Examination of the eyes and an assessment of vision should be performed at every health supervision visit. Eye problems are relatively common in children: refractive errors (including myopia, hyperopia, and astigmatism), amblyopia (loss of visual acuity from cortical suppression of the vision of the eye), and/or strabismus (misalignment of the eyes) occur in 5%–10% of preschoolers. Assessment of vision should include visual inspection of the eyes and eyelids, alignment of eyes, and visual acuity.
Starting at birth, the movement and alignment of the eyes should be assessed and the pupils and red reflexes examined. The red reflex, performed on each pupil individually and then on both eyes simultaneously, is used to detect eye opacities (eg, cataracts or corneal clouding) and retinal abnormalities (eg, retinal detachment or retinoblastoma). By 3 months of age, an infant should be able to track or visually follow a moving object, with both eyes.
Starting at age 3, formal testing of visual acuity should be done if possible. This can be performed in the office with a variety of tests, including the tumbling E chart or picture tests such as Allen cards. In these tests, each eye is tested separately, with the nontested eye completely covered. Credit is given for any line on which the child gets more than 50% correct. Children who are unable to cooperate should be retested, ideally within 1 month, and those who cannot cooperate with repeated attempts should be referred to an ophthalmologist. Because visual acuity improves with age, results of the test are interpreted using the cutoff values in Table 9–2. However, any two-line discrepancy between the two eyes, even within the passing range (eg, 20/20 in one eye, 20/30 in the other in a child aged ≥ 6 years) should be referred to an ophthalmologist.
Table 9–2.Age-appropriate visual acuity.a ||Download (.pdf) Table 9–2.Age-appropriate visual acuity.a
|Age (y) ||Minimal Acceptable Acuity |
|3–5 ||20/40 |
|≥ 6 ||20/30 |
Throughout childhood, clinicians should screen for undetected strabismus (ocular misalignment). The corneal light reflex test can be used starting at 3 months and the cover test can be used beginning at 6 months to assess for strabismus. The corneal light reflex test, the cover test, and visual acuity test are described further in Chapter 16.
Recommendations for vision screening and indications for referral are listed in Table 9–3. Referral to an ophthalmologist is also recommended for preterm infants for evaluation of retinopathy of prematurity (ROP), as well as children with a family history of amblyopia, strabismus, retinoblastoma, or retinal degeneration. Children with Down syndrome should be referred to an ophthalmologist at 6 months of age given their increased risk for refractive error, strabismus, and cataracts.
Table 9–3.Recommended vision screening in the primary care office. ||Download (.pdf) Table 9–3.Recommended vision screening in the primary care office.
|Test ||Age for Screening ||Indication(s) for Referral |
|Inspection of eyes and lids ||All || |
|Red reflex ||Birth until child can read eye chart ||Abnormal red reflex, asymmetry of the red reflexes, or partially obscured red reflex |
|Assessment of fixation and following ||Starting at 2 mo ||Poor fixation/following by 3 mo |
|Corneal light reflex for assessing strabismus ||3 mo to 5 y ||Asymmetry of light reflex (in relation to iris and pupil) |
|Cover testing for assessing strabismus ||6 mo to 5 y ||Presence of refixation movement |
|Fundoscopic examination ||Starting at 3 y || |
|Preliterate eye chart testing ||Starting at 3–4 y ||Unable to pass 20/40 for ages 3–5 or 20/30 for 6 and older. Also refer if there is a difference of two or more lines between the eyes. |
Hearing loss, if undetected, can lead to substantial impairments in speech, language, and cognitive development. Because significant bilateral hearing loss is one of the more common major anomalies found at birth, and early detection and intervention of hearing loss leads to better outcomes for children, universal hearing screening is provided to newborns in most parts of the United States. Hearing in infants is assessed using either evoked otoacoustic emissions or auditory brainstem-evoked responses. Because universal newborn hearing screening is sometimes associated with false-positive test results, confirmatory audiology testing is required for abnormal tests.
Informal behavioral testing of hearing, such as observing an infant’s response to a shaken rattle, may be unreliable. In fact, parental concerns about hearing are of greater predictive value than the results of informal tests, and such concerns should be taken seriously. Prior to age 4, infants should be referred to an audiologist for testing if a concern arises. Conventional screening audiometry, in which a child raises her hand when a sound is heard, can be performed starting at age 4. Each ear should be tested at 500, 1000, 2000, and 4000 Hz and referred at threshold levels of greater than 20 dB at any of these frequencies. Any evidence of hearing loss should be substantiated by repeated testing, and if still abnormal, a referral for a formal hearing evaluation should be made.
The AAP periodicity schedule recommends routine hearing screening at 4, 5, 6, 8, and 10 years of age and several times during adolescence. Children with any risk factors for hearing loss should be closely followed and receive more frequent screening. A number of inherited or acquired conditions increase the risk of hearing loss. Sometimes hearing loss can be mistaken for inattention, and so hearing screening should be part of workup for attention problems. Additional details regarding hearing assessment are provided in Chapter 18.
American Academy of Pediatrics et al: Red reflex examination in neonates, infants, and children. Pediatrics 2008;122:1401
C: American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section of Otolaryngology: Hearing assessment in infants and children: recommendations beyond neonatal screening. Pediatrics 2009;124(4):1252–1263
DR: Hearing impairment in children. Pediatr Clin North Am 2008;55:1175
CO: Pediatric Vision Screening. Pediatr Rev 2013;34:126
Newborn screening involves population-wide testing for metabolic and genetic diseases. It has become an essential component in a public health program that screens over 4 million newborns every year. Blood samples are collected by heel stick from newborns before hospital discharge, and results are usually available within 1 week. Some states routinely repeat blood testing between 7 and 14 days of life, while others recommend it if the child is discharged in less than 24 hours. The state-to-state variation seen in newborn screen panels has begun to diminish as a result of national recommendations. In 2010, the Secretary Advisory Committee on Heritable Disorders in Newborns and Children recommended screening for 32 core conditions with another 26 detectable through differential diagnosis. Most states have adopted these guidelines.
Infants with a positive screening result should receive close follow-up, with additional confirmatory studies performed at a center with experience in doing these tests. Screening tests are usually accurate, but the sensitivity and specificity of a particular screening test must be carefully considered. If symptoms of a disease are present despite a negative result on a screening test, the infant should be tested further. Newborn screening has benefited thousands of infants and their families, preventing and diminishing the morbidity of many diseases. At the same time, the emotional cost of false-positive screening is a continuing challenge. Parents report high levels of stress during the evaluation process. Recommendations for useful resources, given the variability of information on the Internet, and prompt clinical services can help reduce this distress.
et al: Advisory Committee on Heritable Disorders in Newborns and Children: Committee report: method for evaluating conditions nominated for population-based screening of newborns and children. Genet Med 2010 Mar;12(3):153–159
The developing infant and child are at risk of lead poisoning or toxicity because of their propensity to place objects in the mouth and their efficient absorption of this metal. Children with lead toxicity are typically asymptomatic. High blood levels (> 70 mcg/dL) can cause severe health problems such as seizures and coma. Numerous neuropsychological deficits have been associated with increased lead levels. Blood lead levels less than 10 mcg/dL have been correlated with lower intelligence quotients. The primary source of lead exposure in this country remains lead-based paint, even though most of its uses have been banned since 1977. Lead levels have declined nationally from a mean of 16 mcg/dL in 1976 to less than 2 mcg/dL in 2008. However, considerable variation in lead levels exists in different regions of the United States, and a majority of children at risk of lead toxicity are not currently screened. Despite the wide variation in the prevalence of lead toxicity, the CDC recommends universal lead screening for children at ages 1 and 2 and targeted screening for older children living in communities with a high percentage of old housing (> 27% of houses built before 1950) or a high percentage of children with elevated blood lead levels (> 12% of children with levels > 10 mcg/dL). Previously, all Medicaid-enrolled children were screened, but now the recommendation is to screen those at risk because of local variations in lead exposure.
Communities with inadequate data regarding local blood lead levels should also undergo universal screening. Caregivers of children between 6 months and 6 years of age may be interviewed by questionnaire about environmental risk factors for lead exposure (Table 9–4), although the data to support the use of this screening are inconclusive. If risk factors are present, a blood lead level should be obtained. A venous blood sample is preferred over a capillary specimen. An elevated capillary (fingerstick) blood sample should always be confirmed by a venous sample. CDC now states that reference level of 5 mcg/dL should be used to identify children with blood lead levels that are much higher than most levels in children. This new recommendation is based on the US children ages 1–5 years who are in the highest 2.5% of children when tested for lead in their blood.
Table 9–4.Elements of a lead-risk questionnaire. ||Download (.pdf) Table 9–4.Elements of a lead-risk questionnaire.
Does your child live in or regularly visit a house built before 1950? This could include a day care center, preschool, the home of a baby sitter or relative.
Does your child live in or regularly visit a house built before 1978 with recent, ongoing, or planned renovation or remodeling?
Does your child have a sister or brother, housemate, or playmate being followed for an elevated lead level?
Questions that may be considered by region or locality
Does your child live with an adult whose job (eg, at a brass/copper foundry, firing range, automotive or boat repair shop, or furniture refinishing shop) or hobby (eg, electronics, fishing, stained-glass making, pottery making) involves exposure to lead?
Does your child live near a work or industrial site (eg, smelter, battery recycling plant) that involves the use of lead?
Does your child use pottery or ingest medications that are suspected of having a high lead content?
Does your child have exposure to old, nonbrand-type toys or burning lead-painted wood?
Does your child play on an athletic field with artificial turf?
The cognitive development of children with confirmed high blood levels should be evaluated and attempts made to identify the environmental source. Iron deficiency should be treated if present. Chelation of lead is indicated for levels of 45 mcg/dL and higher and is urgently required for levels above 70 mcg/dL. All families should receive education to decrease the risk of lead exposure. With any elevated lead level (> 5 mcg/dL), rescreening should be performed at recommended intervals.
American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children: prevention, detection, and management. Pediatrics 2005;116(4):1036–1046
Iron deficiency is the most common nutritional deficiency in the United States. Severe iron deficiency causes anemia, behavioral problems, and cognitive effects, but recent evidence suggests that even iron deficiency without anemia may cause behavioral and cognitive difficulties. Some effects, such as the development of abnormal sleep cycles, may persist even if iron deficiency is corrected in infancy.
Risk factors for iron deficiency include preterm or low-birth-weight births, multiple pregnancy, iron deficiency in the mother, use of nonfortified formula or cow’s milk before age 12 months, and an infant diet that is low in iron-containing foods. Infants and toddlers consuming more than 24 oz/day of cow’s milk are at risk, as are children with chronic illness, restricted diet, or extensive blood loss.
Primary prevention of iron deficiency should be achieved through dietary means, including feeding ground up meats and iron-containing cereals by age 6 months, avoiding low-iron formula during infancy, and limiting cow’s milk to 24 oz per day in children aged 1–5 years.
Universal screening for anemia should occur at approximately 12 months of age by obtaining a hemoglobin or hematocrit. Premature and low-birth-weight infants may need testing before 6 months of age.
A full CBC to look at mean corpuscular volume (MCV) can aid in the evaluation. Serum ferritin is a useful test to evaluate iron-deficiency anemia, but it can also pick up iron deficiency in the absence of anemia. Because ferritin is an acute-phase reactant and can be falsely reassuring in the presence of inflammation, infection, or malignancy, some experts recommend obtaining a concurrent C-reactive protein (CRP) for accurate interpretation of the ferritin level. Elevated lead levels can cause iron-deficiency anemia and should be explored as a cause for at-risk infants and children.
Management of iron deficiency with or without anemia includes treatment doses of 3–6 mg/kg body weight of elemental iron.
et al: American Academy of Pediatrics; Committee on Nutrition: Diagnosis and prevention and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics 2010;126:1040
Hypercholesterolemia & Hyperlipidemia
Cardiovascular disease is the leading cause of death in the United States, and research has documented that the atherosclerotic process begins in childhood. Genetic factors, diet, and physical activity all play a role in the disease process. Non-fasting lipid screening is recommended universally for children between the ages of 9 and 11. Fasting lipid screening is recommended between the ages of 2 to 8, and ages 12 to 16 if risk factors are present. Diet and weight management strategies are the primary interventions. However, for severe dyslipidemia (LDL ≥ 190 mg/dL), pharmacologic therapy should be considered. However, consideration of pharmacotherapy should be made for severe dyslipidemia (LDL ≥ 190 mg/dL), or at >160 mg/dL if there is a family history of heart disease, and in all patients at > 130 mg/dL depending on their level and amount of risk factors.
FR: Committee on Nutrition: Lipid screening and cardiovascular health in childhood. Pediatrics 2008 Jul;122(1):198–208
et al: Usefulness of non-fasting lipid parameters in children. J Pediatr Endocrinol Metab 2017;30(1):77–83.
According to the CDC, 9272 cases of tuberculosis (TB) were reported in the United States in 2016. Risk of TB should be assessed at well-child visits, and screening should be based on high-risk status. High risk is defined as contact with a person with known or suspected TB; having symptoms or radiographic findings suggesting TB; birth, residence, or travel to a region with high TB prevalence (Asia, Middle East, Africa, Latin America); contact with a person with AIDS or HIV; or contact with a prisoner, migrant farm worker, illicit drug user, or a person who is or has been recently homeless. TB testing can be performed by a skin test or a blood test. The Mantoux test (five tuberculin units of purified protein derivative) is the only recommended skin test. The interferon-gamma release assays (IGRAs) are blood tests that can be useful for patients who have been immunized with bacille Calmette-Guerin (BCG) or for patients who may have difficulty returning for a second appointment to look for skin reaction.
Targeted screening for latent TB for high-risk individuals is the recommended approach based on available evidence. Risk of TB should be assessed at well-child visits, and screening should be based on high-risk status. The following screening questions have been validated to determine high-risk status:
Was your child born outside the United States? If yes, this question would be followed by: Where was your child born? If the child was born in Africa, Asia, Latin America, or Eastern Europe, a TB testing should be performed.
Has your child traveled outside the United States? If yes, this question would be followed by: Where did the child travel, with whom did the child stay, and how long did the child travel? If the child stayed with friends or family members in Africa, Asia, Latin America, or Eastern Europe for more than 1 week cumulatively, TB testing should be performed.
Has your child been exposed to anyone with TB disease? If yes, this question should be followed by questions to determine if the person had TB disease or latent TB infection (LTBI), when the exposure occurred, and what the nature of the contact was. If confirmed that the child has been exposed to someone with suspected or known TB disease, TB testing should be performed. If it is determined that a child had contact with a person with TB disease, notify the local health department per local reporting guidelines.
Does your child have close contact with a person who has a positive TB test? If yes, go to question 3.
American Academy of Pediatrics: Tuberculosis. In: Pickering
LK (ed): 2015 Red Book: Report of the Committee on Infectious Diseases. 30th ed. American Academy of Pediatrics; 2015.
Pediatric Tuberculosis Collaborative Group: Targeted tuberculin skin testing and treatment of latent tuberculosis infection in children and adolescents. Pediatrics 2004 Oct;114(Suppl 4): 1175–1201
Screening of Adolescent Patients
Adolescents may present with chief complaints that are not the true concern for the visit. Repeating the question “Is there anything else you would like to discuss?” should be considered. Since suicide is a leading cause of morbidity and mortality in this age group, screening with the Pediatric Symptom Checklist for Youth is recommended (https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf).
Testing adolescents for blood cholesterol, TB, and HIV should be offered based on high-risk criteria outlined in this chapter and in Chapter 41. Females should have a screening hematocrit once after the onset of menses. During routine visits, adolescents should be questioned sensitively about risk factors (eg, multiple partners; early onset of sexual activity, including child sexual abuse) and symptoms (eg, genital discharge, infectious lesions, pelvic pain) of sexually transmitted infections (STIs). An annual dipstick urinalysis for leukocytes is recommended for sexually active adolescents. Because STIs are often not symptomatic, urine polymerase chain reaction (PCR) for gonorrhea and chlamydia and screening tests for trichomoniasis should be considered. Current guidelines recommend that the first Papanicolaou (Pap) test should be performed at age 21 years, regardless of onset of sexual activity. A complete pelvic examination should be performed when evaluating lower abdominal pain in an adolescent.
Please see Chapter 4 for additional details on adolescent preventive services.
Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention: Tuberculosis Surveillance Reports. http://www.cdc.gov/nchhstp/default.htm
. Accessed March 2, 2015.