Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + ALCOHOL ABUSE AND DEPENDENCE Download Section PDF Listen +++ +++ Population ++ Children and adolescents. +++ Recommendation +++ AAFP 2010, USPSTF 2018, ICSI 2010 ++ Insufficient evidence to recommend for or against screening or counseling interventions to prevent or reduce alcohol misuse by adolescents. +++ Sources ++ USPSTF. Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions. 2018. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_ guidelines/ Ann Fam Med. 2010;8(6):484-492. +++ Comments ++ AUDIT and CAGE questionnaires have not been validated in children or adolescents. Reinforce not drinking and driving or riding with any driver under the influence. Reinforce to women the harmful effects of alcohol on fetuses. + ATTENTION-DEFICIT/HYPERACTIVITY DISORDER Download Section PDF Listen +++ +++ Population ++ Children age 4–18 y with academic or behavioral problems and inattention, hyperactivity, or impulsivity. +++ Recommendations +++ AAFP 2016, AAP 2011, NICE 2018 ++ Do not screen routinely. Initiate an evaluation for ADHD for any child 4–18 y who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. Diagnosis requires that the child meets DSM-IV criteriaa and direct supporting evidence from parents or caregivers and classroom teacher. Evaluation of a child with ADHD should include assessment for coexisting disorders and alternative causes of the behavior. +++ Sources ++ AAFP. Clinical Recommendation: ADHD in Children and Adolescents. 2016. Pediatrics. 2011;128(5):1007. Pediatrics. 2000;105(5):1158. NICE. Attention Deficit Hyperactivity Disorder: Diagnosis and Management. 2018. nice.org.uk/guidance/ng87 +++ Comments ++ Stimulant prescription rates continue to rise. (Lancet. 2016; 387(10024):1240-1250) Current estimates are that 7.2% of children/adolescents meet criteria for ADHD. (Pediatrics. 2015;135(4):e994) The U.S. Food and Drug Administration (FDA) approved a “black box” warning regarding the potential for cardiovascular side effects of ADHD stimulant drugs. (N Engl J Med. 2006;354:1445) + ++ aDSM-IV Criteria for ADHD: I: Either A or B. A: Six or more of the following symptoms of inattention have been present for at least 6 mo to a point that is disruptive and inappropriate for developmental level. Inattention: (1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. (2) Often has trouble keeping attention on tasks or play activities. (3) Often does not seem to listen when spoken to directly. (4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). (5) Often has trouble organizing activities. (6) Often avoids, dislikes, or does not want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). (7) Often loses things needed for tasks and activities (eg, toys, school assignments, pencils, books, or tools). (8) Is often easily distracted. (9) Is often forgetful in daily activities. B: Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 mo to an extent that is disruptive and inappropriate for developmental level. Hyperactivity: (1) Often fidgets with hands or feet or squirms in seat. (2) Often gets up from seat when remaining in seat is expected. (3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). (4) Often has trouble playing or enjoying leisure activities quietly. (5) Is often “on the go” or often acts as if “driven by a motor.” (6) Often talks excessively. Impulsivity: (1) Often blurts out answers before questions have been finished. (2) Often has trouble waiting one’s turn. (3) Often interrupts or intrudes on others (eg, butts into conversations or games). II: Some symptoms that cause impairment were present before age 7 y. III: Some impairment from the symptoms is present in two or more settings (eg, at school/work and at home). IV: There must be clear evidence of significant impairment in social, school, or work functioning. V: The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). + AUTISM SPECTRUM DISORDER Download Section PDF Listen +++ +++ Population ++ Children, age 12–36 mo. +++ Recommendations +++ USPSTF 2016 ++ Insufficient evidence to screen routinely. +++ Source ++ JAMA. 2016;315(7):691-696. +++ AAP 2014 ++ Screen with autism-specific tool at 18 mo and 24 mo. M-CHAT is most commonly used (see page 711). +++ Sources ++ Pediatrics. 2006;118(1):405. Pediatrics. 2014;135(5):e1520. +++ Comments ++ Listen and respond to concerns raised by caregivers; signs may be identifiable by 9 mo of age. Prevalence is 1 in 68; 4.5:1 male:female ratio. (MMWR Surveill Summ. 2016;65(3):1–23) + CELIAC DISEASE Download Section PDF Listen +++ +++ Population ++ Children and adults. +++ Recommendations +++ USPSTF 2017, AAFP 2017 ++ Insufficient evidence regarding screening of asymptomatic people. +++ Sources ++ AAFP. Clinical Recommendation: Screening for Celiac Disease. 2017. JAMA. 2017;317(12):1252. +++ NICE 2015 ++ Do not screen the asymptomatic general population. Serologic testing to rule out celiac disease should be performed for any of the following signs, symptoms, or associated conditions: persistent unexplained abdominal or gastrointestinal symptoms, faltering growth, prolonged fatigue, unexpected weight loss, severe or persistent mouth ulcers, unexplained iron, vitamin B12 or folate deficiency, type 1 diabetes, autoimmune thyroid disease, irritable bowel syndrome (in adults). Screen first-degree relatives of people with celiac disease. +++ Source ++ NICE. Coeliac Disease: Recognition, Assessment and Management. 2015. +++ Comments ++ Patients must continue a gluten-containing diet during diagnostic testing. IgA tissue transglutaminase (TTG) is the test of choice (>90% sensitivity/specificity), along with total IgA level. IgA endomysial antibody test is indicated if the TTG test is equivocal. Avoid antigliadin antibody testing. Consider serologic testing for any of the following: Addison disease; amenorrhea; autoimmune hepatitis; autoimmune myocarditis; chronic immune thrombocytopenic purpura (ITP); dental enamel defects; depression; bipolar disorder; Down syndrome; Turner syndrome; epilepsy; lymphoma; metabolic bone disease; chronic constipation; polyneuropathy; sarcoidosis; Sjögren syndrome; or unexplained alopecia. + CHOLESTEROL AND LIPID DISORDERS Download Section PDF Listen +++ +++ Population ++ Infants, children, adolescents, or young adults (age <20 y). +++ Recommendations +++ USPSTF 2016, NLA 2011 ++ Insufficient evidence to recommend for or against routine universal lab screening. In familial hypercholesterolemia, screen at age 9–11 y with a fasting lipid panel or nonfasting non-HDL-C. If non-HDL-C ≥145 m/dL, perform fasting lipid panel. Genetic screening for familial hypercholesterolemia is generally not needed for diagnosis or clinical management. Cascade screening: testing lipid levels in all first-degree relatives of diagnosed familial hypercholesterolemia patients. +++ Sources ++ J Clin Lipidol. 2011;5:S1-S8. JAMA. 2016;316:625-633. +++ AHA 2007 ++ Screen selectively: obtain fasting lipid panel in patients age >2 y with a parent age <55 y with coronary artery disease, peripheral artery disease, cerebrovascular disease, or hyperlipidemia. +++ Source ++ Circulation. 2007;115:1947-1967. +++ Comments ++ Childhood drug treatment of dyslipidemia lowers lipid levels but effect on childhood or adult outcomes is uncertain. Lifestyle approach is recommended starting after age 2 y. +++ Recommendations +++ National Heart, Lung and Blood Institute Integrated Guidelines 2012 ++ Selective screening age >2 y: positive family history (FH) of dyslipidemia, presence of dyslipidemia, or the presence of overweight, obesity, hypertension, diabetes, or a smoking history. Universal screening in adolescents regardless of FH between age 9 and 11 y and again between age 18 and 21 y. +++ Source ++ NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. 2012. +++ Comments ++ Fasting lipid profile is recommended. If within normal limits, repeat testing in 3–5 y is recommended. Fasting lipid profile or nonfasting non-high-density lipoprotein (HDL) cholesterol level. + DEPRESSION Download Section PDF Listen +++ +++ Population ++ Children age 7–11 y. +++ Recommendation +++ USPSTF 2016 ++ Insufficient evidence to recommend for or against routine screening. +++ Source ++ Ann Intern Med. 2016;164(5):360-366. +++ Population ++ Adolescents. +++ Recommendation +++ USPSTF 2016 ++ Screen all adolescents age 12–18 y for major depressive disorder (MDD). Systems should be in place to ensure accurate diagnosis, appropriate psychotherapy, and adequate follow-up. +++ Sources ++ Ann Intern Med. 2016;164(5):360-366. Wilkinson J, Bass C, et al. Preventative Services for Children and Adolescents. Bloomington: ICSI; 2013. +++ Comments ++ Screen in primary care clinics with the Patient Health Questionnaire for Adolescents (PHQ-A) (73% sensitivity; 94% specificity) or the Beck Depression Inventory-Primary Care (BDI-PC) (91% sensitivity; 91% specificity). See page 722. Treatment options include pharmacotherapy (fluoxetine and escitalopram have FDA approval for this age group), psychotherapy, collaborative care, psychosocial support interventions, and CAM approaches. SSRI may increase suicidality in some adolescents, emphasizing the need for close follow-up. + DIABETES Download Section PDF Listen +++ +++ Population ++ Children at start of puberty or age ≥10 y. +++ Recommendation +++ ADA 2012 ++ Screen all children at risk for DM type 2.a +++ Source ++ Diabetes Care. 2012; 35(suppl 1):S11-S63. + ++ aRisk factors for HIV: men who have had sex with men after 1975; multiple sexual partners; history of intravenous drug use; prostitution; history of sex with an HIV-infected person; history of sexually transmitted disease; history of blood transfusion between 1978 and 1985; or persons requesting an HIV test. + FAMILY VIOLENCE AND ABUSE Download Section PDF Listen +++ +++ Population ++ Children, women, and older adults. +++ Recommendation +++ USPSTF 2018 ++ Insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children. +++ Source ++ USPSTF. Interventions to Prevent Child Maltreatment. 2018. +++ Comments ++ All providers should be aware of physical and behavioral signs and symptoms associated with abuse and neglect, including burns, bruises, and repeated suspect trauma. CDC publishes a toolkit of assessment instruments: https://www.cdc.gov/violence prevention/pdf/ipv/ipvandsvscreening.pdf + HUMAN IMMUNODEFICIENCY VIRUS (HIV) Download Section PDF Listen +++ +++ Population ++ Adolescents and adults. +++ Recommendations +++ AAFP 2013 ++ Screen everyone age 18–65 y. Consider screening high-risk individualsa of other ages. +++ USPSTF 2019 ++ Screen everyone age 15–65 y. Consider screening high-risk individuals of other ages. +++ CDC 2015 ++ Screen everyone age 13–64 y. Consider screening high-risk individuals of other ages. +++ Sources ++ AAFP. Clinical Recommendations: HIV Infection, Adolescents and Adults. 2013. CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. USPSTF. HIV Infection: Screening. 2019. +++ Comments ++ HIV testing should be voluntary and must have a verbal consent to test. Patients may “opt out” of testing. Educate and counsel all high-risk patients regarding HIV testing, transmission, risk-reduction behaviors, and implications of infection. If acute HIV is suspected, also use plasma RNA test. False-positive results with electroimmunoassay (EIA): nonspecific reactions in persons with immunologic disturbances (eg, systemic lupus erythematosus or rheumatoid arthritis), multiple transfusions, recent influenza, or rabies vaccination. Confirmatory testing is necessary using Western blot or indirect immunofluorescence assay. Awareness of HIV positively reduces secondary HIV transmission risk and high-risk behavior and viral load if on highly active antiretroviral therapy (HAART). (CDC, 2006) + HYPERTENSION (HTN), CHILDREN AND ADOLESCENTS Download Section PDF Listen +++ +++ Population ++ Age 3–20 y.a ++ +++ Recommendations +++ Pediatrics 2017, NHLBI 2012, AAFP 2018 ++ Measure BP only at preventative visits for children age ≥3 y. (Table 10-1) Measure BP at each encounter for children age ≥3 y who have obesity, renal disease, h/o aortic arch obstruction or coarctation, diabetes, or are taking medications known to raise blood pressure. ++Table Graphic Jump LocationTABLE 10-1REPRODUCED FROM TABLE 6 IN FLYNN ET AL. CLINICAL PRACTICE GUIDELINE FOR SCREENING AND MANAGEMENT OF BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS. PEDIATRICS. 2017;140(3):E2017-1904View Table||Download (.pdf) TABLE 10-1 REPRODUCED FROM TABLE 6 IN FLYNN ET AL. CLINICAL PRACTICE GUIDELINE FOR SCREENING AND MANAGEMENT OF BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS. PEDIATRICS. 2017;140(3):E2017-1904 Age Boys Girls DBP SBP DBP 1 98 52 98 54 2 100 55 101 58 3 101 58 102 60 4 102 60 103 62 5 103 63 104 64 6 105 66 105 67 7 106 68 106 68 8 107 69 107 69 9 107 70 108 71 10 108 72 109 72 11 110 74 111 74 12 113 75 114 75 13+ 120 80 120 80 +++ Sources ++ Pediatrics. 2017;140(3):e2017-1904. NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. 2012. NHLBI. A Pocket Guide to Blood Pressure Management in Children. 2012. AAFP. High Blood Pressure in Children and Adolescents. 2018. +++ Comments ++ Hypertension: average systolic blood pressure (SBP) or diastolic blood pressure (DBP) ≥95th percentile for gender, age, and height on 3 or more occasions. See pages 692–694. Counsel children and adolescents who have been diagnosed with hypertension regarding lifestyle modifications including diet and physical activity. Prescribe pharmacologic therapy to children and adolescents who fail lifestyle modifications. + ++ aIn children age <3 y, conditions that warrant BP measurement include: prematurity, very low birth weight, or neonatal complications; congenital heart disease; recurrent urinary tract infections (UTIs), hematuria, or proteinuria; renal disease or urologic malformations; familial hypercholesterolemia of congenital renal disease; solid-organ transplant; malignancy or bone marrow transplant; drugs known to raise BP; systemic illnesses; and increased intracranial pressure. + ILLICIT DRUG USE Download Section PDF Listen +++ +++ Population ++ Adults, adolescents, and pregnant women. +++ Recommendation +++ USPSTF 2014, ICSI 2014 ++ Insufficient evidence to recommend for or against routine screening for illicit drug use. +++ Sources ++ ICSI Preventive Services for Adults. 20th ed. 2014. USPSTF. Drug Use, Illicit: Screening. 2014. + LEAD POISONING Download Section PDF Listen +++ +++ Population ++ Children age 1–5 y. +++ Recommendations +++ AAFP 2006, USPSTF 2019, CDC 2000, AAP 2000 ++ Insufficient evidence to recommend for or against routine screening in asymptomatic children at increased risk.a Do not screen asymptomatic children at average risk. +++ Sources ++ USPSTF. Elevated Blood Lead Levels in Childhood and Pregnancy: Screening. 2019. Pediatrics. 1998;101(6):1702. Advisory Committee on Childhood Lead Poisoning Prevention. Recommendations for blood lead screening of young children enrolled in Medicaid: targeting a group at high risk. CDC MMWR. 2000;49(RR14):1-13. AAFP. Clinical Recommendations: Lead Poisoning. 2006. +++ Comments ++ CDC recommends that children who receive Medicaid benefits should be screened unless high-quality, local data demonstrates the absence of lead exposure among this population. Screen at ages 1 and 2 y, or by age 3 y if a high-risk child has never been screened. As of 2012, the threshold for elevated blood lead level has been lowered to 5 μg/dL. (CDC. Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. 2012) CDC personal risk questionnaire (http://www.cdc.gov/nceh/lead/publications/screening.htm): Does your child live in or regularly visit a house (or other facility, eg, daycare) that was built before 1950? Does your child live in or regularly visit a house built before 1978 with recent or ongoing renovations or remodeling (within the last 6 mo)? Does your child have a sibling or playmate who has or did have lead poisoning? + ++ aChild suspected by parent, health care provider, or Health Department to be at risk for lead exposure; sibling or playmate with elevated blood lead level; recent immigrant, refugee, or foreign adoptee; child’s parent or caregiver works with lead; household member uses traditional folk or ethnic remedies or cosmetics or who routinely eats food imported informally from abroad; residence near a source of high lead levels. + MOTOR VEHICLE SAFETY Download Section PDF Listen +++ +++ Population ++ Children and adolescents. +++ Recommendation +++ ICSI 2013 ++ Ask about car seats, booster seats, seat belt use, helmet use while riding motorcycles. +++ Source ++ ICSI. Preventive Services for Children and Adolescents. 19th ed. 2013. +++ Comment ++ One study demonstrated a 21% reduction in mortality with the use of child restraint systems vs. seat belts in children age 2–6 y involved in motor vehicle collisions. (Arch Pediatr Adolesc Med. 2006;160:617-621) + OBESITY Download Section PDF Listen +++ +++ Population ++ Children age ≥6 y. +++ Recommendation +++ USPSTF 2017 ++ Screen children age 6 y and older for obesity. +++ Source ++ JAMA. 2017;317(23):2417-2426. +++ Comments ++ Offer obese children intensive counseling and behavioral interventions to promote improvement in weight status. Intensive interventions (>26 h) can improve weight status; less intensive interventions have not been proven but have little potential harm. +++ Population ++ Children age ≥2 y. +++ Recommendation +++ ICSI 2013 ++ Record height, weight, and body mass index (BMI) annually starting at age 2 y. +++ Source ++ ICSI. Preventive Services for Children and Adolescents. 19th ed. 2013. +++ Comments ++ Children with a BMI ≥25 are 5 times more likely to be overweight as adults when compared with their normal-weight counterparts. Overweight children should be counseled about wholesome eating, 30–60 min of daily physical activity, and avoiding soft drinks. + SCOLIOSIS Download Section PDF Listen +++ +++ Population ++ Adolescents. +++ Recommendation +++ AAFP 2013, USPSTF 2017 ++ Insufficient evidence to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in children and adolescents age 10–18. +++ Sources ++ AAFP. Choosing Wisely: Scoliosis in Adolescents. 2013. USPSTF. Screening for Adolescents Idiopathic Scoliosis. 2017. + SPEECH AND LANGUAGE DELAY Download Section PDF Listen +++ +++ Population ++ Preschool children. +++ Recommendation +++ AAFP 2015, USPSTF 2015 ++ Evidence is insufficient to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to age 5 y. +++ Sources ++ AAFP. Clinical Recommendation: Speech and Language Delay. 2015. Pediatrics. 2015;136(2):e474-481. +++ Comments ++ Fair evidence suggests that interventions can improve the results of short-term assessments of speech and language skills; however, no studies have assessed long-term consequences. In a study of 9000 toddlers in the Netherlands, 2-time screening for language delays reduced the number of children who required special education (2.7% vs. 3.7%) and reduced deficient language performance (8.8% vs. 9.7%) at age 8 y. (Pediatrics. 2007;120:1317) Studies have not fully addressed the potential harms of screening or interventions for speech and language delays, such as labeling, parental anxiety, or unnecessary evaluation and intervention. Insufficient evidence to recommend a specific test, but parent-administered tools are best (eg, Communicative Development Inventory, Infant-Toddler Checklist, Language Development Survey, Ages and Stages Questionnaire). +++ Population ++ Children. +++ Recommendation +++ AAP 2014 ++ Screen using validated test during well child checks at 9, 18, and 24/30 mo. +++ Sources ++ Pediatrics. 2006;118(1):405. Pediatrics. 2015;136(2):e448. + SUICIDE RISK Download Section PDF Listen +++ +++ Population ++ Adolescents. +++ Recommendation +++ AAP 2016 ++ Ask questions about suicidal thoughts in routine history taking throughout adolescence. +++ Source ++ Pediatrics. 2016. Suicide and Suicide Attempts in Adolescents. + TOBACCO USE Download Section PDF Listen +++ +++ Population ++ Children and adolescents. +++ Recommendations +++ USPSTF 2013 ++ Provide interventions, including education or brief counseling to prevent initiation of tobacco use in school-aged children and adolescents. +++ ICSI 2013 ++ Screen for tobacco use beginning at age 10, and reassess at every opportunity. +++ Sources ++ ICSI. Preventive Services for Children and Adolescents. 19th ed. 2013. USPSTF. Tobacco Use Interventions: Children and Adolescents. 2013. +++ Comment ++ Children and adolescents should avoid tobacco use. It is uncertain whether advice and counseling by health care professionals in this area is effective. + TUBERCULOSIS, LATENT Download Section PDF Listen +++ +++ Population ++ Persons at increased risk of developing tuberculosis (TB). +++ Recommendation +++ USPSTF 2016, CDC 2010 ++ Screen by tuberculin skin test (TST) or interferon-gamma release assay (IGRA). Frequency of testing is based on likelihood of further exposure to TB and level of confidence in the accuracy of the results. +++ Sources ++ JAMA. 2016;316(9):962-969. CDC MWWR. 2010;59(RR-5). +++ Comments ++ Risk factors include birth or residence in a country with increased TB prevalence and residence in a congregate setting (shelters, correctional facilities). Typically, a TST is used to screen for latent TB. IGRA is preferred if: Testing persons who have a low likelihood of returning to have their TST read. Testing persons who have received a bacille Calmette–Guérin (BCG) vaccination. + VISUAL IMPAIRMENT Download Section PDF Listen +++ +++ Population ++ Children 3–5 y. +++ Recommendations +++ USPSTF 2017 ++ Screen vision for all children 3–5 y at least once to detect amblyopia. Insufficient evidence for vision screening in children <3 y of age. +++ Sources ++ USPSTF. Vision Screening in Children Aged 6 Months to 5 Years. 2017. JAMA. 2017;318(9):836-844. +++ Comment ++ May screen with a visual acuity test, a stereoacuity test, a cover–uncover test, and the Hirschberg light reflex test.