

The physical layout of a practice and the direction of patient flow can significantly influence the delivery of preventive services. Effective organization of clinic systems and patient flow, along with utilization of all staff members' skills, can improve delivery of services. Analyzing patient flow patterns can be as simple as mapping a patient's path through the office on paper, thus identifying areas where health education messages can be provided or reinforced. The analysis should consider who the patient encounters and what is done at each step. Such an analysis can provide a basis upon which clinic efficiency can be improved.

Use Basic Tools

The use of simple office tools can improve the delivery of preventive health care. The following tools are components of the Put Prevention Into Practice initiative. Many of the tools can be altered to meet individual specifications.

Use other helpful tools

Other useful office tools include chart reminders, behavioral change contracts, health risk appraisals, and electronic medical records.

• Chart reminders alert clinicians to the specific preventive care needs of individual patients

• Prevention prescriptions and behavioral change contracts facilitate behavior change by clearly defining the patient's and the clinician's expectations. In addition, a written plan of action, based on an agreement between the patient and the clinician, emphasizes the patient's ability and responsibility to contribute to his/Her own disease prevention and health promotion. Follow-up telephone calls to determine progress are also helpful for encouraging compliance with health-related recommendations.

• Health risk appraisals can ensure that clients are questioned about all possible risk factors, increase patient awareness of health risks, and provide the clinician with a second source of information other than the patient interview. However, health risk appraisals should be done in the proper context and with an appropriate amount of time allotted for follow-up counseling to ensure that patients understand the implications of such assessments and the steps to be taken in addressing the various risk factors revealed.

• Computerized tracking and prompting systems are commercially available. Some features to look for include: the ability to prompt for preventive services, customize preventive care schedules, send out patient reminders, and determine a practice's performance.

Delegate Tasks and Staff Roles

The most efficient approach to implementing prevention care services is to delegate and share responsibilities among as many staff members as possible. Tasks, such as reviewing charts, administering immunizations, counseling patients, and screening, can be successfully provided by members of the office staff. Another important role for staff is facilitating patients' access to community resources, such as local mammography centers or smoking cessation support groups. Appropriate standards for assuring patient privacy must be maintained, regardless of the number of staff involved in a patient's care.

Perform Follow-up Evaluations

Follow-up chart audits will assist in evaluating both the consistency with which tools are used and the impact of tools on service delivery. Use this information as feedback in quality improvement activities in order to modify your service delivery plan.

In Summary

• Assess your current preventive service delivery system

• Elicit input from entire staff

• Establish a preventive care protocol

• Choose tools that are suited to your setting and system

• Personalize or adapt tools using input from all staff members involved in the process

• Ensure that all staff members understand the intent and purpose of the tools

• Distribute responsibilities across the entire staff

• Perform follow-up evaluations

Clinical Scenario

The following is one example of a systematic approach to the delivery of preventive care services:

Patient Resources

• Personal Health Guide or Child Health Guide. AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907 (800-358-9295). Internet address: http://www.ahcpr.gov/ppip/

Provider Resources

• Copies of the "Health Risk Profile," a health risk appraisal used by the Texas Department of Health, can be obtained by calling or writing the Adult Health Program, Bureau of Chronic Disease Prevention and Control, Texas Department of Health, 1100 W 49th Street, Austin, TX 78756; (512)458-7534.

• The Clinician's Handbook of Preventive Services, 2nd Edition; Waiting Room Poster; and Preventive Care Timeline Posters. AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907 (800-358-9295). Internet address: http://www.ahcpr.gov/ppip/

• Patient Reminder Postcards and Preventive Care Flowsheets. Internet address: http://www.ahcpr.gov/ppip/

Selected References

Recommendations of Major Authorities

• American Academy of Family Physicians (AAFP) and US Preventive Services Task Force (USPSTF) --

• Hemoglobin concentration screening should be performed between 6 and 12 months of age for infants in high-risk groups. The AAFP and USPSTF define high-risk groups as infants living in poverty; African Americans; American Indians; Alaska Natives; immigrants from developing countries; preterm and low-birth-weight infants; and infants whose principal intake is unfortified cow's milk.

• American Academy of Pediatrics and Bright Futures --

• Hemoglobin or hematocrit should be measured once during infancy (between 1 and 9 months) for all children and once during adolescence for all menstruating teenagers. Bright Futures recommends hemoglobin and hematocrit screening at age 6 months if certification for Women, Infants, and Children (WIC) is needed. Bright Futures also recommends annual hemoglobin and hematocrit screening for adolescent females (ages 11 to 21 years) if any of the following risk factors are present: moderate to heavy menses, chronic weight loss, nutritional deficit, or athletic activity.

• Canadian Task Force on the Periodic Health Examination --

• There is conflicting and insufficient evidence to recommend for or against inclusion or exclusion of routine hemoglobin measurements at 6 to 12 months of age in normal infants. However, there is fair evidence to recommend a routine measurement for high-risk infants (infants of families of low socioeconomic status, Chinese or aboriginal ethnic origin, low birth weight [<2500 grams], or fed only whole cow's milk during the first year of life).

Basics of Anemia Screening

Table 1.1. Hemoglobin and Hematocrit Cut Points for (more...)

Table 1.1. Hemoglobin and Hematocrit Cut Points for Anemia in Children 1 Year of Age or Older

Gender	Age, years	Hemoglobin, g/dL	Hematocrit, %
Both Genders	1-1.9	11.0	33.0
	2-4.9	11.2	34.0
	5-7.9	11.4	34.5
	8-11.9	11.6	35.0
Female	12-14.9	11.8	35.5
	15-17.9	12.0	36.0
	> 18	12.0	36.0
Male	12-14.9	12.3	37.0
	15-17.9	12.6	38.0
	> 18	13.6	41.0

From: Centers for Disease Control. CDC criteria for anemia in children and childbearing-aged women. MMWR. 1989;38:400-404.

• 1

  Three basic methods are used to determine hemoglobin levels and hematocrits: venipuncture with analysis by automated cell counter, capillary sampling with analysis by hemoglobinometer, or capillary sampling with microhematocrit analysis by centrifuge. ( NOTE: The microhematocrit method yields slightly higher values and is somewhat less sensitive than the automated cell counter method. The capillary methods may provide less reliable results because of greater variation in sampling technique than venipuncture.)

• 2

  In general, do not screen for anemia in a child who has had fever or infection during the preceding 2 to 3 weeks.

• 3

  If the capillary method is used, observe the following principles of collection:

  • In infants, the best sites are the medial and lateral aspects of the plantar surface of the heel. In older children, the best sites are the medial and lateral aspects of the pulp of a finger; make the puncture perpendicular to the skin and across the dermal ridges.

  • To increase blood flow and accuracy of the test, make sure the heel or finger is warm.

  • Before puncture, clean the site with an antiseptic and allow it to dry.

  • Use sterile, disposable lancets with tips less than 2.5 mm long for infants aged 6 months or younger. Lancets with longer tips (up to 5 mm) may be used for older children.

  • Wipe away the first two to three drops of blood, which contain tissue fluids, with a dry gauze.

  • Do not milk or squeeze the puncture site, because this may cause hemolysis and admixture of tissue fluids with the specimen.

• 4
  Table 1.1 shows hemoglobin and hematocrit cut points for the diagnosis of anemia in children, which are derived from the Second National Health and Nutrition Examination Survey (NHANES II) conducted from 1976 through 1980. Although NHANES II did not provide data for children younger than 1 year of age, the cut points for 6-month-old children determined by extrapolation are only a fraction of a unit less than those for 1-year-old children.

Table 27.1. Adjustments for Hemoglobin and Hematocrit (more...)

Table 27.1. Adjustments for Hemoglobin and Hematocrit Cut Points for Anemia in Smokers

Smoking Status	Hb (g/dL)	Hct (%)
Nonsmoker	0.0	0.0
Smoker (all)	+0.3	+1.0
0.5-<1.0 pack per day	+0.3	+1.0
1.0-2.0 packs per day	+0.5	+1.5
>2.0 packs per day	+0.7	+2.0

From: Centers for Disease Control. Reference criteria for anemia screening. MMWR. 1989;38:400-404.

Table 27.2. Altitude Adjustments for Hemoglobin and Hematocrit (more...)

Table 27.2. Altitude Adjustments for Hemoglobin and Hematocrit Cut Points for Anemia

Altitude (Ft)	Hb (g/dL)	Hct (%)
<3000	0.0	0.0
3000-3999	+0.2	+0.5
4000-4999	+0.3	+1.0
5000-5999	+0.5	+1.5
6000-6999	+0.7	+2.0
7000-7999	+1.0	+3.0
8000-8999	+1.3	+4.0
9000-9999	+1.6	+5.0
> 10,000	+2.0	+6.0

From: Centers for Disease Control. Reference criteria for anemia screening. MMWR. 1989;38:400-404.

• Cut points for anemia should be adjusted upward for children and adolescents who live at high altitudes or smoke (See Tables 27.1 and 27.2).

Patient Resources

• Sickle Cell Anemia (New Hope for People With). FDA Office of Consumer Affairs. HFE 88 Rm 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

Recommendations of Major Authorities

• American Academy of Pediatrics and Bright Futures --

• Blood pressure should be measured in children at 3, 4, 5, 6, and 8 years of age, and annually beginning at 10 years of age.

• American Medical Association --

• During adolescence, blood pressure should be measured annually.

• National Heart, Lung, and Blood Institute Task Force on Blood Pressure Control in Children --

• Blood pressure should be measured annually beginning at 3 years of age.

• US Preventive Services Task Force --

• Measurement of blood pressure during office visits is recommended for children and adolescents. Beginning age and periodicity are not specified. This recommendation is based on the proven benefits of early detection of treatable causes of secondary hypertension.

Basics of Blood Pressure Screening

Figure 2.1 Determination of proper cuff size: step (more...)

    Figure 2.1 Determination of proper cuff size: step 1

From: National Institutes of Health, National Heart, Lung, and Blood Institute. Update on the Task Force Report (1987) on High Blood Pressure in Children and Adolescents: a Working Group Report From the National High Blood Pressure Education Program. Bethesda, Md: National Institutes of Health; 1996. NIH Publication No. 96-3790.

Figure 2.2 Determination of proper cuff size: step (more...)

   Figure 2.2 Determination of proper cuff size: step 2

The cuff bladder should cover 80% to 100% of the circumference of the arm.

From: National Institutes of Health, National Heart, Lung, and Blood Institute. Update on the Task Force Report (1987) on High Blood Pressure in Children and Adolescents: a Working Group Report From the National High Blood Pressure Education Program. Bethesda, Md: National Institutes of Health; 1996. NIH Publication No. 96-3790.

• 1

  Advise patients, especially adolescents, not to smoke or otherwise use tobacco or ingest caffeine, including cola products, for at least 30 minutes before the measurement.

• 2

  Perform the measurement in a controlled area and after 3 to 5 minutes of rest with the child in the seated position. The right arm should be fully exposed and the cubital fossa supported at heart level.

• 3

  The mercury column sphygmomanometer is preferred over the calibrated aneroid manometer.

• 4
  Choose an appropriately sized cuff. The bladder width should be 40% of the arm circumference measured at midpoint between the olecranon and acromion (Figure 2.1). This usually translates into a cuff that covers 80% to 100% of the circumference of the arm without impinging on the antecubital fossa (Figure 2.2). Use of a cuff that is too small will result in falsely elevated measurements. Use of a cuff that is too large will result in falsely low measurements.

• 5

  Place the bell of the stethoscope lightly on the antecubital fossa over the brachial artery. Applying too much pressure may lead to inaccurate measurements. Rapidly inflate the cuff to approximately 20 mm Hg above the point at which the pulse is no longer audible. Then deflate the cuff at a rate of 2 to 3 mm Hg per second. The onset of a tapping sound (the first Korotkoff sound) is used to determine systolic blood pressure, and the
  disappearance of Korotkoff sounds determines the diastolic blood pressure.

• 6

  Documentation of the patient's position, limb used, and cuff size may be required for consistency of repeated blood pressure measurements.

• 7

  The systolic and diastolic blood pressures corresponding to the 90th and 95th percentiles according to gender, age, and percentile of height are shown in Tables 2.1 and 2.2. The height percentile is determined from the standard growth charts. A child is considered normotensive if the blood pressure is below the 90th percentile. Blood pressures in the 90th through 94th percentiles are considered high normal, and those at or above the 95th percentile are considered elevated.

• 8

  Standards for systolic and diastolic BP for infants younger than 1 year are available. In children of this age, systolic BP is used to define hypertension.

Patient Resources

• Eat Right to Lower Your High Blood Pressure; High Blood Pressure: Treat it for Life; Check Your Healthy Heart IQ; High Blood Pressure and What You Can Do About It; Six Good Reasons to Control Your High Blood Pressure. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Provider Resources

• The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

• Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617. (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

Recommendations of Major Authorities

• American Academy of Family Physicians and US Preventive Services Task Force --

• Measure height and weight periodically.

• American Academy of Pediatrics and Bright Futures --

• Height, weight, and head circumference should be measured at birth, at 2 to 4 weeks, and at 1, 2, 4, 6, 9, 12, 15, 18, and 24 months of age. Height and weight should also be measured at 3, 4, 5, 6, and 8 years of age, and annually beginning at 10 years of age. Bright Futures also recommends scoliosis and sexual maturity ratings as part of a complete physical exam for adolescents (ages 10 to 21).

• American Medical Association --

• All adolescents should be screened annually for eating disorders and obesity by measuring weight and stature and by asking about body image and dieting patterns.

• Canadian Task Force on the Periodic Health Examination --

• There is fair evidence for the inclusion of serial measurements of height, weight, and head circumference in the periodic health examination of infants and children.

Basics of Body Measurement

• 1

  To ensure accurate measurements of infants and young children, use an assistant, and if necessary, take measurements more than once, particularly when children are very young or uncooperative.

• 2

  Determine the height of children younger than 2 years of age by measuring their length while they are recumbent. Use a measuring board with a stationary headboard and a sliding vertical foot piece, if one is available. Otherwise, use a horizontal surface, a stationary vertical surface, a movable vertical-surfaced object, and a measuring tape. The general principles for taking the measurement are the same, regardless of the apparatus used:

  • Have the child lie flat on his/her back along the center of the board or examining table with all parts of the body touching the board

  • Position the child's head against the headboard, with eyes looking upward

  • Fully extend the hips and knees

  • Move the foot piece until it rests firmly against the child's heels with feet flat

  • Record measurements to the nearest l/8 inch (0.3 cm)

• 3

  Obtain the standing height of children beginning at 2 years of age. Use of a stadiometer, an instrument specifically designed for height measurements, is preferred. However, accurate measurements may be obtained by using a graduated ruler or tape attached to a wall and placing a flat-surfaced object horizontally on top of the child's head. Height-measuring rods that are attached to weight scales tend to become inaccurate with use; in general, do not use them unless they are checked frequently for accuracy. The general principles for taking the measurement are as follows:

  • Have the child remove his/her shoes before being measured

  • Have the child stand with the head, shoulder blades, buttocks, and heels touching the wall

  • Make sure the knees are straight and the feet are flat on the floor

  • Ask the child to look straight ahead

  • Lower the flat-surfaced object (or movable headboard) until it touches the crown of the child's head, compressing the hair

• 4

  Use a balance-beam or electronic scale to weigh infants and children. Spring-type scales are not sufficiently accurate for this use. Check the scale before each use to ensure that it is zeroed. The infant or child should wear only a dry diaper or light undergarment while being weighed. Check scales regularly for accuracy, and make an effort to use the same scale on subsequent visits.

• 5

  Measure a child's head circumference by extending a nonstretchable measuring tape (disposable paper tapes are better than cloth) around the most prominent part of the occiput to the middle of the forehead. Tighten the tape to compress the hair.

• 6

  Plot measurements on age- and gender-specific National Center for Health Statistics (NCHS) growth charts for comparison with NCHS reference values. Recording serial measurements over time provides an accurate record of growth; large or sustained deviations signal a potential problem. Interpret measurements within the context of the individual child's family and growth history. If a child's measurements fall within the 10th through 25th percentile range or the 75th through 90th percentile range, assess past growth patterns and genetic and environmental factors to determine if follow-up is necessary. Recheck measurements that are below the 5th percentile or above the 95th percentile. If these measurements are confirmed, further medical evaluations may be needed.

• NOTE: Disagreement exists about the validity of using a single set of reference standards for all subpopulations of children in the United States. Although measurements should be assessed within the context of genetic and environmental factors, most authorities support use of the NCHS reference standards. Exceptions include children with genetic conditions such as Down's, Turner's, Marfan's, and fragile X syndromes, achondroplasia, sickle cell disease, and neurofibromatosis. Separate growth charts have been developed for some of these conditions. Growth charts also have been developed for use with infants born prematurely (See Selected References).

• 7

  Some authorities, including the American Medical Association, recommend using body mass index (BMI) calculation to assess the weight of adolescents. ( See chapter 29 for information about the calculation and use of BMI.) However, because of the lack of standardized recommended values to assess BMI in adolescents, growth charts are the preferred method for assessing their weight.

Patient Resources

• Health Diary: Myself, My Baby. This booklet contains information about pregnancy and early childhood development. To order, contact the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325.

• The Child Health Record. This material includes growth charts and other record forms. Rx for Good Health Growth Chart. This 8-1/2" x 33" poster contains information on growth for children from birth to 10 years of age. Your Child's Growth: Developmental Milestones. Presents guidelines to gauge normal stages of development in children 3 months to 6 years of age. To order, contact the American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

• Your Growing Baby. This pamphlet includes information on growth. To order, contact Ross Laboratories, Dept L-1120, Columbus, OH 43260; (800)227-5767.

Provider Resources

Growth Charts: Mead Johnson Nutritional Division. For the name and telephone number of an area representative, call: (812)429-5000.

Growth Charts: Ross Laboratories, Dept L-1120, Columbus, OH 43260; (800)227-5767.

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

Recommendations of Major Authorities

• Canadian Task Force on the Periodic Health Examination --

• There is insufficient evidence to recommend for or against routine cholesterol screening of children and adolescents. Individual clinical judgment should be exercised to determine the need for screening.

• National Heart, Lung, and Blood Institute's National Cholesterol Education Program Expert Panel on Blood Cholesterol Levels in Children and Adolescents; American Academy of Pediatrics; Bright Futures; and American Medical Association --

• Universal screening of children and adolescents for cholesterol levels is not recommended. Children older than 2 years of age who have a parent with a total cholesterol level of 240 mg/dL or greater should be screened for both total serum cholesterol and HDL cholesterol levels. Children (older than age 2 years) and adolescents with a family history of premature cardiovascular disease (ie, a parent or grandparent who, at age 55 years or younger, had a documented myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death, or underwent diagnostic coronary arteriography and was found to have atherosclerosis, or underwent coronary artery bypass surgery or angioplasty) should be screened for lipoprotein levels after a 12-hour fast. In children whose family history is not obtainable, screening may be indicated, especially if risk factors for coronary artery disease are present (eg, high blood pressure, smoking, overweight, or excessive consumption of saturated fat and cholesterol).

• US Preventive Services Task Force --

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

Basics of Cholesterol Screening

Figure 4.1 Assessment and Follow-up of Total Cholesterol Measurements (more...)

   Figure 4.1 Assessment and Follow-up of Total Cholesterol Measurements

From: National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 1991. US Department of Health and Human Services publication NIH 91-2732.

Figure 4.2 Assessment and Follow-up of Lipoprotein (more...)

   Figure 4.2 Assessment and Follow-up of Lipoprotein Analysis

From: National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 1991. US Department of Health and Human Services publication NIH 91-2732.

• 1

  Children may eat a normal diet before total cholesterol screening. Children undergoing lipoprotein analysis should fast, ingesting nothing but water for 12 hours before the blood sample is taken.

• 2

  Do not screen children who are acutely ill, including those with infectious diseases. Do not screen pregnant adolescents.

• 3

  A venous sample obtained with the patient in the sitting position yields the most accurate results; recumbency lowers lipid levels. Documentation of position is important when comparing follow-up measurements.

• 4

  Take into account the cholesterol-raising effect of certain medications, including corticosteroids, isotretinoin, thiazides, anticonvulsants, beta blockers, and certain anabolic steroids. If a patient meeting screening criteria takes one of these drugs, a potential strategy is to perform the test, and if the result is elevated, consider the magnitude of the elevation and the ease and safety of suspending medication for retesting in the absence of drugs.

• 5

  The laboratory used for analysis should participate in a program of external standardization to ensure compliance with standards of precision and accuracy. The National Cholesterol Education Program's Laboratory Standardization Panel recommends that bias not exceed ±5% from the true value and that the intralaboratory coefficient of variation not exceed ±5%.

• 6
  The National Cholesterol Education Program has recommended protocols for assessing cholesterol levels in the screening of children (Figures 4.1 and 4.2).

Patient Resources

• Step by Step: Eating to Lower Your High Blood Cholesterol; So You Have High Blood Cholesterol; Parents Guide: Cholesterol in Children -- Healthy Eating is a Family Affair. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

• Growing up Healthy: Fat, Cholesterol, and More. This brochure provides health and eating guidelines for children 2 to 6 years old. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016.

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

Recommendations of Major Authorities

• American Academy of Pediatrics and Bright Futures --

• Behavioral assessment should be a routine part of health supervision throughout childhood and adolescence. Adolescents and their parents should be asked about suicidal thoughts or threats.

• American Medical Association --

• Because of the pervasive nature of mood disorders, all adolescents should be screened annually for signs and symptoms of recurrent or severe depression. Special attention should be directed at adolescents who are performing poorly in school, who use alcohol or drugs, or who have had a deteriorating relationship with parents and peers. Physicians should also screen adolescents annually to identify those at risk for suicide. Parents or other adult care-givers of adolescents with suicidal intent should be counseled to remove weapons and potentially lethal medications from the home.

• Canadian Task Force on the Periodic Health Examination --

• Routine screening for depression is not recommended, but physicians should maintain a high level of clinical sensitivity. Evaluation of suicide risk is recommended for persons at high risk: those with a history of psychiatric illness, depression, or drug and alcohol abuse, especially those living in isolation; those with chronic terminal illness; Native and Aboriginal people, especially young males; those with a family history of suicide; and first-generation immigrant women.

• US Preventive Services Task Force --

• There is insufficient evidence to recommend for or against performance of routine screening tests for depression in asymptomatic patients in the primary care setting. Clinicians should, however, maintain an especially high index of suspicion for depressive symptoms in adolescents and young adults, persons with a family or personal history of depression, those with chronic illness, those who perceive or have experienced a recent loss, and those with sleep disorders, chronic pain, or multiple unexplained somatic complaints. There is also insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in asymptomatic persons. Clinicians should be alert to evidence of suicidal ideation when the history reveals risk factors for suicide, such as depression, alcohol or other drug abuse, other psychiatric disorders, prior attempted suicide, recent divorce, separation, unemployment, and recent bereavement.

Basics of Screening for Depression and Suicide

Depression

Table 5.1. Symptoms of Major Depression

Table 5.1. Symptoms of Major Depression

Depressed mood (or irritable mood in children and adolescents)

Markedly diminished interest or pleasure in activities

Significant weight loss or gain when not dieting, or decrease/increase in appetite (in children, consider failure to make expected weight gains), insomnia or hypersomnia

Psychomotor agitation or retardation

Fatigue or loss of energy, indecisiveness

Feelings of worthlessness or excessive or inappropriate guilt

Diminished ability to think or concentrate, problems at school

Recurrent thoughts of death, recurrent suicidal ideation

Adapted from: American Psychiatric Association, Committee on Nomenclature. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, DC: American Psychiatric Association; 1987. Reproduced by permission of the publisher; copyright © 1987.

• 1
  Become familiar with the risk factors for and symptoms of depression (See Recommendations of Major Authorities and Table 5.1).

• 2

  Identify any risk factors or symptoms indicating the need for in-depth evaluation by a mental health professional.

Patient Resources

• Facts for Families: The Depressed Child; Teen Suicide; Children and Grief; Manic Depressive Illness in Teens. American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave, NW, Washington, DC 20016-3007; (202)966-7300; E-mail: 74003.264@compuserve.com

• Surviving: Coping with Adolescent Depression and Suicide; Caring for Your Adolescent: Age 12 to 21; Divorce and Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60000-0927; (800)443-9016. Internet address: http://www.aap.org

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

• The Classification of Child and Adolescent Mental Diagnosis in Primary Care. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

• Prevention in Child and Adolescent Psychiatry; Prevention of Mental Disorders, Alcohol and Other Drug Use in Children and Adolescents. American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave, NW, Washington, DC 20016-3007; (202)966-7300; E-mail 74003.264@compuserve.com

• National Institute of Mental Health, 5600 Fishers Ln, Room 14C-02, Rockville, MD 20857; (800)421-4211. Internet address: http://www.nimh.nih.gov

• National Mental Health Association, 1021 Prince St, Alexandria, VA 22314; (800)969-6642.

Selected References

Recommendations of Major Authorities

Basics of Hearing Screening

1. Assess the family and medical history of every child for risk factors for hearing impairment.

2. Ask parents about the auditory responsiveness and speech and language development of young children. Any parental reports of impairment should be seriously evaluated.

3. In infants, assessment of hearing by observational techniques is very imprecise. Consider referring all infants and young children with suspected hearing difficulties to an audiologist.

4. When performing physical examinations, remain alert for structural defects of the ear, head, and neck. Remain alert for abnormalities of the ear canal (inflammation, cerumen impaction, tumors, or foreign bodies) and the eardrum (perforation, retraction, or evidence of effusion).

5. Children as young as 6 months of age, depending on how cooperative they are, may be screened by pure-tone audiometry. Two screening methods are suggested as the most appropriate tools for children who are functioning at 6 months to 3 years developmental age: visual reinforcement audiometry (VRA) and conditioned play audiometry (CPA). For children from approximately 6 months through 2 years of age, VRA is the recognized method of choice. As children mature beyond their second birthday, CPA may be attempted. For those children who can be conditioned for VRA, screen using earphones (conventional or insert), with 1000, 2000, and 4000 Hz tones at 30 dB HL. For those children who can be conditioned for play audiometry, screen using earphones (conventional or insert), with 1000, 2000, and 4000 Hz tones at 20 dB HL. Hand-held audiometers are of unproven effectiveness in screening children.

After 6 months of age, any child may be screened for middle ear dysfunction using tympanometry. Perform tympanometry with a low frequency (220, 226 Hz) probe tone and a positive to negative air pressure sweep. Middle ear pressure peaks between -150 mmhos and +150 mmhos are considered normal. Patients with pressure peaks outside this range or lack of any identifiable pressure peak should be referred for otologic follow-up.

6. Repeat screening to substantiate audiometric evidence of hearing impairment. Remove and reposition the earphones and carefully repeat the instructions to the child to assure proper understanding and attention to the test. Referral to a qualified specialist (ie, audiologist, otolaryngologist) is recommended for confirmation and work-up of hearing impairment.

Patient Resources

• Is My Baby's Hearing Normal? American Academy of Otolaryngology -- Head and Neck Surgery, Order Department, 1 Prince St, Alexandria, VA 22314; (703)836-4444.

• Answers to Questions About Otitis Media, Hearing, and Language Development; How Does Your Child Hear and Talk?; Recognizing Communication Disorders. American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852. For general information, call: (800)638-8255. To order, call: (301)897-5700, ext 218; Internet address: http://www.asha.org

• Middle Ear Fluid in Young Children: Parent Guide; Ear Infection in Children. The American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

National Institute on Deafness and Other Communication Disorders. Internet address: http://www.nih.gov/nidcd

American Speech-Language-Hearing Association.
Internet address: http://www.asha.org

Selected References

Recommendations of Major Authorities

• American Academy of Family Physicians --

• Determination of lead levels is recommended for infants at 12 months of age who live in communities in which the prevalence of lead levels requiring intervention is high or undefined; live in or frequently visit a home built before 1950 with dilapidated paint or with recent or ongoing renovation or remodeling; have close contact with a person who has an elevated lead level; live near lead industry or heavy traffic; live with someone whose job or hobby involves lead exposure; use lead-based pottery; or take traditional remedies that contain lead.

• American Academy of Pediatrics --

• Pediatric-care providers should increase their efforts to screen children for lead exposure. Blood lead screening should be a part of routine health supervision of children and can best be addressed by increasing children's access to health care. Because lead is ubiquitous in the US environment, this screening should occur at about 9 to 12 months of age and, if possible, again at about 24 months of age. The Centers for Disease Control and Prevention has raised the possibility that there may be low-risk communities that do not require screening, but no explicit guidance has been developed for determining a community's risk. As more data are collected, it may become evident that there are locales where selective screening of children is more appropriate than routine screening.

• Canadian Task Force on the Periodic Health Examination --

• There is insufficient evidence to recommend for or against universal lead screening of children to detect mild or moderate lead exposure. Screening is recommended for children at high risk: children who live in or regularly visit homes built before 1960 with deteriorating paint or recent, ongoing, or planned renovation or remodeling; who have a sibling, housemate, or playmate known to have had lead poisoning; who live with an adult whose job or hobby involves exposure to lead; or who live near lead industries or busy highways.

Table 7.1. Recommended Questions for Assessing Lead (more...)

Table 7.1. Recommended Questions for Assessing Lead Exposure Risk

Does your child live in or regularly visit a house built before 1950? (Including daycare centers, preschools, homes of baby-sitters or relatives)

Does your child live in or regularly visit a house built before 1978 (the year lead-based paint was banned for residential use) with recent, ongoing, or planned renovation or remodeling?

Does your child have a sibling, housemate, or playmate being followed or treated for lead poisoning (blood lead level 15 µg/dL)?

Adapted from: Centers for Disease Control and Prevention. Screening Young Children for Lead Poisoning. Expected date of publication: 1997.

• Centers for Disease Control and Prevention (CDC) --

• (NOTE: Revised guidelines are expected to be published in the fall of 1997. Revisions to the CDC guidelines were being considered at the time of this publication. Please consult Provider Resources below for information on how to obtain current recommendations.) CDC's draft guidelines recommend that state and local health officials make screening recommendations that are based on an assessment of local lead exposure sources and on blood lead screening data. Where risk is widespread, universal screening should be recommended; where risk is less or confined to small pockets, targeted screening should be recommended. Screening should be focused on children at 12 and at 24 months of age. A targeted screening recommendation would call for screening of children who meet criteria established by the health department. Likely criteria include: residence in a high-risk zip code or neighborhood, poverty, or response to a personal-risk questionnaire that is tailored to local conditions. An example of one such basic questionnaire is presented in Table 7.1. Health departments will be expected to tailor the questionnaire to make it appropriate to local sources of exposure.

• US Preventive Services Task Force --

• Screening for elevated lead levels by measuring blood lead at least once at about 12 months of age is recommended for all children at increased risk of lead exposure. All children with identifiable risk factors should be screened, as should children living in communities in which the prevalence of blood lead levels requiring individual intervention, including chelation therapy or residential lead hazard control, is high or undefined. If capillary blood is used, elevated lead levels should be confirmed by measurement of venous blood lead. The optimal frequency of screening for lead exposure in children, or for repeated testing of children previously found to have elevated blood lead levels, is unknown and is left to clinical discretion; consideration should be given to the degree of elevation, the interventions provided, and the natural history of lead exposure, including the typical peak in lead levels at 18 to 24 months of age. In communities where the prevalence of blood lead levels requiring individual intervention is low, a strategy of targeted screening, possibly using locale-specific questionnaires of known and acceptable sensitivity and specificity, can be used to identify high-risk children who should have blood lead testing. There is currently insufficient evidence to recommend an exact population prevalence below which targeted screening can be substituted for universal screening. Clinicians should seek guidance from their local or state health department.

Basics of Lead Screening

Table 7.2. Recommendations for Minimizing the Contamination (more...)

Table 7.2. Recommendations for Minimizing the Contamination of Capillary Blood Samples Obtained by Finger Stick

Personnel who collect specimens should be well trained in and completely familiar with the collection procedure and observe universal precautions.

Puncturing the fingers of infants younger than 1 year of age is not recommended. The heel is a more suitable site for these children.

If examination gloves are coated with powder, rinse them with tap water.

Thoroughly wash the child's hands or heel with soap and water, and then dry with a clean, low-lint towel.

Once the finger or heel to be punctured is washed, clean it with alcohol; do not allow it to come into contact with any surface, including the child's other fingers.

Although its effectiveness in reducing contamination is under study, silicone spray can be used to form a protective layer between the skin and blood droplets.

Use sterile gauze or a cotton ball to wipe off the first droplet of blood, which contains tissue fluids.

Do not collect blood that has run down the finger or onto the fingernail.

Avoid contact between the skin and the collection container.

Adapted from: Centers for Disease Control. Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control. Atlanta, GA: Centers for Disease Control; 1991.

Table 7.3. CDC Recommendations for Follow-up of Blood (more...)

Table 7.3. CDC Recommendations for Follow-up of Blood Lead Measurements

Blood Lead Level (BLL) (µg/dL)	Action
<9	Reassess or rescreen in 1 year. No additional action necessary unless exposure sources change
10-14	Family lead education
	Follow-up testing
	Social services, if necessary
15-19	Family lead education
	Follow-up testing
	Social services, if necessary
	If BLLs persist (ie, 2 venous BLLs in this range at least 3 months apart) or worsen, proceed according to actions for BLLs 20-44
20-44	Coordination of care (case-management)
	Clinical management *
	Environmental investigation
	Lead-hazard reduction
45-69	Within 48 hours, begin coordination of care (case management), clinical management*, environmental investigation, lead hazard reduction
>70	Hospitalize child and begin medical treatment immediately. Begin coordination of care (case management), clinical management*, environmental investigation and lead-hazard reduction immediately

* Refer to CDC source publication, Screening Young Children for Lead Poisoning, for description of clinical management.

Adapted from: Centers for Disease Control. Screening Young Children for Lead Poisoning. Expected date of publication: 1997.

• 1

  Begin risk assessment and counseling during prenatal visits and continue after birth during regular office visits until the child is at least 6 years of age. Counsel parents against sanding old lead paint while remodeling during pregnancy.

• 2
  Evaluate each child's risk of lead toxicity. Use of a structured set of questions such as that developed by CDC (Table 7.1) can be very helpful. If the answer to any of the questions is positive, consider the child at high risk for exposure.

• 3

  Measurement of the blood lead level is more sensitive and specific than measurement of the erythrocyte protoporphyrin (EP) level.

• 4
  Screening blood lead levels may be obtained from capillary sampling. Follow the precautions listed in Table 7.2 to minimize the chance of contamination from environmental sources. Confirm elevated blood lead test results (15 µg/dL or greater) obtained on capillary specimens by using venous blood. A child with a capillary lead level of 70 µg/dL or greater requires immediate retesting using a venous sample.

• 5
  Interpret and manage blood lead test results according to the CDC recommendations listed in Table 7.3. Several states require primary care providers and persons in charge of lead screening programs to report both presumptive and confirmed cases of lead toxicity to the appropriate health agency.

• 6

  Laboratories where blood is tested for lead levels must participate in a blood-lead proficiency testing program, such as the collaborative program between the Health Resources and Services Administration and CDC. Information on this program is available by calling the Wisconsin State Hygiene Laboratory (608)262-1146.

• 7

  Because iron deficiency can enhance lead absorption and toxicity, test all children with blood lead levels of 20 µg/dL or greater for iron deficiency.

• 8

  Provide guidance to parents about creating an environment safe from lead exposure for their children. Include advice on eliminating peeling or chipping paint, decreasing the lead content of water, preventing contact via hobbies or contaminated work clothing, remaining alert for pica behavior, and assuring good hygiene. ( See Patient Resources for publications to aid in counseling.)

Patient Resources

• Department of Housing and Urban Development, Office of Lead-Based Paint. Internet access: htp://www.hud.gov/lea

• National Lead Information Center of the National Safety Council; (800)LEADFYI.

• What Everyone Should Know About Lead Poisoning. To obtain individual copies, contact: Alliance to End Childhood Lead Poisoning, 600 Pennsylvania Ave SE, Suite 100, Washington, DC 20003. To obtain bulk copies, contact: Channing L. Bete Co, Inc, 200 State Rd, South Deerfield, MA 01373; (800)628-7733.

• Protect your family from lead in your home. Centers for Disease Control and Prevention, Lead Poisoning Prevention Program, 1600 Clifton Rd NE, Atlanta, GA 30333; (770)488-7330.

Provider Resources

• Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control; The Strategic Plan for the Elimination of Lead Poisoning; Nutrition and Childhood Lead Poisoning Prevention. Centers for Disease Control and Prevention, Lead Poisoning Prevention Program, 1600 Clifton Rd NE, Atlanta, GA 30333; (770)488-7330.

• Case Studies in Environmental Medicine: Lead Toxicity. Agency for Toxic Substances and Disease Registry, Division of Health Education, Mailstop E33, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-6205.

Selected References

Recommendations of Major Authorities

• American Academy of Pediatrics and Bright Futures --

• Newborn screening should be performed according to each state's regulations.

National authorities have made recommendations for the following specific conditions:

Basics of Newborn Screening

Patient Resources

• Sickle Cell Disease: Guide for Parents. Agency for Health Care Policy and Research Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295.

• Sickle Cell Anemia (New Hope for People With). FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

• Understanding PKU. PKU Clinic, Children's Hospital Medical Center, 300 Longwood Ave, Boston, MA 02115; (617)355-6394.

Provider Resources

• Sickle Cell Disease: Clinical Practice Guideline; Sickle Cell Disease: Guideline Report; Sickle Cell Disease: Quick Reference Guide. Agency for Health Care Policy and Research Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; (800)358-9295.

• Blood Collection on Filter Paper for Neonatal Screening Programs -- Second Edition; Approved Standard. National Committee for Clinical Laboratory Standards (NCCLS), 940 W Valley Rd, Suite 1400, Wayne, PA 19087-1898. An educational videotape depicting the LA4-A2 collection procedure is also available.

• Management and Therapy of Sickle Cell Disease. NIH publication No. 96-2117. NHLBI Information Center, PO Box 30105, Bethesda, MD 20814-0105.

• New England Connection for PKU and Allied Disorders, 16 Angelina Ln, Mansfield, MA 02048. Various brochures on PKU, maple syrup urine disease, homocystinuria, tyrosinemia, urea cycle disorders, and organic acidemias are available; (508)261-1291.

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

Recommendations of Major Authorities

Basics of Tuberculosis Screening

NOTE: Persons who are not likely to be infected with M. tuberculosis generally should not undergo skin testing, because the predictive value of a positive skin test in low-risk populations is poor.

• 1

  The Mantoux test is the standard method of testing. Multiple-puncture tests should not be used to determine whether a person is infected.

• 2

  For the Mantoux test, use 0.1 mL of purified protein derivative (PPD) containing 5 tuberculin units. Administer PPD using a disposable tuberculin syringe, with the bevel of the needle facing upward. Administer the injection intradermally on the volar surface of the forearm to produce a pale, discrete elevation of the skin (weal) 6 to 10 mm in diameter. The weal disappears shortly after the test is administered.

• 3

  Read the test 48 to 72 hours after injection by measuring the diameter of induration (not erythema) transverse to the long axis of the forearm. Record the actual millimeters of induration. Do not consider the erythema that may surround the area of induration.

• 4

  The definition of a positive skin test reaction depends on the likelihood of tuberculosis infection and the risk of tuberculosis disease if infection has occurred. A positive skin reaction can be expected 2 to 10 weeks after infection with TB has occurred.

• 5

  Do not retest patients who have a documented history of a positive Mantoux test; such testing has no diagnostic utility.

• 6

  Live-virus vaccines, such as measles-mumps-rubella (MMR), varicella (VCV), and oral polio vaccine (OPV), may interfere with a response to a tuberculin skin test. The tuberculin skin test should either be administered on the same day as the live-virus vaccinations, or postponed until 4 to 6 weeks after the vaccinations.

Basics of Tuberculosis Prophylaxis

1. Indications

Table 43.1. Criteria for Determining Need for Preventive Therapy (more...)

Table 43.1. Criteria for Determining Need for Preventive Therapy by Category and Age Group

Category	Age Group (Years)
	< 35	> 35
With risk factor *	Treat at all ages if reaction to 5 TU purified protein derivative >10 mm (or >5 mm and recent TB contact, HIV-infected, or has radiographic evidence of old TB)
Without risk factor High-incidence group **	Treat if PPD >10 mm	Do not treat
Without risk factor Low-incidence group	Consider treating if PPD >15 mm***	Do not treat

* Risk factors include: HIV infection; recent (within past 3 months) contact with infectious person; radiograph other than entirely normal; injection drug abuse; certain medical risk factors; and recent skin-test conversion. Recent converters are defined as: infants and children younger than 4 years of age with a 10-mm PPD; children and adults younger than 35 years of age with an increase in PPD reaction of >10 mm within a 2-year period; or adult >35 years of age with an increase in PPD reaction >15 mm within a 2-year period. Medical risk factors include: HIV infection, diabetes, end-stage renal disease, hematologic and reticuloendothelial diseases, prolonged steroid use, immunosuppressive therapy, and conditions associated with rapid weight loss (intestinal bypass surgery, gastrectomy, peptic ulcer disease, chronic malabsorption, chronic alcoholism, carcinomas of the oropharynx and upper gastrointestinal tract that prevent adequate nutrition).

** High-incidence groups include: foreign-born persons from high-prevalence countries; medically underserved low-income populations (including high-risk racial or ethnic minority populations, especially African Americans, Hispanics, and American Indians); and residents of long-term care facilities.

*** Consider treatment with isoniazid (INH) based on individual assessment of risks and benefits.

Adapted from: Centers for Disease Control. The use of preventive therapy for tuberculosis infection in the United States: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR. 1990;39:(No. RR-8):9-12.

Information also incorporated from: American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med. 1994;149:1359-1374. Official journal of the American Thoracic Society. Copyright American Lung Association.

A child with a positive Mantoux test result but without active disease is a candidate for isoniazid prophylaxis. Active disease is excluded by a normal chest radiograph and a lack of symptoms suggesting TB disease. See Table 43.1 for more information on general indications for prophylaxis.

Special pediatric cases should be considered candidates for isoniazid prophylaxis even if they lack documentation of a positive Mantoux test:

• Newborn prophylaxis: Infants whose mothers have active disease (even if noncontagious) and infants whose mothers have a positive Mantoux test but do not have active disease (preventive therapy can be discontinued after the entire family is demonstrated to have negative tuberculin skin tests)

• Children who are both anergic or HIV-positive and from populations where the prevalence of TB infection is higher than 10% (eg, injection drug users, homeless persons, migrant laborers, and individuals from Asia, Africa, or Latin America)

• Children who have had close contact within the past 3 months with a person with infectious TB.

Basics of BCG Vaccination

Patient Resources

• Facts About the TB Skin Test; Facts About Tuberculosis. American Lung Association, 1740 Broadway, New York, NY 10019-4374; (212)315-8700.

• TB: Get the Facts; Tuberculosis: Connection between TB and HIV. Centers for Disease Control and Prevention, Attn: Information Technology and Services, Mailstop E-06, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-1819.

Provider Resources

• Core Curriculum on Tuberculosis. Centers for Disease Control and Prevention; 1994. Centers for Disease Control and Prevention, Attn: Information Technology and Services, Mailstop E-06, 1600 Clifton Rd NE, Atlanta, GA 30333; (404)639-1819.

• Initial Therapy for TB in the Era of Multiple Drug Resistance; Mantoux Tuberculin Skin Testing (videotape). Centers for Disease Control and Prevention, Attn: Information Services Office, 1600 Clifton Rd NE, Atlanta GA 30333; (404)639-8135.

Selected References

Recommendations of Major Authorities

• American Academy of Family Physicians and US Preventive Services Task Force (USPSTF) --

• Routine screening of males and most females for asymptomatic bacteriuria is not recommended; there is insufficient evidence for or against routine screening of diabetic women (including children and adolescents). The Canadian Task Force on the Periodic Health Examination and the USPSTF recommend against screening for asymptomatic bacteriuria with urinalysis in infants, children, and adolescents.

• American Academy of Pediatrics --

• Urinalysis should be performed once at 5 years of age. Also, dipstick leukocyte esterase testing to screen for sexually transmitted diseases should be performed once in adolescence, preferably at 14 years of age.

• American Medical Association and Bright Futures --

• Sexually active adolescent males should be screened yearly for gonorrhea and chlamydia by urinalysis with a dipstick leukocyte esterase test.

Basics of Urinalysis

• 1

  To obtain urine from infants and young children, apply a plastic urine bag to the perineum. This method is associated with a relatively high rate of false-positive results (up to 30%) because of contamination. Positive test results of urine obtained by bag collection should be confirmed by catheterization or suprapubic aspiration.

• 2

  In screening children and adolescents for bacteriuria, obtain specimens using midstream "clean catch" techniques. This method permits follow-up culture testing of dipstick-positive specimens. The vulva of girls and the glans of boys should be cleansed well with a mild soap solution. Do not use antiseptic solutions because of the potential for suppressing bacterial growth in the sample. During urination, the labia of girls should be held open to avoid impinging on the flow of urine. This may be accomplished without manual holding by having the girl sit backward with legs astride a toilet seat. The foreskin of uncircumcised boys should be retracted to avoid impinging on the flow of urine.

• 3

  The sensitivity of screening for bacteriuria may be improved by obtaining a specimen from the first void of the day, which is more concentrated and contains higher amounts of bacteria and bacterial breakdown products compared with subsequent voids. Specimen collection from later voids is acceptable and may be more practical.

• 4

  The dipstick leukocyte esterase test is the most efficient way to screen specimens for bacteriuria. The sensitivity and specificity of both this test and the more labor-intensive microscopic analysis are roughly equivalent (approximately 80%). The nitrite test is also available on many dipsticks, but its low sensitivity, approximately 30%, makes it an inadequate screening tool if used alone. A positive nitrite test result, however, is approximately 99% specific for significant bacteriuria.

• 5

  To screen males for sexually transmitted diseases, collect a urine sample from the first 15 to 20 mL of a void and test the unspun sample with a leukocyte esterase dipstick. Because of the poor specificity and relatively high cost of this test, as well as the potential morbidity associated with treatment, confirm positive test results with more specific techniques, such as enzyme immunoassay and/or culture. Negative results from symptomatic males should always be confirmed by enzyme immunoassay and/or culture.

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617. (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

Recommendations of Major Authorities

Normal-Risk Children

• American Academy of Family Physicians --

• Children should be screened for amblyopia and strabismus at 3 to 4 years of age.

• American Academy of Pediatrics and Bright Futures --

• Visual acuity testing should first be performed at 3 years of age. If the child is uncooperative, retesting should occur 6 months later. Subsequent testing should occur at 4, 5, 10, 12, 15, and 18 years of age. Subjective assessment by history should occur at visits at all other ages. All infants should be examined by 6 months of age to evaluate fixation preference, alignment, and presence of any eye disease. Children should again be medically evaluated for these problems by 3 to 4 years of age.

Table 11.1. Eye and Vision Examination Recommendations (more...)

Table 11.1. Eye and Vision Examination Recommendations for Primary Care Clinicians

Age	Screening Method	Indicators Requiring Further Evaluation
Newborn to 3 months old	Red reflex	Abnormal or asymmetric
	Corneal light reflex	Asymmetric
	Inspection	Structural abnormality
6 months to 1 year old	Red reflex	Abnormal or asymmetric
	Corneal light reflex	Asymmetric
	Differential occlusion	Failure to object equally to covering each eye
	Fix and follow with each eye	Failure to fix and follow
	Inspection	Structural abnormality
3 years old (approximately)	Visual acuity*	20/50 or worse or difference of 2 lines between eyes
	Red reflex	Abnormal or asymmetric
	Corneal light reflex/cover-uncover	Asymmetric/ocular refixation movements
	Stereoacuity**	Failure to appreciate random dot or Titmus stereogram
	Inspection	Structural abnormality
5 years old (approximately)	Visual acuity*	20/30 or worse
	Red reflex	Abnormal or asymmetric
	Corneal light reflex/cover-uncover	Asymmetric/ocular refixation movements
	Stereoacuity**	Failure to appreciate random dot or Titmus stereogram
	Inspection	Structural abnormality

*Allen figures, HOTV, Tumbling E, or Snellen

**Optional, sometimes advocated in lieu of visual acuity; Random Dot E game (RDE), Titmus stereograms, Randot stereograms

From: American Academy of Ophthalmology, Quality of Care Committee, Pediatric Ophthalmology Panel. Comprehensive Pediatric Eye Evaluation. San Francisco, Calif. American Academy of Ophthalmology; 1992. Reproduced by permission of the publisher; copyright 1992.

• American Academy of Ophthalmology (AAO), American Association for Pediatric Ophthalmology and Strabismus (AAPOS), and American Optometric Association (AOA) --

• Eye and vision screening should be performed at birth and at approximately 6 months, 3 years, and 5 years of age. AAO has published recommendations regarding screening methods and indications for referral to be used by primary care clinicians in screening preschool children (Table 11.1). AAO and AAPOS recommend that screening after 5 years of age be carried out at routine school checks or after the appearance of symptoms. AOA recommends optometric examinations every 2 years throughout school years.

• Canadian Task Force on the Periodic Health Examination --

• Repeat examination of the eyes for strabismus is recommended during well-baby visits, especially during the first 6 months of life. There is fair evidence to include testing of visual acuity in the periodic health examination of preschool children.

• US Preventive Services Task Force --

• All children should have testing for amblyopia and strabismus once before entering school, preferably at 3 to 4 years of age. Stereoacuity testing may be more effective than visual acuity testing in detecting these conditions. There is insufficient evidence to recommend for or against routine screening for diminished visual acuity among asymptomatic school children. Recommendations against such screening can be made on other grounds, including the inconvenience and cost of routine screening and the fact that refractive errors can be readily corrected when they produce symptoms. Clinicians should be alert for signs of ocular misalignment when examining all newborns, infants, and children.

Basics of Vision Screening

Patient Resources

• Amblyopia: Is it Affecting Your Child's Sight?;Cataracts in Children: Eye Safety and Children; Eyeglasses for Infants and Children; Home Eye Test for Strabismus. American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelop with your request.

• Your Child's Eyes. American Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

• Answers to Your Questions About: Lazy Eye, Nearsightedness, Astigmatism, Eye Coordination, Color Deficiency, Crossed-Eyes; Signs of a Child's Vision Problems; Toys, Games and Your Child's Vision; Your Child's Eyes; Your Preschool Child's Eyes; Your School-Aged Child's Eyes. American Optometric Association, 243 N Lindbergh Blvd, St.Louis, MO 63141; (314)991-4100. Internet address: http://www.aoanet.org/

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

• Policy Statement: Frequency of Ocular Examinations; National Eyecare Project (for those who do not have an eye doctor); Glaucoma 2001 Project (for people at risk for glaucoma). American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelope with your request.

• Pediatric Eye and Vision Examination, Care of the Patient with Amblyopia, and other clinical practice guidelines. American Optometric Association, 243 N Lindbergh Blvd, St. Louis, MO 63141; (800)262-2210. Internet address: http://www.aoanet.org/

Selected References

Recommendations of Major Authorities

• Most major authorities, including Advisory Committee on Immunization Practices, American Academy of Family Physicians, American Academy of Pediatrics, American College of Preventive Medicine, Bright Futures, and US Preventive Services Task Force --

• All children should receive immunization against diphtheria, tetanus, and pertussis: 5 doses total by their seventh birthday (3 doses of primary series at 2, 4 and 6 months of age and 2 doses of booster vaccine at 15 to 18 months and 4 to 6 years of age). All US authorities recommend that a booster dose of Td (tetanus-diphtheria toxoid for adult use) be given at 11 to 16 years of age.

• Canadian Task Force on the Periodic Health Examination --

• All children should receive immunization against diphtheria, tetanus, and pertussis at 2, 4, 6 and 18 months.

Basics of Diphtheria, Tetanus, and Pertussis Immunization

2. Schedule

Table 12.1. Schedule for Diphtheria, Tetanus, Pertussis Vaccination (more...)

Table 12.1. Schedule for Diphtheria, Tetanus, Pertussis Vaccination

Dose	Age	Notes
Dose 1 a	2 months	Administer first 3 doses a minimum of 4 weeks apart.
Dose 2	4 months
Dose 3	6 months
Dose 4 b	15 - 18 months	Administer dose 4 at least 6 months after the third dose.
Dose 5 c	4-6 years

a May be given as early as 6 weeks of age

b If the interval between the third and fourth doses is greater than 6 months and the child is not likely to return for a visit at the recommended age, the fourth dose of either DTaP or DTP may be administered as early as 12 months of age.

c Fifth vaccination is not necessary if the fourth vaccination was given when the child was 4 years of age or older.

The Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians currently recommend the following schedule for diphtheria, tetanus, and pertussis vaccination (Table 12.1):

4. Contraindications/Precautions

Table B.3. Contraindications and Precautions for Childhood Immunizations (more...)

Table B.3. Contraindications and Precautions for Childhood Immunizations *

True Contraindications	NOT Contraindications
and Precautions	(vaccines may be given)
Anaphylactic reaction to a vaccine contraindicates further doses of that vaccine Anaphylactic reaction to a vaccine constituent contraindicates the use of vaccines containing that substance	Moderate or severe illness with or without fever Mild to moderate local reaction (soreness, redness, swelling) following a dose of an injectable antigen Mild acute illness with or without low-grade fever Current antimicrobial therapy Convalescent phase of illnesses Prematurity (same dosage and indications as for normal, full-term infants) Recent exposure to an infectious disease History of penicillin or other nonspecific allergies or fact that relatives have such allergies

* This information is based on the recommendations of the Advisory Committee on Immunization Practices (ACIP) and those of the Committee on Infectious Diseases (Red Book Committee) of the American Academy of Pediatrics (AAP). These recommendations may vary from those contained in the manufacturers' package inserts.

From: National Vaccine Advisory Committee. Standards for Pediatric Immunization Practices. Atlanta, Ga: Centers for Disease Control and Prevention; 1993.

Table 12.2. Contraindications for Administration of (more...)

Table 12.2. Contraindications for Administration of DTP and DTaP Vaccines

True Contraindications	NOT Contraindications (vaccines may be given)
History of anaphylaxis or anaphylactic shock within 24 hours	Temperature <40.5°C (104.9°F) following a previous dose of DTaP/DTP
Encephalopathy within 7 days of administration of previous dose of DTP/DTaP	Personal or family history of convulsions **
	Family history of sudden infant death syndrome
	Family history of an adverse event following DTP/DTaP administration
Precautions
Fever > 40.5°C (104.9°F) within 48 hours after vaccination with a previous dose of DTP/DTaP *
Collapse or shock-like state (hypotonic-hyporesponsive episode) within 48 hours of receiving a previous dose of DTP/DTaP *
Seizures within 3 days of receiving a previous dose of DTP/DTaP *
Persistent, inconsolable crying lasting 3 hours within 48 hours of receiving a previous dose of DTP/DTaP *

* Precautions should be carefully reviewed. The benefits and risks of administering a specific vaccine to a child under the circumstances should be considered. If the risks are believed to outweigh the benefits, withhold immunization; if the benefits are believed to outweigh the risks (eg, during an outbreak or foreign travel), administer vaccine.

** Pertussis vaccination is not a contraindication for children with a family history of seizures. The ACIP recommends that DTaP should be the vaccine of choice, when pertussis vaccination is considered for children with personal history of seizures. Infants with evolving neurologic conditions should not be vaccinated until a treatment regimen has been established and the condition has stabilized.

Adapted from: National Vaccine Advisory Committee. Standards for Pediatric Immunization Practices. Atlanta, Ga: Centers for Disease Control and Prevention; 1993.

There are few, true contraindications to administering vaccinations. See Appendix B, Table B.3 for a listing of valid contraindications. Table 12.2 lists contraindications specific to DTaP/DTP vaccination.

• Pertussis vaccine is contraindicated in children over 7 years of age.

• Because of the high diphtheria toxoid content of DT, it is not recommended for use in children over the age of 7; vaccinate children over 7 years of age with Td.