Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- October 2008.

This guideline is intended to assist in the prioritization of screening maneuvers, tests and counseling opportunities. It is not intended to diagnose or treat any condition. Consequently, once a health issue or condition has been uncovered, other ICSI guidelines (such as "Prevention and Management of Obesity [Mature Adolescents and Adults]" guideline) will take precedence during any further diagnosis and management.

Recommendations for preventive services for children and adolescents are presented in the form of an algorithm with 6 components, accompanied by detailed annotations. An algorithm is provided for Preventive Services for Children and Adolescents. Clinical highlights follow.

Class of evidence (A-D, M, R, X) definitions are provided at the end of the "Major Recommendations" field.

Preventive services in this guideline are grouped into four groups, based on their evidence of effectiveness and their priority ranking, as follows:

Level I Preventive Services that providers and care systems must deliver (based on best evidence). (Annotation #2)

Level II Preventive Services that providers and care systems should deliver (based on good evidence). (Annotation #3)

Level III Preventive Services for which the evidence is currently incomplete and/or high burden and low cost, therefore left to the judgment of individual medical groups, clinicians and their patients. (Annotation #4)

Level IV Preventive services that are not supported by evidence and not recommended. (Annotation #5)

Table 1: Child Preventive Services That Providers and Care Systems Must Deliver (Based on Best Evidence) (Level I)

Childhood Immunization Series

Routine Immunization Schedule for Infants, Children, and Adolescents

Please check manufacturer for specifications for dosing, as all intervals may not be needed.

For the latest information on vaccine shortages, please see the CDC Web site at: http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm.

Abbreviations: DTaP, diphtheria, tetanus, acellular pertussis; IPV, inactivated poliovirus vaccine; MMR, measles, mumps, and rubella; MMRV, measles, mumps, rubella and varicella vaccine; Hib, Haemophilus influenzae type b; Hep B, hepatitis B; Hep A, hepatitis A; Tdap, tetanus-diphtheria toxoid

Table 2: Child Preventive Services That Providers and Care Systems Should Deliver (Based on Good Evidence) (Level II)

Preventive Services for Which the Evidence Is Currently Incomplete and/or High Burden and Low Cost, Therefore Left to the Judgment of Individual Medical Groups, Clinicians and Their Patients (Level III)

• Alcohol use screening and counseling
• Blood lead screening
• Cervical cancer screening
• Clinical breast exam screening
• Dental and periodontal disease counseling
• Developmental/behavioral assessment screening
• Domestic violence and abuse screening and counseling
• Dyslipidemia screening
• Dysplasia of the hip screening
• Folic acid chemoprophylaxis counseling
• Household and recreational injury prevention screening
• Infectious disease prevention screening
• Iron deficiency screening
• Nutritional counseling
• Preconception counseling
• Pregnancy prevention counseling
• Scoliosis screening
• Secondhand smoke exposure counseling
• Sexually transmitted infection (other than Chlamydia) counseling
• Sexually transmitted infection (other than Chlamydia) screening
• Skin cancer screening and counseling
• Undescended testicles screening

Preventive Services That Are Not Supported by Evidence and Not Recommended (Level IV)

Level IV services are those with low predictive value and/or uncertain beneficial action for true positives.

• Blood chemistry screening
• Child maltreatment screening
• Hemoglobin (for anemia screening five years and older)
• Tuberculin skin screening (for average risk)
• Urinalysis

Clinical Highlights

• All clinic visits—whether acute, chronic, or for preventive service —are opportunities for prevention. Incorporate appropriate preventive services at every opportunity. (Annotation #1)
• Address or initiate child preventive services that providers and care systems must deliver (based on best evidence) (Level 1). (Annotation #2; Aims #1, 4, 6)
  • Childhood immunization series
  • Chlamydia screening
  • Vision impairment screening
• Provide timely feedback, appropriate interventions, and optimal follow-up. (Annotation #6)

Preventive Services for Children and Adolescents Algorithm Annotations

1. System Support Alert for Preventive Services

   In order to provide consistent, high-quality care, the identification and delivery of preventive services needed by each patient require a systematic care team-based approach rather than relying solely on the memory and actions of individual clinicians. Components of system support include not only standing orders, task delegation, and automatic reminders, but concepts such as previsit planning, postvisit or between-visit outreach, decision support, system alerts, shared decision-making, patient activation, and care management [R].

   In order to provide preventive services, it is first necessary to know which services are needed for individual patients. This includes both knowing when the last services were provided and an evaluation of individual risk factors. The National Guideline Clearinghouse (NGC) summary of the Institute for Clinical Systems Improvement (ICSI) guideline Primary Prevention of Chronic Disease Risk Factors can be a helpful starting point. As the dates of latest service and risk factors are identified, they should be recorded in the medical record in a way that facilitates visualization and action during visits.

   Nearly every patient contact for any reason should be used to identify and address preventive service needs. A system that supports preventive care should include both the patient and the whole care team. However, the work group recognizes that urgent or emergent visits or even routine visits may not always present preventive service opportunities. In order to facilitate the necessary prioritization of services when time is limited, the work group has separated effective services into two groups so that those services that have the largest impact and are most cost effective can be addressed first. This prioritization can be used during individual patient visits, as well as by the clinic or medical group in developing or improving practice systems for addressing the needs of whole clinic populations.

2. Preventive Services That Providers and Care Systems Must Deliver (Based on Best Evidence). (Level I)

   Level I preventive services are worthy of attention at every visit. Busy clinicians cannot deliver this many services in any single visit. However, with systems in place to track whether or not patients are up-to-date with the high-priority preventive services recommended for their age group, clinicians can offer the high-priority services as opportunities present.

   Childhood Immunization Series (Level I)

   Service

   Providers must screen and immunize infants, children, and adolescents for age-appropriate vaccines.

   Refer to Table 1 above for routine immunization schedule for infants, children, and adolescents.

   Counseling Messages

   Educate parents to immunize children according to age-appropriate schedule.

   Related Guidelines

   See the NGC summary of the ICSI Immunizations guideline.

   Chlamydia Screening (Level I)

   Services

   Routine screening for chlamydia must be performed for all sexually active women aged 25 years and younger [M], [R].

   Risk factors include:

   • Having new or multiple sex partners
   • Having a prior history of a sexually transmitted infection (STI)
   • Not using condoms consistently and correctly

   Refer to the original guideline document for information on burden of suffering.

   Efficacy

   The sensitivity of available screening tests for chlamydia infection is 80% and higher [M]. The U.S. Preventive Services Task Force does not recommend a specific screening test as studies have generally been performed in ideal circumstances in small populations with high prevalence rates. However, the U.S. Preventive Services Task Force concluded that nucleic acid amplification tests had higher sensitivities and specificities than older antigen detection tests and better sensitivities than culture [M]. Following detection, treatment with antibiotics approaches 100% efficacy. Two randomized studies have observed a decrease in pelvic inflammatory disease following chlamydia screening [A], [C].

   Neonatal Screening (Level I)

   Service

   Screening in the first week of life for conditions that are initially asymptomatic but that result in serious health issues in the first month of life must be performed for hemoglobinopathies [M], phenylketonuria [M], and hypothyroidism [M] and other conditions according to state law.

   Efficacy

   Newborn screening for metabolic and other disorders is designed to detect infants with serious health conditions that are initially asymptomatic like inborn errors of metabolism and hypothyroidism. Early identification in many cases can avert a poor outcome for a child with various interventions, depending on the condition. There is strong evidence to support screening for hemoglobinopathies [M], phenylketonuria [M], and hypothyroidism [M]. Approximately 4,000 infants per year are identified with a condition through the newborn metabolic screening program. Each state varies on the test required to be done by law, but a uniform approach with all states using mass spectrometry is being promoted by various national groups (http://www.mchb.hrsa.gov/screening).

   Counseling Message

   All infants should receive a newborn metabolic screening test prior to hospital discharge, ideally when greater than 24 hours of age. Infants who receive screening before 24 hours of age should receive a repeat test before the second week of age.

   System alerts should provide notice of positive results. Appropriate follow-up services must be provided for any child with a positive test.

   Vision Impairment Screening (Level I)

   Service

   Vision screening must be performed for children four years old and younger. Screening should be used to detect amblyopia, strabismus, and defects in visual acuity. By age five, vision screening should be performed in the clinic or school as part of preschool screening [M].

   Efficacy

   No direct evidence demonstrates that vision screening and early treatment in children lead to improved visual acuity and/or other outcomes such as school performance. The U.S. Preventive Services Task Force concluded that effectiveness of screening in preschool children is supported by indirect evidence that screening is effective in identifying strabismus and amblyopia, treatment of strabismus and amblyopia is effective, and more intensive screening leads to improved visual acuity compared to usual screening [M]. A single randomized control trial demonstrated that children randomized to more intensive screening between 8 and 37 months of age had a lower prevalence of severe amblyopia, and at 7.5 years of age lower prevalence of amblyopia after treatment [A].

   A prospective study of two matched cohorts of over 700 preschool children each in Ontario found that 3% of children screened before entry to school had moderate to severe vision impairment (visual acuity 20/50 or greater) compared to 6% of children in the matched cohort screened 6-12 months later, indicating that effectiveness of treatment is approximately 50% [B]. Those found to have vision problems using the illiterate E screening instrument were referred to their family doctor.

   Counseling Messages

   Normal objective vision screening performed at schools need not be repeated by clinics for average-risk, asymptomatic children [A].

3. Preventive Services That Providers and Care Systems Should Deliver (Based on Good Evidence (Level II)

   Level II services have been shown to be effective and should be provided whenever possible. If systems/care management teams are successful in keeping patients on time with high-priority services during illness and disease management visits, preventive services in the second group can be delivered.

   Refer to Table 2 above for information on Level II preventive services.

   Hearing Screening (Level II)

   Service

   Universal screening of infants for congenital hearing loss should be performed before one month of age [M].

   Efficacy

   There is good evidence to recommend newborn hearing screening by otoacoustic emissions (OAE) and/or auditory brainstem response (ABR) prior to one month of age [M]. Screening for asymptomatic hearing impairment beyond age three is not recommended, although thorough follow-up should be provided of potential cases identified by symptoms or through school-based screening programs [M].

   The U.S. Preventive Services Task Force found good evidence to recommend universal newborn hearing screening. The testing methodology of a one- or two-step validated protocol showed high sensitivity (0.92) and specificity (0.98) for the two-step protocol (otoacoustic emissions followed by auditory brainstem response for those who failed otoacoustic emissions) [C]. There is good evidence that screening improves outcomes [C]. Harms of screening in this age group were felt to be minimal.

   After age three, undetected hearing problems are rare, and the majority of cases can be identified by thorough examination of children with otitis media with effusion. There is insufficient evidence on the effectiveness of early detection in asymptomatic children [M].

   Infant Sleep Positioning and Sudden Infant Death Syndrome (SIDS) Counseling (Level II)

   Service

   Providers should ask how child is positioned for sleep. Inform parents of importance of back-sleeping position. Demonstrate the appropriate sleeping position when the patient is under medical care.

   Refer to the original guideline document for information on efficacy of SIDS counseling and burden of suffering.

   Counseling Message

   Infants should be placed on their back for sleep. Side sleeping is no longer recognized as an alternative position. Parents should be advised about the appropriate sleeping position starting in the newborn nursery. Health care workers should be careful to place babies on their back to demonstrate to parents the appropriate sleeping position. Continued work to educate all potential caregivers of infants should be supported.

   Infant sleep surfaces should be firm and there should be no loose bedding or soft objects around the infant.

   Parents should be encouraged not to smoke, as a no-smoking environment has many important health benefits. Smoking during pregnancy has been shown to be associated with increased risk of SIDS [R].

   A proximate but separate sleeping environment and the use of pacifiers have been recommended [R]. These should be discussed with parents in the context of fully supporting breastfeeding.

   Motor Vehicle Safety Screening and Counseling (Level II)

   Service

   Providers should ask the following:

   Ask about the use of car seats, booster seats, and seat belts in the family.

   Ask about helmet use in motorcycle riders.

   Refer to the original guideline document for information on the efficacy of counseling and burden of suffering from motor vehicle injuries.

   Counseling Messages

   Age Group - Birth to 9 Years

   • Install and use federally approved child safety seats.
   • Discuss the fact that infants should face the rear of the vehicle until they are both 1 year of age and 20 pounds, and should not be placed in any seat with an air bag. (Best: middle rear seat) [R].
   • All children under four years of age must ride in appropriate car seat.
   • Discuss the fact that children between four and nine years and weighing less than 80 pounds should be in a belt positioning booster seat [R].

   All Individuals, Including Older Children and Drivers of Motor-Vehicles with Child Passengers

   • Discuss always wearing a safety belt when driving or riding in a car. Discuss the fact that 50% of death and disability from motor vehicle accidents can be prevented when passengers routinely wear seat belts.
   • Do not drive or ride in a motor vehicle when the driver is under the influence of alcohol or drugs.
   • Discuss the fact that passengers should not ride in cargo areas of any vehicle.
   • The safest way to travel is to ensure that EVERYONE in the vehicle is correctly buckled up and that all children under age 13 ride in the back seat.
   • Front passenger seats should be moved as far back as possible.
   • Motorcycle riders should always wear helmets to reduce the risk of head injury.

   Obesity Screening (Level II)

   Service

   Height, weight, and body mass index (BMI) should be recorded annually beginning at age two as part of a normal visit schedule.

   Refer to the original guideline document for information on efficacy of obesity screening.

   Counseling Messages

   Encourage wholesome eating and physical activity.

   2-18 years

   Encourage:

   • Consumption of fruits, vegetables, whole grains, and low-fat dairy products
   • Limiting total fat, especially saturated, trans fats, and cholesterol
   • Daily participation of 30 to 60 minutes of moderate to vigorous physical activity appropriate for age
   • Regular meals

   Discourage:

   • Foods with added sugars
   • Sweetened beverages
   • Television and video games; limit to one hour per day [R]

   Related Guidelines

   ICSI's Technology Assessment Report on Treatment of Obesity in Children and Adolescents and the NGC summary of ICSI guideline Prevention and Management of Obesity (Mature Adolescents and Adults).

   Tobacco Use Screening, Prevention, and Intervention in Adolescents (Level II)

   Service

   Providers should establish tobacco use and secondhand smoke exposure and reassess at every opportunity. (See section on Secondhand Smoke Exposure in the original guideline document).

   Reinforce non-users to continue non-use of tobacco products.

   Offer tobacco cessation services on a regular basis to all patients who use tobacco. (All forms of tobacco should be considered.)

   Efficacy

   Tobacco use is the single most preventable cause of death and disease in our society. There is good evidence that tobacco cessation interventions are best carried out when the entire clinical staff is organized to provide these services. The recommended clinical intervention incorporates the scientifically based concept of readiness stages for behavior change. It appears that these stages can focus the clinician message and make it more effective and feasible [R].

   Structured physician clinical-based smoking cessation counseling is more effective than usual care in reducing smoking rates [A]. The addition of telephone-based counseling may result in further improvements in cessation [A]. The success of this approach in the adult population has led to the adoption of the same approach in the pediatric population. Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.

   Two treatment elements are effective for tobacco cessation intervention: social support for cessation and skills training/problem-solving. The more intense the treatment, the more effective it is in achieving long-term abstinence from tobacco.

   The key components of successful tobacco cessation interventions are to:

   • Ask about tobacco use and smoke exposure at every opportunity.
   • Advise all users to quit.
   • Assess willingness to make a quit effort.
   • Assist users' willingness to make a quit attempt.
   • Arrange follow-up.

   Counseling Message

   For children and adolescents aged 10 years and above and the child or adolescent is using tobacco:

   • Emphasize short-term negative effects of tobacco use.
   • Advise tobacco users to quit.
   • Assess user's willingness to make a quit attempt.
   • Provide counseling depending on readiness-to-quit stage. Provide a motivational intervention if the user is not ready to make a quit effort.
   • Assist in quitting if ready to make a quit effort. Negotiate a quit date. Counsel to support cessation and build abstinence skills. Offer phone line for more assistance.
   • Arrange follow-up to occur soon after the quit date.

   For all ages:

   • If accompanying household member uses tobacco, encourage member to quit. If the member user is interested in quitting, encourage a visit at his or her clinic for more cessation assistance.
   • Provide educational and self-help materials.

4. Preventive Services for Which the Evidence Is Currently Incomplete and/or High Burden and Low Cost, Therefore Left to the Judgment of Individual Medical Groups, Clinicians and Their Patients (Level III)

   Level III services either have insufficient evidence to prove their effectiveness and/or have important harms. For these preventive services in particular, decisions about offering the service should be made on a patient-by-patient basis. It is important to remember that insufficient evidence does not mean the service is not effective, but rather that the current literature is not sufficient to say whether or not the service is effective.

   The list of Level III preventive services is provided at the beginning of the "Major Recommendations" field. Please refer to the original guideline document for information on Level III preventive services.

5. Preventive Services That Are Not Supported by Evidence and Not Recommended (Level IV)

   Level IV services are those with low predictive value and/or uncertain beneficial action for true positives. They may also be a combination of insufficient evidence, potential for harm in treatment, no defined benefit and/or overuse.

   The list of Level IV preventive services is provided at the beginning of "Major Recommendations" field. Please refer to the original guideline document for detailed information on Level IV preventive services.

6. Care Coordination

   Although some individuals, following health risk assessments and screening tests, will initiate and sustain lifestyle changes on their own, most will require some degree of structured feedback and follow-up to achieve even modest improvements. Patient-centered health care systems should implement evidence-based changes to ensure consistent follow-up of conditions and risk factors, and support for healthier lifestyles.

   Timely feedback

   • Clear, strong personal message
   • Include documentation of "lifestyle vital signs"

   Appropriate interventions

   • Integrate into decision support
   • If screening and/or counseling results warrant treatment, see treatment guidelines

   Optimal follow-up

   • Plan for and anticipate upcoming preventive service needs. Electronic systems may be particularly beneficial for advanced ordering of services
   • Providing preventive screening and counseling services
   • If screening and/or counseling results warrant additional follow-up, proceed as indicated. See also treatment guidelines, as noted in the specific topic sections

Definitions:

Classes of Research Reports:

1. Primary Reports of New Data Collection:

   Class A:

   • Randomized, controlled trial

   Class B:

   • Cohort study

   Class C:

   • Non-randomized trial with concurrent or historical controls
   • Case-control study
   • Study of sensitivity and specificity of a diagnostic test
   • Population-based descriptive study

   Class D:

   • Cross-sectional study
   • Case series
   • Case report

2. Reports that Synthesize or Reflect upon Collections of Primary Reports:

   Class M:

   • Meta-analysis
   • Systematic review
   • Decision analysis
   • Cost-effectiveness analysis

   Class R:

   • Consensus statement
   • Consensus report
   • Narrative review

   Class X:

   • Medical opinion

A detailed and annotated clinical algorithm is provided for Preventive Services for Children and Adolescents.

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org.

ICSI's conflict of interest policy and procedures are available for review on ICSI's website at www.icsi.org.

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

• Preventive services for children and adolescents. Executive summary. Bloomington (MN): Institute for Clinical Systems Improvement, 2008 Oct. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the Institute for Clinical Systems Improvement (ICSI) Web site.
• ICSI pocket guidelines. May 2007 edition. Bloomington (MN): Institute for Clinical Systems Improvement, 2007.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

Electronic copies: Available in Portable Document Format (PDF) from the Institute for Clinical Systems Improvement (ICSI) Web site.

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