Keywords
Bright Futures, Screening, Anticipatory guidance, Discipline
Health maintenance or supervision visits should consist of a comprehensive assessment of the child’s health and of the parent’s/guardian’s role in providing an environment for optimal growth, development, and health. The American Academy of Pediatrics’ (AAP) Bright Futures information standardizes each of the health maintenance visits and provides resources for working with the children and families of different ages (see https://brightfutures.aap.org ). Elements of each visit include evaluation and management of parental concerns; inquiry about any interval illness since the last physical, growth, development, and nutrition; anticipatory guidance (including safety information and counseling); physical examination; screening tests; and immunizations ( Table 9.1 ). The Bright Futures Recommendations for Preventive Pediatric Health Care, found at https://www.aap.org/en-us/Documents/periodicity_schedule.pdf , summarizes requirements and indicates the ages that specific prevention measures should be undertaken, including risk screening and performance items for specific measurements. Bright Futures is now the enforced standard for the Medicaid and the Children’s Health Insurance Program, along with many insurers. Health maintenance and immunizations now are covered without copays for insured patients as part of the Patient Protection and Affordable Care Act.
| FOCUS ON THE CHILD |
| Concerns (parent’s or child’s) |
| Past problem follow-up |
| Immunization and screening test update |
| Routine care (e.g., eating, sleeping, elimination, and health habits) |
| Developmental progress |
| Behavioral style and problems |
| FOCUS ON THE CHILD’S ENVIRONMENT |
| Family |
| Caregiving schedule for caregiver who lives at home |
| Parent-child and sibling-child interactions |
| Extended family role |
| Family stresses (e.g., work, move, finances, illness, death, marital, and other interpersonal relationships) |
| Family supports (relatives, friends, groups) |
| Community |
| Caregivers outside of the family |
| Peer interaction |
| School and work |
| Recreational activities |
| Physical Environment |
| Appropriate stimulation |
| Safety |
Screening Tests
Children usually are quite healthy and only the following screening tests are recommended: newborn metabolic screening with hemoglobin electrophoresis, hearing and vision evaluation, anemia and lead screening, and tuberculosis testing. Children born to families with dyslipidemias or early heart disease should also be screened for lipid disorders; in addition, all children should have a routine cholesterol test between ages 9 and 11. (Items marked by a star in the Bright Futures Recommendations should be performed if a risk factor is found.) Sexually experienced adolescents should be screened for sexually transmissible infections and have an HIV test at least once between 16 and 18. When an infant, child, or adolescent begins with a new physician, the pediatrician should perform any missing screening tests and immunizations.
Newborn Screening
Metabolic Screening
Every state in the United States mandates newborn metabolic screening. Each state determines its own priorities and procedures, but the following diseases are usually included in metabolic screening: phenylketonuria, galactosemia, congenital hypothyroidism, maple sugar urine disease, and organic aciduria (see Section 10 ). Many states now screen for cystic fibrosis (CF) by testing for immunoreactive trypsinogen. If that test is positive, then a DNA analysis for the most common cystic fibrosis mutations is performed. This is not a perfect test due to the myriad mutations that lead to CF. Clinical suspicion warrants evaluation even if there were no CF mutations noted on the DNA analysis.
Hemoglobin Electrophoresis
Children with hemoglobinopathies are at higher risk for infection and complications from anemia, which early detection may prevent or ameliorate. Infants with sickle cell disease are begun on oral penicillin prophylaxis to prevent sepsis, which is the major cause of mortality in these infants (see Chapter 150 ).
Critical Congenital Heart Disease Screening
New for the fourth edition of Bright Futures is newborn screening for critical congenital heart disease (CCHD). Newborns with cyanotic congenital heart disease may be missed if the ductus arteriosus is still open; when the ductus closes, these children become profoundly cyanotic, leading to complications and even death. The AAP now mandates screening with pulse oximetry of the right hand and foot. The baby passes screening if the oxygen saturation is 95% or greater in the right hand and foot and the difference is three percentage points or less between the right hand and foot. The screen is immediately failed if the oxygen saturation is less than 90% in the right hand and foot. Equivocal tests are repeated, or echocardiography and pediatric cardiology consultation are warranted (see Chapters 143 and 144 ).
Hearing Evaluation
Because speech and language are central to a child’s cognitive development, the hearing screening is performed before discharge from the newborn nursery. An infant’s hearing is tested by placing headphones over the infant’s ears and electrodes on the head. Standard sounds are played, and the transmission of the impulse to the brain is documented. If abnormal, a further evaluation using evoked response technology of sound transmission is indicated.
Hearing and Vision Screening of Older Children
Infants and Toddlers
Inferences about hearing are drawn from asking parents about responses to sound and speech and by examining speech and language development closely. Inferences about vision may be made by examining gross motor milestones (children with vision problems may have a delay) and by physical examination of the eye. Parental concerns about vision should be sought until the child is 3 years of age and about hearing until the child is 4 years of age. If there are concerns, definitive testing should be arranged. Hearing can be screened by auditory evoked responses, as mentioned for newborns. For toddlers and older children who cannot cooperate with formal audiologic testing with headphones, behavioral audiology may be used. Sounds of a specific frequency or intensity are provided in a standard environment within a soundproof room, and responses are assessed by a trained audiologist. Vision may be assessed by referral to a pediatric ophthalmologist and by visual evoked responses.
Children 3 Years of Age and Older
At various ages, hearing and vision should be screened objectively using standard techniques as specified in the Bright Futures Recommendations. Asking the family and child about any concerns or consequences of poor hearing or vision accomplishes subjective evaluation. At 3 years of age, children are screened for vision for the first time if they are developmentally able to be tested. Many children at this age do not have the interactive language or interpersonal skills to perform a vision screen; these children should be re-examined at a 3-6-month interval to ensure that their vision is normal. Because most of these children do not yet identify letters, using a Snellen eye chart with standard shapes is recommended. When a child is able to identify letters, the more accurate letter-based chart should be used. Audiologic testing of sounds with headphones should be begun on the fourth birthday (although Head Start requires that pediatricians attempt the hearing screening at 3 years of age). Any suspected audiologic problem should be evaluated by a careful history and physical examination with referral for comprehensive testing. Children who have a documented vision problem, failed screening, or parental concern should be referred, preferably to a pediatric ophthalmologist.
Anemia Screening
Children are screened for anemia at ages when there is a higher incidence of iron deficiency anemia. Infants are screened at birth and again at 4 months if there is a documented risk, such as low birthweight or prematurity. All infants are screened at 12 months of age because this is when a high incidence of iron deficiency is noted. Children are assessed at other visits for risks or concerns related to anemia (denoted by a star in the Bright Futures Recommendations at http://brightfutures.aap.org/clinical_practice.html ). Any abnormalities detected should be evaluated for etiology. Anemic infants do not perform as well on standard developmental testing. When iron deficiency is strongly suspected, a therapeutic trial of iron may be used (see Chapter 150 ).
Lead Screening
Lead intoxication may cause developmental and behavioral abnormalities that are not reversible, even if the hematologic and other metabolic complications are treated. Although the Centers for Disease Control and Prevention (CDC) recommends environmental investigation at blood lead levels of 20 µg/dL on a single visit or persistent 15 µg/dL over a 3-month period, levels of 5-10 µg/dL may cause learning problems. Risk factors for lead intoxication include living in older homes with cracked or peeling lead-based paint, industrial exposure, use of foreign remedies (e.g., a diarrhea remedy from Central or South America), and use of pottery with lead paint glaze. Because of the significant association of lead intoxication with poverty, the CDC recommends routine blood lead screening at 12 and 24 months. In addition, standardized screening questions for risk of lead intoxication should be asked for all children between 6 months and 6 years of age ( Table 9.2 ). Any positive or suspect response is an indication for obtaining a blood lead level. Capillary blood sampling may produce false-positive results; thus, in most situations, a venous blood sample should be obtained or a mechanism implemented to get children tested with a venous sample if they had an elevated capillary level. County health departments, community organizations, and private companies provide lead inspection and detection services to determine the source of the lead. Standard decontamination techniques should be used to remove the lead while avoiding aerosolizing the toxic metal that a child might breathe or creating dust that a child might ingest (see Chapters 149 and 150 ).
| Does the child spend any time in a building built before 1960 (e.g., home, school, barn) that has cracked or peeling paint? |
| Is there a brother, sister, housemate, playmate, or community member being followed or treated (or even rumored to be) for lead poisoning? |
| Does the child live with an adult whose job or hobby involves exposure to lead (e.g., lead smelting and automotive radiator repair)? |
| Does the child live near an active lead smelter, battery recycling plant, or other industry likely to release lead? |
| Does the family use home remedies or pottery from another country? |
Tuberculosis Testing
The prevalence of tuberculosis is increasing largely as a result of the adult HIV epidemic. Children often present with serious and multisystem disease (miliary tuberculosis). All children should be assessed for risk of tuberculosis at health maintenance visits at 1 month, 6 months, 12 months, and then annually. The high-risk groups, as defined by the CDC, are listed in Table 9.3 . In general, the standardized purified protein derivative intradermal test is used with evaluation by a health care provider 48-72 hours after injection. The size of induration, not the color of any mark, denotes a positive test. For most patients, 10 mm of induration is a positive test. For HIV-positive patients, those with recent tuberculosis contacts, patients with evidence of old healed tuberculosis on chest film, or immunosuppressed patients, 5 mm is a positive test (see Chapter 124 ). The CDC has also approved the QuantiFERON-TB Gold Test, which has the advantage of needing one office visit only.
