Screening Test For Children and Teenagers

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Screening tests in children and adolescents
Author: Nancy R Kelly, MD, MPH

Section Editor: Jan E Drutz, MD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2018. | This topic last updated: Mar 26, 2018.
INTRODUCTION — The schedule of and recommendations for common screening tests in children in the
United States will be reviewed here. The specific diseases and conditions are discussed separately.
OVERVIEW
General principles — Screening is defined as testing for disease in an individual or population that appears
to be healthy [1]. The goal of screening is to identify children who are at increased risk of disease and warrant
additional testing.
The following characteristics of a disease render it a good candidate for screening [1]:
● Substantial morbidity or mortality occurs if the disease is untreated
● The prevalence warrants testing in an apparently healthy population
● The existence of a preclinical phase is detectable by the test
● A cost-effective treatment is available
● Preclinical detection of disease provides some benefit (eg, improved prognosis, ease of treatment,
decreased risk of transmission to others)
Screening tests for diseases conducive to screening should [1,2]:
● Be easy to perform and interpret
● Measure something directly related to the disease
● Have low risk, morbidity, and cost
● Be highly sensitive and specific
Adverse effects of screening that must be weighed against the potential benefits include [2,3]:
● False-positive test results must be followed up
● False-negative test results may delay diagnosis
● The cost of the screening program may compete with the cost of diagnosis, treatment, or primary
prevention efforts
Test characteristics — In choosing an appropriate screening test, the sensitivity, specificity, and predictive
value of the test must be considered [2,3]. These concepts are depicted in the classic 2 x 2 table (table 1).
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(See "Glossary of common biostatistical and epidemiological terms".)

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● Sensitivity – Proportion of individualsContinue
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disease and have a positive test result.
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● Specificity – Proportion of individuals who do not have the disease and have a negative test result.
The best screening tests have a high sensitivity (few false negatives) so that individuals who have the disease
are identified by the screening test. A test that has a high specificity (few false positives) is also desired so that
individuals are not erroneously labeled as having disease when they are disease free.
In addition to sensitivity and specificity, interpretation of test results also depends upon the test's predictive
value:
● Positive-predictive value – The proportion of patients with a positive test that have the disease.
● Negative-predictive value – The proportion of patients with a negative test that do not have disease.
The predictive values (and the proportion of positive and negative evaluations that can be expected) depend
upon the prevalence of a disease within a population. Thus, for given values of sensitivity and specificity, a
patient with a positive test is more likely to truly have the disease if the patient belongs to a population with a
high prevalence of the disease (figure 1). (See "Glossary of common biostatistical and epidemiological terms".)
Types of screening — There are two types of screening programs:
● Universal (or population) screening refers to the screening of every individual within a population
● Selective (targeted or risk-based) screening refers to the screening of individuals for whom there is
reason to believe that the screening may be positive
Selective screening increases the positive predictive value of a test by increasing the prevalence of the
disease in the population that is screened (figure 1).
Screening guidelines — In pediatric practice, screening is routinely performed for a number of conditions,
as discussed below. For most of these conditions, there is a lack of direct evidence from randomized controlled
trials supporting the beneficial effects of screening and/or quantifying the potential benefits and harms. The
lack of evidence does not necessarily mean that screening is not beneficial, only that it has not yet been
adequately tested.
When deciding whether screening should be performed, the potential benefits and harms of screening must be
considered. The balance between risks and benefits varies depending upon the condition, the clinical
circumstances of the child and family, the availability of resources, and the values that patients (or patients'
caregivers) place on the potential benefits and harms [4].
For many conditions, screening is regulated by local, state, or federal policies. In addition, recommendations
regarding screening for various conditions are made by several professional groups and updated periodically.
In the United States, these groups include:
● The American Academy of Pediatrics and Bright Futures [5-8]
● The American Academy of Family Physicians [9]
● The United States Preventive Services Task Force
● The Centers for Disease Control and Prevention
Recommendations regarding screening vary from country to country. The information below focuses on
screening in the United States. A discussion of screening recommendations for other countries is beyond the
scope of this topic review. Policies for individual countries may be available online (eg, United Kingdom,
Canada).
Continue or find out more.
State mandates for school screening — Within the United States, each state has its own mandates for
school health screening. Most states require schools to assess students' vision and hearing at specific ages. In
addition, some states require screening for oral health problems, elevated body mass index, type 2 diabetes,
asthma, or scoliosis. The National Association of State Boards of Education provides information regarding
state-specific mandates for school health screening.
COMMON SCREENING TESTS IN PEDIATRICS
Newborn genetic and metabolic screen — In the United States, programs for screening newborns for
genetic and metabolic disease vary from state to state. Clinicians should comply with local regulations. All
states test for phenylketonuria and congenital hypothyroidism. (See "Overview of phenylketonuria", section on
'Diagnosis' and "Clinical features and detection of congenital hypothyroidism", section on 'Newborn
screening'.)
Other diseases that may be included in the newborn screen are biotinidase deficiency, maple syrup urine
disease, congenital adrenal hyperplasia, cystic fibrosis, galactosemia, homocystinuria, hemoglobinopathies,
toxoplasmosis, and tyrosinemia. Newborn screening is discussed in detail separately. (See "Newborn
screening".)
Newborn bilirubin screening — Newborn bilirubin screening is discussed separately. (See "Evaluation of
unconjugated hyperbilirubinemia in term and late preterm infants", section on 'Universal screening'.)
Critical congenital heart disease — Screening newborns for critical congenital heart disease using pulse
oximetry is discussed separately. (See "Newborn screening for critical congenital heart disease using pulse
oximetry".)
Hearing screen — Significant bilateral hearing loss is present in 0.1 to 0.3 percent of newborn infants in the
well-baby nursery population and in 2 to 4 percent in the neonatal intensive care population [10]. In addition,
hearing loss of at least 16 dB in either low- or high-frequency range is present in approximately 15 percent of
children aged 6 to 19 years [11]. Causes of hearing loss are discussed separately. (See "Hearing loss in
children: Etiology".)
Newborns — In the United States, programs for universal hearing screening vary from state to state.
Clinicians should comply with local regulations. The American Academy of Pediatrics (AAP) recommends
universal hearing screening for all newborns by one month of age, with a goal of detecting hearing loss in
infants before three months of age, and appropriate intervention no later than six months of age [12]. The
American Academy of Family Physicians (AAFP) and United States Preventive Services Task Force (USPSTF)
found insufficient evidence to make a recommendation for or against universal newborn hearing screening
[9,13].
Newborn hearing screening is discussed separately. (See "Screening the newborn for hearing loss".)
Infants and children — Hearing screening beyond the newborn period is necessary to identify children
with hearing loss that is acquired (eg, from meningitis, trauma, noise exposure), progressive (eg, related to
particular neurodegenerative syndromes), has delayed onset (eg, intrauterine infection), or was not detected
on newborn hearing screen [14-16]. (See "Hearing loss in children: Etiology".)
Although most children with hearing impairment are identified before they begin school [17], some cases are
missed [18]. In accord with the AAP/Bright Futures guidelines, we suggest a hearing risk assessment at all
health maintenance visits and periodic hearing screening between 4 and 10 years of age [6,8]. The AAP/Bright
Futures guidelines suggest hearing screening if risk factors are identified during risk assessment at any health
maintenance visit and for all children at 4, 5, 6, 8, and 10 years; audiometry screening that includes 6000 and
8000 hertz frequencies is recommended once between 11 and 14 years, once between 15 and 17 years, and
once between 18 and 21 years [6,8,19]. These suggestions place a high value on the potential for improved
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● Risk assessment – Hearing risk assessment consists of auditory skills monitoring, developmental
surveillance, and assessment of parental concern [19,20]. Additional risk factors associated with an
increased risk of permanent congenital, delayed-onset, or progressive hearing loss in childhood include
[12,19,21]:
• Caregiver concerns regarding hearing, speech, language or developmental delay
• Family history of permanent childhood hearing loss (however, because most hereditary hearing loss
is autosomal recessive, many children with hereditary hearing loss may not have affected relatives)
• Neonatal intensive care unit (NICU) stay of >5 days
• NICU stay (regardless of duration) requiring extracorporeal membrane oxygenation, assisted

ventilation, exchange transfusion for hyperbilirubinemia, or exposure to ototoxic drugs or loop
diuretics
• Congenital or central nervous system infections
• Ototoxic drug exposure, including chemotherapy
• Congenital head and neck deformities (eg, anomalies of the pinna or temporal bone, ear canal, ear
tags, ear pits) and trauma (particularly basal skull and temporal bone fractures)
• Neurodegenerative disorders
• Syndromes associated with hearing loss (table 2)
• Chronic or recurrent otitis media with effusion
• Anatomic deformities and other disorders that affect eustachian tube function
Children with one or more of the above risk factors should have at least one diagnostic audiology assessment
by 24 to 30 months of age and ongoing developmentally appropriate hearing screening [19]. (See "Hearing
impairment in children: Evaluation".)
The use of digital music players is another risk factor that must be considered, particularly if they are used for
extended periods of time and at high volume [22]. (See "Hearing loss in children: Etiology", section on 'Noise
exposure'.)
The following questions can be used to identify older children and adolescents for whom a hearing screen may
be necessary [23]:
● Do you have a problem hearing over the telephone?
● Do you have trouble following the conversation when two or more people are talking at the same time?
● Do others complain that you turn the television volume too high?
● Do you have to strain to understand conversation?
● Do you have trouble hearing in a noisy background?
● Do you find yourself asking other people to repeat themselves?
● Do many people you talk to seem to mumble (or not speak clearly)?
● Do you misunderstand what others are saying and respond inappropriately?

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● Do people get annoyed because you misunderstand what they say?
● Screening methods – In older children, hearing can be screened in the office setting with any of the
following methods:
• Otoacoustic emissions [24]
• In-office audiology [6]
• Otoscope audiograms [25]
Children who fail hearing screening by any of these methods should be referred for formal audiologic testing,
as should all children who are at risk for hearing loss [19]. The abnormal results should be explained to the
parents, and the child's medical record should be flagged to facilitate follow-up. (See "Hearing impairment in
children: Evaluation".)
Vision screen — Screening for vision problems varies with the age of the child.
Children <5 years — The prevalence of undetected vision problems in preschool children is estimated to
be 5 to 10 percent [26]. One to 3 percent have amblyopia ("lazy eye," loss of vision due to disuse) that usually
develops between infancy and five to seven years of age [27]. Early detection and treatment of amblyopia
improves the prognosis for normal eye development. (See "Visual development and vision assessment in
infants and children" and "Amblyopia in children: Classification, screening, and evaluation", section on
'Epidemiology'.)
In accord with the AAP, AAFP, and USPSTF, we recommend screening to detect amblyopia, strabismus, and
defects in visual acuity in children younger than five years of age (table 3) [6,8,9,28] (see "Visual development
and vision assessment in infants and children"). The AAP/Bright Futures guidelines suggest vision risk
assessment at all health maintenance visits, and vision screening or referral, as indicated, if risk factors are
identified [6,8]. If available, a photoscreener or autorefractor may be used for vision risk assessment in
children beginning at age 12 months [7]. (See "Visual development and vision assessment in infants and
children", section on 'Instrument-based screening'.)
Risk factors for vision problems include a history of prematurity; family history of congenital cataracts,
retinoblastoma, and metabolic or genetic disease; significant developmental delay or neurologic difficulty; and
systemic diseases associated with eye problems [29]. Parents should be asked [29,30]:
● Does the child seem to see well?
● Does the child have any difficulty seeing objects that are near-by (eg, arm's length) or further away (eg,
more than several feet)?
● Does the child hold objects close to his or her face when trying to focus?
● Do the child's eyes appear straight, or do they seem to cross or drift or seem lazy?
● Do the child's eyes appear unusual?
● Do the child's eyelids droop, or does one eyelid tend to close?
● Have the child's eyes ever been injured?
The AAP/Bright Futures guidelines suggest vision screening at three and four years of age [6,8]. Vision
screening should include tests of monocular distance acuity (table 3) [8,31,32]. For children who are unable to
cooperate with visual acuity screening, we repeat screening within one to six months. Referral to an
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Systematic reviews of vision screening tests for the detection of amblyopia found few high-quality data
regarding the performance of preschool vision screening [33-37]. However, because of the importance of early
detection, vision risk assessment should be performed at every well-child visit, with subsequent screening as
indicated [6,8].
Children ≥5 years — In accord with the AAP/Bright Futures guidelines, we suggest vision risk assessment
at all health maintenance visits, and vision screening or referral, as indicated, if risk factors are identified (table
3) [6,8]. We also suggest periodic assessment of visual acuity (vision screening) throughout childhood and
adolescence. For children ≥5 years of age, the AAP/Bright Futures guidelines suggest visual acuity
measurement at ages 5, 6, 8, 10, 12, and 15 years [6,8]. These suggestions place a high value on the
potential for improved outcome with early detection and intervention (compared to the cost, inconvenience,
and lost time necessary for follow-up of a potentially false-positive result). (See "Visual development and vision
assessment in infants and children", section on 'Visual history'.)
Data are limited regarding the prevalence of uncorrected refractive errors and undiagnosed vision problems in
school children and adolescents [38]. Evidence that early detection of refractive errors is associated with
important clinical benefits, compared to testing based on symptoms, is sparse [39].
The AAP, American Academy of Ophthalmology, the American Association of Certified Orthoptists, and the
American Association for Pediatric Ophthalmology and Strabismus recommend routine vision screening
beginning at three to four years of age, and every one to three years thereafter throughout childhood and
adolescence [6,8,32]. The USPSTF does not address screening for visual impairment in children older than
five years.
Development and behavior screens — The AAP/Bright Futures guidelines recommend developmental
screening at 9, 18, and 30 months of age and screening for autism spectrum disorder at 18 and 24 months of
age [6,8]. Developmental and behavioral screening are discussed separately. (See "Autism spectrum disorder:
Surveillance and screening in primary care", section on 'Guidelines for surveillance and screening' and
"Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'.)
Iron deficiency — The AAP/Bright Futures guidelines recommend risk assessment for iron deficiency anemia
at four months of age and measurement of hemoglobin or hematocrit at 12 months of age [6]. They also
suggest repeat risk assessment at 15, 18, 24, 30, and 36 months of age and annually thereafter. The risk
assessment at four months of age includes history of prematurity or low birth weight, and diet (ie, use of low-
iron formula or not receiving iron-fortified formula) [40,41]. Risk assessment after one year of age includes
questions about socioeconomic status (particularly children of Mexican American descent), limited access to
food, diets low in iron (eg, vegetarian diet), exposure to lead, and excessive menstrual bleeding (for girls who
are menstruating) [40,41]. The AAFP and USPSTF found insufficient evidence to recommend for or against
routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months [9,42].
Screening for iron deficiency in infants, children, and adolescents is discussed separately. (See "Iron
deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis",
section on 'Screening recommendations' and "Iron requirements and iron deficiency in adolescents", section
on 'Screening'.)
Lead poisoning
Background — In 2012, the Centers for Disease Control and Prevention (CDC) revised the definition for
elevated blood lead level (BLL) for children in the United States from 10 mcg/dL (0.48 micromol/L) to a
reference value based on the 97.5th percentile of the BLL distribution among children one to five years of age
[43,44]. The 2012 reference value is 5 mcg/dL (0.24 micromol/L); the reference value will be updated every
four years. This change emphasizes the absence of a specific threshold for lead's irreversible
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[45].
The revised definition is part of the CDC Advisory Committee on Childhood Lead Poisoning Prevention's
(ACCLPP) renewed emphasis on primary prevention of lead poisoning [44]. In addition, the ACCLPP
recommends that clinicians educate families about prevention of lead exposure and provide environmental
assessments to identify sources of lead exposure before testing children for lead poisoning. Blood lead
screening remains necessary to identify children for whom primary prevention is unsuccessful.
The goal of primary prevention is to minimize the neurodevelopmental effects of lead poisoning through source
control and early detection. (See "Childhood lead poisoning: Clinical manifestations and diagnosis" and
"Childhood lead poisoning: Exposure and prevention".)
As the prevalence of childhood lead poisoning declines, there has been a move from screening all children
(universal screening) to targeted screening of children at increased risk [46-54]. The AAP/Bright Futures
guidelines and the ACCLPP suggest that screening for lead poisoning should be done in accordance with
federal, state, and local laws as applicable [6,8,44,45]. Information regarding state screening plans is available
through the CDC. For children who live in states that do not have a state screening program in place, we
suggest universal lead testing during the ages of peak exposure; the AAP/Bright Futures guidelines and the
ACCLPP suggest universal lead testing for such children at ages 12 and 24 months [8,44]. (See "Childhood
lead poisoning: Exposure and prevention".)
The AAFP and USPSTF found insufficient evidence to recommend for or against routine screening for
elevated BLL children aged one to five years who are at increased risk of lead poisoning, and recommend
against routine screening in children who are at average risk [9,52,55]. The USPSTF found no direct evidence
from controlled studies that screening children resulted in improved health outcomes [52]. For children with
elevated BLL, they found conflicting evidence regarding the effectiveness of early detection and intervention.
Targeted testing — We agree with the AAP Council on Environmental Health suggestion for targeted
testing for lead poisoning with BLL for children 12 to 24 months of age who live in communities or census block
groups in the United States with one or more of the following [45,56]:
● Inadequate data on the prevalence of elevated BLLs
● ≥25 percent of housing built before 1960
● ≥5 percent of children 12 to 24 months of age with BLLs ≥5 mcg/dL (0.24 micromol/L)
In addition, children and adolescents between 6 months and 16 years of age who enter the United States as
an immigrant, refugee, or international adoptee should be tested for blood lead concentration at the time of
arrival (or at the initial pediatric health care visit if the results of the arrival test are not available) [54,57-59].
For such children between six months and six years, lead testing should be repeated three to six months after
placement in a permanent residence, regardless of the initial test results.
Lead risk assessment — The AAP/Bright Futures recommendations for preventive health care suggest
that the risk for lead poisoning be assessed at 6, 9, 12, 18, and 24 months of age, and annually thereafter
through six years of age [8]. The BLL should be checked if any risk is detected.
The risk of lead poisoning is increased in children who [45]:
● Live in or visit a home or child care facility with an identified lead hazard
● Live in or visit a home or child care facility that was built before 1960 and is in poor repair or was
renovated in the past six months [44,60]
Other exposures that may increase the of lead poisoning include folk remedies, certain types of ceramics,
pewter cookware, and certain parental occupations (eg, smelting, soldering, auto body repair) or hobbies
(table 4) [52,54]. Patient risk factors include inadequate nutrition, frequent hand-mouth activity, and
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(See "Childhood lead poisoning: Exposure Continue or find out
and prevention" and more.
"Childhood lead poisoning: Clinical
manifestations and diagnosis", section on 'History'.)
Screening for and management of lead poisoning in pregnant and lactating women is discussed separately.
(See "Adult occupational lead poisoning", section on 'Pregnancy and breastfeeding'.)
The management of children with lead poisoning is discussed separately. (See "Childhood lead poisoning:
Management".)
Measurement of BLL — Measurement of the BLL is the test for lead poisoning. Lead poisoning is
diagnosed if the BLL is ≥5 mcg/dL (0.24 micromol/L).
The BLL may be measured on a capillary or venous blood sample. Patients who have elevated lead on
capillary sampling should have confirmatory venous blood testing. (See "Childhood lead poisoning: Clinical
manifestations and diagnosis", section on 'Lead levels'.)
Venous BLLs may be inaccurately low if they were measured with Magellan Diagnostics LeadCare analyzers
[62,63]. Retesting is recommended for the following patients who had venous BLL performed using a
Magellan Diagnostics LeadCare analyzer:
● Children who had a BLL <10 mcg/dL (0.48 micromol/L) and were <6 years of age on May 17, 2017
● Pregnant or lactating women
For retesting, venous samples should be sent to Clinical Laboratory Improvement Amendments (CLIA)-
compliant laboratories that use inductively coupled plasma mass spectrometry or graphite furnace atomic
absorption spectrometry (also known as electrothermal atomic absorption spectrometry) instruments. Capillary
samples may be sent to CLIA-compliant laboratories using any CLIA-compliant analyzer (including Magellan
Diagnostics' LeadCare analyzers).
Oral health screening — In accord with the AAP/Bright Futures guidelines, we suggest oral health risk
assessment, including the need for fluoride supplementation, beginning at six months of age and referral to a
dental home at one year of age or as soon thereafter as possible [6,8]. The AAP/Bright Futures guidelines
recommend oral health risk assessment at six and nine months, and referral to a dental home at one year of
age, if a dental home is available [6,8]. Oral health risk assessment should continue at 18, 24, and 30 months
until a dental home is available. (See "Preventive dental care and counseling for infants and young children",
section on 'Risk assessment'.)
Latent tuberculosis — In accord with the AAP, AAFP, CDC, American Thoracic Society, and the Infectious
Disease Society of America, we recommend targeted screening for latent tuberculosis infection (LTBI)
[8,9,64,65]. The AAP/Bright Futures guidelines suggest tuberculosis risk assessment by one month of age, at
ages 6, 12, and 24 months, and annually thereafter [6,8]. Screening for latent tuberculosis in children is
discussed separately. (See "Latent tuberculosis infection in children".)
Urinalysis — The AAP no longer recommends a screening urinalysis for children [6,8,66,67].
Hypertension — We agree with the AAP/Bright Futures recommendations for hypertension screening [6,68].
● For children without risk factors or conditions associated with hypertension (table 5A-B), we measure
blood pressure (BP) annually at health supervision visits, beginning at age three years.
● For children <3 years with risk factors for hypertension (table 5A), we measure BP at all health supervision
visits.
● For children ≥3 years with risk factors for hypertension (table 5B), we measure BP at all health
encounters.
Children whose BP is >90th percentile for age, sex, and 5th percentile height require further evaluation, starting
with repeat blood pressure measurement. These values have a negative predictive value of >99 percent (table
6) [69]. They should be used only for identification of children and adolescents who need further evaluation.
Diagnosis of hypertension is based upon the child's age, sex, and actual height percentile. (See "Definition
and diagnosis of hypertension in children and adolescents", section on 'Diagnosis'.)
Lipid profile — The AAP/Bright Futures guidelines recommend dyslipidemia risk assessment at 2, 4, 6, 8, and
12 years, and annually thereafter [6,70]. They recommend dyslipidemia screening (a fasting lipid profile) once
at age 9 through 11 years and once at age 17 through 21 years.
Screening for dyslipidemia is discussed separately. (See "Pediatric prevention of adult cardiovascular disease:
Promoting a healthy lifestyle and identifying at-risk children", section on 'Identifying children at risk for CVD'
and "Dyslipidemia in children: Definition, screening, and diagnosis".)
Sickle cell disease or trait — Screening children and adolescents for sickle cell disease and sickle cell trait
are discussed separately. (See "Diagnosis of sickle cell disorders", section on 'Newborn screening' and "Sickle
cell trait", section on 'Screening'.)
Screening for STI — The screening of sexually active adolescents for sexually transmitted infections (STI) is
discussed separately. (See "Screening for sexually transmitted infections", section on 'Screening
recommendations'.)
Cervical dysplasia screening — The screening of sexually active female adolescents for cervical cancer is
discussed separately. (See "Screening for cervical cancer", section on 'Initial screening'.)
Tobacco, alcohol, and substance use — In accord with the AAP/Bright Futures guidelines, we suggest
annual screening for tobacco, alcohol, and substance use, typically beginning at age 11 years [6,71-73].
The AAP encourages clinicians to begin discussing the dangers of drinking alcohol with patients as young as
nine years of age [74]. Early initiation of this discussion is suggested because children begin to view alcohol
positively between 9 and 13 years of age (given the frequent exposure to alcohol advertising) and because
alcohol use is so common [75]. In a multisite survey of rural 1193 adolescents, approximately 2 percent of
those aged 12 through 14 years and 10 percent of those aged 15 through 20 years met the Diagnostic and
Statistics Manual of Mental Disorders, 5th edition (DSM-5) diagnostic criteria for alcohol use disorder (AUD),
according to self-reported frequency and quantity of alcohol use and DSM-5 AUD symptoms.
Data from the 2015 Youth Risk Behavior Surveillance System indicate that among high school students in the
United States [76]:
● Approximately 17 percent reported having their first drink of alcohol (more than a few sips) before they
were 13 years old
● Approximately 7 percent reported having smoked a whole cigarette before they were 13 years old
● Approximately 8 percent reported having tried marijuana before they were 13 years old
Early alcohol and substance use has been associated with increased risk of unintentional injuries, motor
vehicle crashes, abuse and dependence during adulthood, and alcohol-related health and social problems
during adulthood [77,78]. Binge drinking increases the risk of adverse outcomes [74]. (See "Substance use
disorder in adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and
diagnosis", section on 'Clinical consequences'.)
Despite the lack of evidence to support the counseling of adolescents in the primary care setting against
alcohol and substance use, the AAP/Bright Futures guidelines suggest risk assessment for alcohol and drug
use yearly, typically beginning at age 11 years [6,72,79], although screening for alcohol use may begin as
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The AAP/Bright Futures guidelines suggest asking the adolescent directly about experimentation with or use of
tobacco, alcohol, or drugs [6,72]. It is important to ask specifically about smokeless tobacco, electronic
cigarettes, inhalants, anabolic steroids, and nonmedical use of prescription stimulants [80-82]. If substance
use is reported, additional information is gathered regarding duration, amount, and frequency.
The AAP/Bright Futures guidelines suggest using the CRAFFT screen to identify problematic substance use.
The CRAFFT screen is a brief screening tool that has been validated in the adolescent primary care setting
[83,84]. The six CRAFFT screening questions are asked if the adolescent endorses drinking alcohol, smoking
marijuana or hashish, or using any other substance to get high during the previous 12 months. The CRAFFT
screening questions include:
● C(ar) – Have you ever ridden in a car driven by someone (including yourself) who was "high" or had been
using alcohol or drugs?
● R(elax) – Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
● A(lone) – Do you ever use alcohol or drugs while you are by yourself, alone?
● F(orget) – Do you ever forget things you did while using alcohol or drugs?
● F(riends) – Do your family or friends ever tell you that you should cut down on your drinking or drug use?
● T(rouble) – Have you ever gotten into trouble while you were using alcohol or drugs?
One point is scored for each "yes" answer. In a large, hospital-based adolescent clinic, a score of ≥2 had a
sensitivity and specificity of 76 and 94 percent, respectively, for identifying problem use (use associated with
adverse consequences), abuse (continued use despite harm), or dependence (associated with tolerance,
withdrawal) [83]. Exploration of "yes" responses on the CRAFFT screen and of problems related to substance
use may provide information that can be used in intervention [71]. In a multicenter observational study in 1573
racially and ethnically diverse adolescents (12 through 18 years of age), the sensitivity and specificity of the
CRAFFT screen were 98 percent (95% CI 91-100 percent) and 73 percent (95% CI 71-76 percent),
respectively, for alcohol use disorder and 88 percent (95% CI 83-92 percent) and 80 percent (95% CI 78-82
percent), respectively, for cannabis use disorder (using the Diagnostic Interview Schedule for Children Version
IV as the reference standard) [85].
Other screening tools that can be administered by an interviewer or self-administered and are sensitive and
specific in identifying substance use disorders as defined by the Diagnostic and Statistical Manual of Mental
Disorders, Fifth edition criteria include [71]:
● The Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) assesses the frequency of use during
the past 30 days, 90 days, and year [86]. Cutoffs of ≥6 days for tobacco and ≥2 days for alcohol or
marijuana correlated with problematic use. The BSTAD is available in the full text of reference [86].
● The Screening to Brief Intervention (S2BI) tool (available through the Massachusetts Child Psychiatry
Access Project) assesses the frequency of tobacco, alcohol, marijuana, and other/illicit drug use in the
past year [87]. It discriminates among clinically relevant use categories: no substance use disorder (SUD;
"once or twice"), mild or moderate SUD ("monthly"), and severe SUD ("weekly or more") [71].
Alcohol-only screening tools may be used if time does not permit full substance screening [74]. One such
screen was developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in collaboration with
the AAP (table 7) [88]. This screen focuses on friends drinking (an early warning signal and predictor of the
patient's future drinking levels) and frequency of drinking (a predictor of alcohol-related harm [89]). In a
multicenter observational study in 1573 racially and ethnically diverse adolescents (12 through 18 years of
age), the sensitivity and specificity of the NIAAA/AAP screen were 87 percent (95% CI 76-94 percent) and 84
This site
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Schedule for Children Version IV as the reference or find out more.
[85].
The AAP Substance Use Screening and Intervention Guide provides additional information about screening,
brief intervention, and referral to treatment [90].
Depression screening — In accord with the Bright Futures/AAP, we suggest universal screening for
depression annually from age 12 through 21 years [6,91]. We also suggest targeted screening for depression
in children ≥10 years and adolescents at high risk of depression, including those:
● With a personal or family history of depression, bipolar disorder, suicidality, substance use, or other
psychiatric illness
● With significant psychosocial stressors (eg, family crises, physical or sexual abuse, neglect, other trauma)
● With frequent somatic complaints
● Who are in foster care or have been adopted
Depression is an important risk factor for suicide, which is among the leading causes of death for children and
adolescents. Screening for suicide is discussed separately. (See "Suicidal ideation and behavior in children
and adolescents: Evaluation and management", section on 'Screening for suicidal ideation'.)
In nationwide surveys of high school students (1999 to 2013), approximately 29 percent of students reported
feeling so sad or hopeless every day for ≥2 weeks in a row that they stopped doing some usual activities [92].
Effective treatments for adolescent depression include medications (eg, selective serotonin reuptake
inhibitors) and psychotherapy (cognitive behavioral therapy or interpersonal therapy). (See "Suicidal behavior
in children and adolescents: Epidemiology and risk factors", section on 'Epidemiology' and "Overview of
prevention and treatment for pediatric depression", section on 'Acute treatment'.)
There is limited evidence to guide the choice of a depression screening tool [91]. A number of tools have been
evaluated in primary care practice, including depression-specific tools, broader psychosocial tools, and
combined tools for depression and other psychiatric disorders. Providers are encouraged to choose a tool that
will work best for their practice, patients, and health organizations. They are also encouraged to screen for
suicidality. (See "Suicidal ideation and behavior in children and adolescents: Evaluation and management",
section on 'Screening for suicidal ideation'.)
The Bright Futures/AAP recommendations for preventive pediatric health care suggest that adolescents can
be screened for depression with the Patient Health Questionnaire-2 item screen (PHQ-2) [93]:
"Over the past two weeks, how often have you been bothered by any of the following problems:
● Little interest or pleasure in doing things?
● Feeling down, depressed, or hopeless?"
The responses for each question include "not at all" (0 points); "several days" (1 point); "more than half the
days" (2 points); and "nearly every day" (3 points). Adolescents with a score of ≥3 should undergo additional
assessment for depressive disorder. In a primary care sample of 499 adolescents, a PHQ-2 score ≥3 had a
sensitivity of 74 percent and specificity of 75 percent for detecting major depression according to the
Diagnostic and Statistical Manual of Mental Disorders [94]. (See "Pediatric unipolar depression: Epidemiology,
clinical features, assessment, and diagnosis", section on 'Assessment'.)
Other validated depression screening tools for adolescents include the PHQ-9 Modified for Teens (in English
or Spanish (table 8)), the Kutcher Adolescent Depression Scale-6-item, the Mood and Feelings Questionnaire,
and the Columbia Depression Scale (parent or teen version) [95-99]. These tools and scoring instructions are
available in the Guidelines for Adolescent Depression in Primary Care Took Kit [100]. In systematic reviews,
theThis site uses
sensitivities of cookies. Byranged
these tools continuing to to
from 70 browse this site
90 percent and you are agreeing
specificities from 40to
toour use of cookies.
90 percent [101,102].
Studies in adult patients suggest that screening improves identification of depression (see "Screening for
depression in adults", section on 'Effectiveness of screening'). Studies comparing outcomes among
adolescents screened and not screened for depression are lacking [91,103]. However, in a randomized trial,
adolescent patients with depressive symptoms who were identified in primary care and received six months of
effective treatment (eg, psychotherapy and/or medication) had fewer depressive symptoms and improved
mental health-related quality of life than those who received usual care [104].
The USPSTF recommends screening of adolescents (12 to 18 years) for major depressive disorder in primary
care when systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up
[103,105].
Screening for poverty — We agree with the AAP recommendation to screen for poverty during health care
visits [106]. Screening for basic needs (eg, food, housing, heat) may uncover both obvious and less apparent
economic difficulties associated with adverse health outcomes [107,108]. Providers can then link the families
with available community services (eg, 2-1-1, a free and confidential helpline and website for people in North
America).
A variety of screening instruments may be used, including the single question: "Do you (ever) have difficulty
making ends meet at the end of the month?" In a pilot study in a primary care practice, this question was 98
percent sensitive and 40 percent specific in identifying families with a need for community resources [109,110].
The Well-child Care Visit, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE)
survey instrument may prompt discussion of poverty-related topics and referral for community resources [111];
the survey instrument is available in the appendix of reference [111].
Other screens that may be used for specific needs include:
● Food – Endorsement of either of the following questions as often or sometimes true rather than never true
is an accurate indication of food insecurity [112-115]:
• "Within the past 12 months we worried whether our food would run out before we got money to buy
more."
• "Within the past 12 months the food we bought just didn't last, and we didn't have money to get
more."
In a validation study, endorsement of either of these statements was 97 percent sensitive and 83 percent
specific in identifying food insecurity compared with the 18-item United Stated Department of Agriculture
Household Food Security Scale, a research tool from which the questions were taken [113].
In a systematic review, household food insecurity was associated with behavioral, emotional, and
developmental problems in children of all ages [116]. Children from families with food insecurity may
warrant enhanced developmental/behavioral surveillance. (See "Developmental-behavioral surveillance
and screening in primary care".)
The AAP and Food Research & Action Center have developed a toolkit to help clinician address food
insecurity.
● Housing – Asking whether families have moved frequently in the past year or lived with another family for
financial reasons helps to identify housing insecurity [117].
Screening for poverty may have unintended harms (eg, patient/family frustration if they have unrealistic
expectations about the type or quality of resources and services that are available; patient/family feeling
stigmatized if screening is limited to particular subgroups, etc) [70]. The risk of unintended harm can be
minimized through care coordination, collaboration with service providers, involving the family in shared-
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decision usesbefore
making cookies. By continuing
making to browse
referrals, screening the this site
entire you are
practice agreeing
population to our
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subgroups, and
acknowledging and building on patient andContinue or find out more.
family strengths.
SUMMARY AND RECOMMENDATIONS
● We suggest hearing risk assessment at all health maintenance visits and periodic hearing screening
between 4 and 21 years of age (Grade 2C). (See "Screening the newborn for hearing loss", section on
'Implementation' and 'Infants and children' above.)
● We recommend screening to detect amblyopia, strabismus, and defects in visual acuity for children
younger than five years of age (Grade 1B). Screening includes vision risk assessment at all health
maintenance visits and vision screening at three, four, and five years of age. (See 'Children <5 years'
above and "Visual development and vision assessment in infants and children".)
● For children older than five years, we suggest vision risk assessment at all health maintenance visits and
periodic vision screening throughout childhood and adolescence (Grade 2C). (See 'Children ≥5 years'
above and "Visual development and vision assessment in infants and children".)
● Screening for lead poisoning should be performed in accordance with state laws as applicable. (See 'Lead
poisoning' above.)
● We suggest oral health risk assessment beginning at six months of age and referral to a dental home at
one year of age or as soon thereafter as possible (Grade 2C). (See 'Oral health screening' above and
"Preventive dental care and counseling for infants and young children", section on 'Risk assessment'.)
● We recommend targeted rather than universal screening for tuberculosis (Grade 1B). Tuberculosis risk
assessment should be performed at 1, 6, 12, and 24 months, and annually thereafter. (See 'Latent
tuberculosis' above.)
● We screen children without risk factors or conditions associated with hypertension by measuring blood
pressure annually at health supervision visits, beginning at age three years. For children <3 years with
risk factors for hypertension (table 5A), we measure BP at all health supervision visits. For children ≥3
years with risk factors for hypertension (table 5B), we measure BP at all health encounters. (See
'Hypertension' above.)
● We suggest screening for alcohol, tobacco, and substance use annually, beginning at age 11 years
(Grade 2C). (See 'Tobacco, alcohol, and substance use' above.)
● We suggest screening adolescents for depression annually, beginning at age 12 years (Grade 2B). (See
'Depression screening' above.)
● Screening for poverty during health care visits may identify economic difficulties for which community
services are available. (See 'Screening for poverty' above.)
● Screening for other conditions is discussed separately. These include:
• Screening newborns for genetic and metabolic disease, hyperbilirubinemia, critical congenital heart
disease, and hearing loss. (See "Newborn screening" and "Evaluation of unconjugated
hyperbilirubinemia in term and late preterm infants", section on 'Universal screening' and "Newborn
screening for critical congenital heart disease using pulse oximetry" and "Screening the newborn for
hearing loss".)
• Iron deficiency in infants and adolescents. (See "Iron deficiency in infants and children <12 years:
Screening, prevention, clinical manifestations, and diagnosis", section on 'Screening
recommendations' and "Iron requirements and iron deficiency in adolescents", section on
'Screening'.)
• Developmental and behavioral problems. (See "Autism spectrum disorder: Surveillance and
screening Bycare"
in primary continuing to browse this site yousurveillance
and "Developmental-behavioral are agreeingandtoscreening
our use in
ofprimary
cookies.
care".) Continue or find out more.
• Dyslipidemia. (See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle
and identifying at-risk children", section on 'Identifying children at risk for CVD' and "Dyslipidemia in
children: Definition, screening, and diagnosis".)
• Sexually transmitted infections. (See "Screening for sexually transmitted infections", section on
'Screening recommendations'.)
• Cervical cancer. (See "Screening for cervical cancer".)
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problems. Pediatrics 2012; 129:205.
90. American Academy of Pediatrics. Substance use screening and intervention implementation guide. http
s://www.aap.org/en-us/Documents/substance_use_screening_implementation.pdf (Accessed on May 25,
2017).
91. Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care
(GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics
2018.
92. Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior surveillance--United States, 2013. MMWR
Suppl 2014; 63:1.
93. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression
screener. Med Care 2003; 41:1284.
94. Richardson LP, Rockhill C, Russo JE, et al. Evaluation of the PHQ-2 as a brief screen for detecting major
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Pediatrics this site you are agreeing to our use of cookies.
2010; 125:e1097.
95. Shaffer D, Fisher P, Lucas CP, et al. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH
DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J
Am Acad Child Adolesc Psychiatry 2000; 39:28.
96. LeBlanc JC, Almudevar A, Brooks SJ, Kutcher S. Screening for adolescent depression: comparison of the
Kutcher Adolescent Depression Scale with the Beck depression inventory. J Child Adolesc
Psychopharmacol 2002; 12:113.
97. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen
Intern Med 2001; 16:606.
98. Richardson LP, McCauley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 Item
for detecting major depression among adolescents. Pediatrics 2010; 126:1117.
99. Katon W, Russo J, Richardson L, et al. Anxiety and depression screening for youth in a primary care
population. Ambul Pediatr 2008; 8:182.
100. Guidelines for Adolescent Depression in Primary Care Took Kit http://www.glad-pc.org/ (Accessed on Feb
ruary 25, 2014).
101. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care
(GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007; 120:e1299.
102. Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLA
D-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management.Supplemental info
rmation. Available at: http://pediatrics.aappublications.org/content/early/2018/02/22/peds.2017-4081.sup
plemental (Accessed on February 28, 2018).
103. Forman-Hoffman V, McClure E, McKeeman J, et al. Screening for Major Depressive Disorder in Children
and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med
2016; 164:342.
104. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent
depression in primary care clinics: a randomized controlled trial. JAMA 2005; 293:311.
105. Siu AL, U.S. Preventive Services Task Force. Screening for Depression in Children and Adolescents:
U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2016; 164:360.
106. COUNCIL ON COMMUNITY PEDIATRICS. Poverty and Child Health in the United States. Pediatrics 2016;
137.
107. Palakshappa D, Fiks AG. Implications of Poverty for Practices Serving Suburban Families. Pediatrics
2016; 138.
108. Sandel M, Sheward R, Ettinger de Cuba S, et al. Unstable Housing and Caregiver and Child Health in
Renter Families. Pediatrics 2018; 141.
109. Brcic V, Eberdt C, Kaczorowski J. Development of a tool to identify poverty in a family practice setting: a
pilot study. Int J Family Med 2011; 2011:812182.
110. Brcic V, Eberdt C, Kaczorowski J. Corrigendum to "Development of a Tool to Identify Poverty in a Family
Practice Setting: A Pilot Study". Int J Family Med 2015; 2015:418125.
111. Garg A, Butz AM, Dworkin PH, et al. Improving the management of family psychosocial problems at low-
income children's well-child care visits: the WE CARE Project. Pediatrics 2007; 120:547.
112. COUNCIL ON COMMUNITY PEDIATRICS, COMMITTEE ON NUTRITION. Promoting Food Security for All
Children. Pediatrics 2015; 136:e1431.
113. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at
risk for food insecurity. Pediatrics 2010; 126:e26.
114. Makelarski JA, Abramsohn E, Benjamin JH, et al. Diagnostic Accuracy of Two Food Insecurity Screeners
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107:1812.
115. Baer TE, Scherer EA, Fleegler EW, Hassan A. Food Insecurity and the Burden of Health-Related Social
Problems in an Urban Youth Population. J Adolesc Health 2015; 57:601.
116. Shankar P, Chung R, Frank DA. Association of Food Insecurity with Children's Behavioral, Emotional, and
Academic Outcomes: A Systematic Review. J Dev Behav Pediatr 2017; 38:135.
117. Cutts DB, Meyers AF, Black MM, et al. US Housing insecurity and the health of very young children. Am J
Public Health 2011; 101:1508.
Topic 2872 Version 54.0
GRAPHICS
Definitions of sensitivity, specificity, and positive and negative predictive values
Disease present Disease absent
Test positive A B
Test negative C D
Sensitivity = A ÷ (A + C)
Specificity = D ÷ (B + D)
Positive predictive value = A ÷ (A + B)
Negative predictive value = D ÷ (C + D)
Graphic 77832 Version 3.0
Effect ofuses
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Consider a population of 2000 people and a diagnostic test that is 90

percent sensitive and specific. The positive and negative predictive values
of the test vary when the prevalence of the disease is varied.
Left panel: If the prevalence of the disease is high at 50 percent, the
positive and negative predictive values will be similar to the sensitivity
and specificity (90 percent, respectively).
Right panel: In contrast, if the prevalence of the disease is only 10
percent, the positive predictive value decreases (50 percent), and the
negative predictive value increases (99 percent).
Selected genetic
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Caused
Syndrome Features by Sensorineural Conductive Mixed
mutation
Waardenburg White forelock, X X

syndrome (AD) heterochromic irides,
broad mandible,
deafness
Usher syndrome (AR) Retinitis pigmentosa, X X

ataxia, deafness
Pendred syndrome Familial goiter, X X

(AR) dysfunctional iodide
organization, deafness
Alport syndrome (XL, Nephritis, deafness, X X

AR, AD) lens, defects, retinitis
Craniofacial anomalies Craniosynostosis, X X X

(eg, Apert syndrome, micrognathia,
Pfeiffer syndrome, syndactyly
Crouzon syndrome)
CHARGE (AD, isolated Choanal atresia, X X X

cases) colobomas, heart
defect, intellectual
disability, genital
hypoplasia, ear
anomalies, deafness
Hemifacial microsomia Facial hypoplasia, ear X X X

(oculo-auriculo- anomalies,
vertebral spectrum, hemivertebrae, parotid
Goldenhar syndrome) gland dysfunction
(sporadic, AD)
Mucopolysaccharidosis Coarse facies, stiff X X

Hurler (AR), Hunter joints, intellectual
(XL), Maroteaux-Lamy disability, cloudy
(AR) corneas
Treacher-Collins Facial malformation, X X

syndrome (AD) cleft palate, deafness
Otopalatodigital Deafness, cleft palate, X

syndrome (XL) broad digits
Stickler syndrome (AD) Cleft palate, X X

micrognathia, myopia,
cataracts,
spondyloepiphyseal
dysplasia, deafness
LEOPARD syndrome Multiple lentigenes, X X

(AD) pulmonic stenosis,
hypertelorism,
deafness, genital
anomalies
Ciliary dyskinesia (AR) Situs inversus, immobile X

cilia, heart defects,
splenic anomalies,
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Cockayne syndrome Continue or find
Retinal degeneration, X out more.X
(AR) senile-like changes,
growth retardation,
photosensitivity,
deafness
Achondroplasia (AD) Short limbs, X X

hydrocephalus
Branchiootorenal Branchial anomalies, X X X X

syndrome (AD) ear malformations,
renal anomalies
Klippel-Feil syndrome Fused cervical X X X

(sporadic, AD, AR) vertebrae, webbed
neck, deafness,
congenital heart defect
Duane syndrome Ocular strabismus, ear X X

(sporadic, AD) anomalies, skeletal
anomalies, cranial
nerve palsies, deafness
Marfan syndrome (AD) Lens subluxation, X X X X

arachnodactyly, aortic
aneurysm,
hyperextensibility,
deafness
Mobius syndrome Cranial nerve palsies, X

(sporadic, AD, AR) limb anomalies,
hypoglossia,
micrognathia, deafness
Muckle-Wells Amyloid nephropathy, X X

syndrome (AD) urticaria, deafness
Pierre-Robin Micrognathia, cleft X

syndrome (AR, XL) palate, glossoptosis,
deafness
Jervell and Lange- Long QT, deafness X X

Nielsen syndrome (AR)
Neurofibromatosis Neurofibromas, café-au- X

type I (AD) lait spots, optic glioma
Osteogenesis Fragile bones, blue X X

imperfecta (AD, AR) sclera
Ehlers-Danlos (AD, AR) Joint hyperextensibility, X X

fragile skin
Konigsmark syndrome Low-frequency hearing X X

(AD) loss,
macrothrombocytopenia
Syndromes are listed roughly in order of relative frequency as a cause of hereditary hearing loss.
AD: autosomal dominant inheritance; AR: autosomal recessive inheritance; XL: X-linked inheritance;
CHARGE: Coloboma, Heart defect, Atresia choanae (also known as choanal atresia), Retarded growth and
development, Genital abnormalities, and Ear abnormalities; LEOPARD: Lentigines, Electrocardiographic
conduction abnormalities, Ocular hypertelorism, Pulmonary stenosis, Abnormal genitalia, Retarded
growth, Deafness.

Assessment
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Important aspects of Ophthalmology referral
Age Examination
history indications
Newborn Birth weight <1500 grams Vision assessment (fixate Positive history
to 6 or gestational age <30 and follow response) Abnormal examination
months weeks External eye examination (eg, abnormal red reflex,
(lids, orbit, conjunctiva, pupillary asymmetry of
Family history of:
cornea, iris) ≥1 mm, unilateral ptosis,
Congenital cataracts
Pupillary response unable to fix and follow
Retinoblastoma
by age 3 months)
Metabolic or genetic Simultaneous red reflex
disease
6 to 12 Neurologic abnormality Vision assessment (fixate Positive history

months Systemic disease and follow response) Abnormal examination
associated with eye External eye examination (eg, abnormal red reflex,
abnormalities (lids, orbit, conjunctiva, pupillary asymmetry of
cornea, iris) ≥1 mm, unilateral ptosis,
Does the infant recognize
unable to fix and follow)
faces and objects? Ocular motility
Does the infant fix and Pupillary response
follow? Simultaneous red reflex
Do the parents notice:
Eye deviation?
Tearing?
1 to 3 Neurologic abnormality Age-appropriate visual Positive history

years assessment: Abnormal examination
Systemic disease
associated with eye Infants and young (eg, abnormal red reflex,
abnormalities toddlers: Fixate and pupillary asymmetry of
follow response ≥1 mm, unilateral ptosis)
Does the child recognize
faces and objects? Cooperative older Eye preference or unable
toddlers: Monocular to fix and follow
Does the child fix and
visual acuity with HOTV* Ocular alignment
follow?
or LEA ¶ optotypes abnormalities
Do the parents notice: Visual acuity worse than
Instrument-based vision
Eye deviation? 20/50 in one or both
screening (eg,
Tearing? photoscreening, eyes
autorefraction) if available Visual acuity difference of
two or more lines
External eye examination
(lids, orbit, conjunctiva, between eyes
cornea, iris) Failed instrument-based

screening as indicated by
Ocular motility
the device
Pupillary response
Simultaneous red reflex
Ophthalmoscopy if possible
4 to 5 Neurologic abnormality External eye examination Positive history

years Systematic disease (lids, orbit, conjunctiva, Abnormal examination
associated with eye cornea, iris) (eg, abnormal red reflex,
abnormalities Ocular motility pupillary asymmetry of
≥1 mm, unilateral ptosis)
Does the child recognize Pupillary response
faces and objects? Eye preference
Simultaneous red reflex
Do the parents notice: Corneal light reflex Ocular alignment

AbnormalBy continuing to browse
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Ocular alignment
posturing? Continue or find
uncover out more.
test) Visual acuity worse than
Squinting or 20/40 for children 48
Monocular visual acuity Δ◊:
blepharospasm? through 59 months or
Snellen letters or worse than 20/30 for
Eye deviation?
numbers children ≥60 months in
Tearing?
Surrounded HOTV* or one or both eyes
LEA ¶ optotypes Visual acuity difference of
Instrument-based vision two or more lines
screening (eg, between eyes
photoscreening, Failed instrument-based
autorefraction) if available screening as indicated by
Ophthalmoscopy if possible the device
>6 years Neurologic abnormality External eye examination Positive history

Systematic disease (lids, orbit, conjunctiva, Abnormal examination
cornea, iris) (eg, abnormal red reflex,
associated with eye
abnormalities Ocular motility pupillary asymmetry of
≥1 mm, unilateral ptosis)
Does the child recognize Pupillary response
Eye preference
faces and objects? Simultaneous red reflex
Ocular alignment
Do the parents notice: Monocular visual acuity ◊: abnormalities
Abnormal head
Sloan or Snellen letters Visual acuity worse than
posturing?
or numbers 20/30 in one or both
Squinting or
Surrounded HOTV* eyes
blepharospasm?
LEA symbols ¶ Visual acuity difference of
Eye deviation?
two or more lines
Ophthalmoscopy if possible
Tearing? between eyes
* HOTV is an optotype vision chart using only the letters H, O, T, and V. "Surrounded" HOTV refers to the
use of crowding bars around the letters. Crowding bars improve detection of amblyopia and should be
used when single optotypes rather than a row of figures are presented.
¶ LEA is an optotype vision chart using four simple shapes (an apple, a pentagon, a square, and a circle).
Δ Testing distance of 10 feet is recommended; testing with line of figures rather than single figures is
preferred.
◊ Instrument-based vision screening (eg, photoscreening, autorefraction) is suggested if visual acuity
testing cannot be performed with age-appropriate optotypes.
Adapted from:
1. COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, SECTION ON OPHTHALMOLOGY, AMERICAN
ASSOCIATION OF CERTIFIED ORTHOPTISTS, et al. Visual System Assessment in Infants, Children, and
Young Adults by Pediatricians. Pediatrics 2015.
2. Donahue SP, Baker CN, Committee on Practice and Ambulatory Medicine, et al. Procedures for the
Evaluation of the Visual System by Pediatricians. Pediatrics 2015.
3. Essman SW, Essman TF. Screening for pediatric eye disease. Am Fam Phys 1992; 46:1243.
Sources of lead
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cookies. By continuing to browse this site you are agreeing to our use of cookies.
Occupational Homes/Buildings
Plumbers, pipe fitters Lead-containing paint/pigment
Lead miners Soil/dust near lead industries, roadways, lead-painted homes
Lead smelters and refiners Plumbing leachate
Auto repairers Ceramic ware (especially imported)
Glass manufacturers Leaded gasoline
Shipbuilders Vinyl miniblinds*
Printers Hobbies and related activities

Plastic manufacturers Glazed pottery making
Police officers Target shooting at firing ranges
Steel welders or cutters Lead soldering (eg, electronics)
Construction workers Painting
(especially renovation and
Preparing lead shot, fishing sinkers
rehabilitation)
Stained-glass making
Rubber product
manufacturers Car or boat repair
Gas station attendants Home remodeling

(past exposure)
Other sources
Battery manufacturers
Folk remedies (Mexican: azarcon, greta, alarcon, coral liga, Maria
Battery recyclers Luisa, rueda; Asian: ba-baw-san, bali goli, chuifong, ghasard,
Bridge reconstruction kandu, tokuwan)
workers Tobacco smoking
Firing range instructors Cosmetics
Moonshine whiskey
Gasoline "huffing"
Ayurvedic medications
* Made outside the United States and purchased before 1997.
Adapted from:
1. Environmental Health and Medicine Education. Lead Toxicity: Who Is at Risk of Lead Exposure? Agency
for Toxic Substances & Disease Registry. Available at: http://www.atsdr.cdc.gov/csem/csem.asp?
csem=7&po=7.
2. Environmental Health and Medicine Education. Lead Toxicity: Where is Lead Found? Agency for Toxic
Substances & Disease Registry. Available at: http://www.atsdr.cdc.gov/csem/csem.asp?csem=7&po=5.
Risk factors
This site uses for hypertension
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to browse years
Check BP at health supervision visits for children with the following:*
Perinatal risk factors:

Born at <32 weeks gestation
Small for gestational age
Birth weight <1500 g
Neonatal complications that required intensive care or umbilical artery catheterization
Recurrent urinary tract infection, hematuria, or proteinuria
Renal disease or urologic malformation
Family history of congenital renal disease
Solid organ or hematopoietic cell transplant
Malignancy or other systemic illness associated with hypertension (eg, neurofibromatosis,

tuberous sclerosis complex, sickle cell disease)
Treatment with drugs known to raise blood pressure (eg, caffeine, nonsteroidal anti-inflammatory
drugs, glucocorticoids)
Evidence of elevated intracranial pressure
BP: blood pressure.

* For children without risk factors, BP should be measured annually at health supervision visits beginning
at age 3 years.
Reproduced with permission from: Pediatrics, Vol. 140, doi: 10.1542/peds.2017-1904. Copyright © 2017 by
the AAP.
Risk factors
This site uses for hypertension
cookies. in children
By continuing ≥3
to browse years
Check BP at all health encounters for children with the following:*
Obesity
Type 1 or type 2 diabetes
Renal disease
History of aortic arch obstruction or coarctation
Treatment with or taking drugs known to increase blood pressure:

Decongestants
Caffeine
Nonsteroidal anti-inflammatory drugs
Glucocorticoids
Stimulants
Hormonal contraception
Tricyclic antidepressants
Amphetamines
Cocaine
BP: blood pressure.

* For children without risk factors, BP should be measured annually at health supervision visits beginning
at age 3 years.
Adapted from: Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and
management of high blood pressure in children and adolescents. Pediatrics 2017.
Screening blood
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BP (mmHg)
Age (years) Boys Girls
Systolic BP Diastolic BP Systolic BP Diastolic BP
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
This table is designed as a screening tool only for the identification of children and adolescents who need
further evaluation of their BP, starting with repeat BP measurements. The table should not be used by
itself to diagnose elevated BP or hypertension. Refer to UpToDate content on hypertension in children for
additional details.
BP: blood pressure.
Reproduced with permission from: Pediatrics, Vol. 140, doi: 10.1542/peds.2017-1904. Copyright © 2017 by
the AAP.
Two-question screenBy
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Age group Screening questions Risk assessment*
9 to 11 years "Do you have any friends who drank Any drinking by friends heightens
beer, wine, or any drink containing concern ¶
alcohol in the past year?"
"How about you – have you ever had Any drinking indicates highest risk Δ
more than a few sips of beer, wine, or
any drink containing alcohol?"
11 to 14 years "Do you have any friends who drank Any drinking by friends heightens
beer, wine, or any drink containing concern ¶
alcohol in the past year?"
"How about you – in the past year, on 11 years: Any drinking: Highest risk Δ
how many days have you had more
12 to 14 years:
than a few sips of beer, wine, or any Δ
1 to 5 days: Moderate risk
drink containing alcohol?"
>5 days: Highest risk Δ
14 to 18 years "In the past year, on how many days 14 through 15:
have you had more than a few sips of 1 to 5 days: Moderate risk Δ
beer, wine, or any drink containing >5 days: Highest risk Δ
alcohol?"
16 years:
1 to 5 days: Lower risk
Δ
6 to 11 days: Moderate risk
17 years:
6 to 23 days: Moderate risk Δ
18 years:
12 to 51 days: Moderate risk Δ
"If your friends drink, how many Binge drinking ◊ by friends heightens
drinks do they usually drink on an concern ¶
occasion?"
* Use in conjunction with what you already know about the patient's physical and psychosocial
development, level of family support, drinking and smoking habits of parents and siblings, school
functioning, or trouble with authority figures to provide advice and assistance. Refer to the practitioner's
guide for details.
¶ If the patient does not drink, but friends do, explore the patient's views about friends' drinking and ask
about his or her plans to stay alcohol free.
Δ For patients at moderate or higher risk, obtain additional information about drinking pattern, drinking-
related problems or risk-taking, and other substance use.
◊ Binge drinking: ≥3 drinks for girls (all ages) and boys ages 9 to 13 years; ≥4 drinks for boys 14 through
15 years; ≥5 drinks for boys age ≥16 years.
Adapted from: National Institute on Alcohol Abuse and Alcoholism. Alcohol screening and brief intervention for
youth: A practitioner's guide. Available at: https://www.niaaa.nih.gov/publications/clinical-guides-and-
manuals/alcohol-screening-and-brief-intervention-youth (Accessed on June 20, 2017).
PHQ-9:
This site Modified for By
uses cookies. teens
Name:
Clinician: Date:
Instructions: How often have you been bothered by each of the following symptoms during the
past two weeks? For each symptom put an "X" in the box beneath the answer that best describes
how you have been feeling.
More
than Nearly
Not at Several
half every
all days
the day
days
Score (0) (1) (2) (3)
1. Feeling down, depressed, irritable, or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep, or sleeping

too much?
4. Poor appetite, weight loss, or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself — or feeling that you are

a failure, or that you have let yourself or your family
down?
7. Trouble concentrating on things like school work,

reading, or watching TV?
8. Moving or speaking so slowly that other people could

have noticed?
Or the opposite — being so fidgety or restless that
you were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of

hurting yourself in some way?
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
0 to 4: No or minimal depression
5 to 9: Mild
10 to 14: Moderate
15 to 19: Moderately severe
≥20: Severe
In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
Yes
No
If you are experiencing any of the problems on this form, how difficult have these problems made it
for you to do your work, take care of things at home, or get along with other people?
This siteNot
uses cookies.
difficult at all By continuing to browse this site you are agreeing to our use of cookies.
Somewhat difficult
Very difficult
Extremely difficult
Has there been a time in the past month when you have had serious thoughts about ending your
life?
Yes
No
Have you ev er, in your whole life, tried to kill yourself or made a suicide attempt?
Yes
No
FOR OFFICE USE Score:

ONLY
PHQ: Patient Health Questionnaire.
Modified from PHQ developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with
an educational grant from Pfizer Inc.
Contributor Disclosures
Continue
Nancy R Kelly, MD, MPH Nothing to disclose Janor find out
E Drutz, MDmore.
Nothing to disclose Mary M Torchia,
MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
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Screening Test For Children and Teenagers

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2018/6/7 Screening tests in children and adolescents - UpToDate

Screening tests in children and adolescents

Author: Nancy R Kelly, MD, MPH

● Substantial morbidity or mortality occurs if the disease is untreated

● The prevalence warrants testing in an apparently healthy population

● The existence of a preclinical phase is detectable by the test

● A cost-effective treatment is available

Screening tests for diseases conducive to screening should [1,2]:

● Be easy to perform and interpret

● Measure something directly related to the disease

● Have low risk, morbidity, and cost

● Be highly sensitive and specific

● False-positive test results must be followed up

● False-negative test results may delay diagnosis

(See "Glossary of common biostatistical and epidemiological terms".)

Types of screening — There are two types of screening programs:

● The American Academy of Pediatrics and Bright Futures [5-8]

● The American Academy of Family Physicians [9]

● The United States Preventive Services Task Force

● The Centers for Disease Control and Prevention

COMMON SCREENING TESTS IN PEDIATRICS

• Caregiver concerns regarding hearing, speech, language or developmental delay

• Neonatal intensive care unit (NICU) stay of >5 days

• NICU stay (regardless of duration) requiring extracorporeal membrane oxygenation, assisted

• Congenital or central nervous system infections

• Ototoxic drug exposure, including chemotherapy

• Syndromes associated with hearing loss (table 2)

• Chronic or recurrent otitis media with effusion

● Do you have a problem hearing over the telephone?

● Do you have to strain to understand conversation?

● Do you have trouble hearing in a noisy background?

● Do you find yourself asking other people to repeat themselves?

● Do you misunderstand what others are saying and respond inappropriately?

• Otoacoustic emissions [24]

• In-office audiology [6]

• Otoscope audiograms [25]

● Does the child seem to see well?

● Do the child's eyes appear unusual?

● Do the child's eyelids droop, or does one eyelid tend to close?

● Have the child's eyes ever been injured?

● Inadequate data on the prevalence of elevated BLLs

● ≥25 percent of housing built before 1960

● ≥5 percent of children 12 to 24 months of age with BLLs ≥5 mcg/dL (0.24 micromol/L)

The risk of lead poisoning is increased in children who [45]:

● Pregnant or lactating women

● With frequent somatic complaints

● Who are in foster care or have been adopted

● Little interest or pleasure in doing things?

● Feeling down, depressed, or hopeless?"

Other screens that may be used for specific needs include:

SUMMARY AND RECOMMENDATIONS

● Screening for other conditions is discussed separately. These include:

• Cervical cancer. (See "Screening for cervical cancer".)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 2872 Version 54.0

Disease present Disease absent

Positive predictive value = A ÷ (A + B)

Negative predictive value = D ÷ (C + D)

Graphic 77832 Version 3.0