The Guide to Clinical Preventive Services 2008 - part 8 potx

Clinical Considerationsn This USPSTF recommendation addresses screeningfor elevated blood levels in children aged 1 to 5years who are both at average and increased risk,and in asymptomat

n Increased IOP, family history, older age, and being

of African American descent place an individual atincreased risk for glaucoma Older African

Americans have a higher prevalence of glaucomaand perhaps a more rapid disease progression, and if

it is shown that screening for glaucoma reduces thedevelopment of visual impairment, African

Americans would likely have greater absolutebenefit than whites People with a limited lifeexpectancy would likely have little to gain fromglaucoma screening

n The natural history of glaucoma is heterogeneousand not well defined There is a subgroup of peoplewith POAG in whom there is either no diseaseprogression, or the progression is so slow that thecondition would never have an important effect ontheir vision The size of this subgroup is uncertainand may depend on the ethnicity and age of thepopulation Others experience more rapidly

progressing disease, leading to reduced related function within 10 years Whether anindividual’s glaucoma will progress cannot bepredicted with precision, but those with higherlevels of IOP and worse visual fields at baseline, andthose who are older, tend to be at greater risk forthe more rapid progression of glaucoma Whetherthe rate of progression of visual field defects remainsuniform throughout the course of glaucoma isunknown

vision-Screening for Glaucoma

n Measurement of visual fields can be difficult Thereliability of a single visual field measurement may

be low; several consistent visual field measurementsare needed to establish the presence of defects.Dilated opthalmoscopy or slit lamp exam are used

by specialists to examine changes in the optic disc;however, even experts vary in their ability to detectglaucomatous optic disc progression Additionally,there is no agreed-upon single standard to defineand measure progression of visual field defects The primary treatments for POAG reduce IOP; theseinclude medications, laser therapy, or surgery Thesetreatments effectively reduce the development andprogression of small, visual field defects Themagnitude of their effectiveness, however, inreducing impairment in vision-related function isuncertain Harms caused by these interventionsinclude formation of cataracts, harms resulting fromcataract surgery, and harms of topical medication This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality Rockville,

MD, March 2005 http://www.preventiveservices.ahrq.gov

Screening for Glaucoma

All recommendation statements in this Guide are abridged To see the full recommendation statements

Section 3.

Recommendations for Children

Clinical Considerations

n This USPSTF recommendation addresses screeningfor elevated blood levels in children aged 1 to 5years who are both at average and increased risk,and in asymptomatic pregnant women

n The highest mean blood lead levels in the U.S.occur in children aged 1-5 years (geometric mean1.9 µg/dL) Children under 5 years of age are atgreater risk for elevated blood lead levels and lead

Summary of Recommendations

The U.S Preventive Services Task Force

(USPSTF) concludes that evidence is insufficient

to recommend for or against routine screening forelevated blood lead levels in asymptomatic children

aged 1 to 5 who are at increased risk Grade: I Statement.

The USPSTF recommends against routine

screening for elevated blood lead levels in

asymptomatic children aged 1 to 5 years who are

at average risk Grade: D Recommendation.

The USPSTF recommends against routine

screening for elevated blood lead levels in

asymptomatic pregnant women Grade: D

Recommendation.

Screening for Elevated Blood Lead Levels in Children and Pregnant Women

toxicity because of increased hand-to-mouthactivity, increased lead absorption from the

gastrointestinal tract, and the greater vulnerability

of the developing central nervous system Riskfactors for increased blood lead levels in childrenand adults include: minority race/ethnicity; urbanresidence; low income; low educational attainment;older (pre-1950) housing; recent or ongoing homerenovation or remodeling; pica exposure; use ofethnic remedies, certain cosmetics, and exposure tolead-glazed pottery; occupational and para-

occupational exposures; and recent immigration.Additional risk factors for pregnant women includealcohol use, smoking, pica, and recent immigrationstatus

n Blood lead levels in childhood, after peaking atabout 2 years of age, decrease during short- andlong-term followup without intervention Most lead

is stored in bone High bone lead levels can bepresent with normal blood lead levels, so that bloodlead levels often do not reflect the total amount oflead in the body This could explain the lack ofeffect of blood lead level-lowering measures onreducing neurotoxic effects

n Screening tests for elevated blood lead levels includefree erythrocyte (or zinc) protoporphyrin levels andcapillary or venous blood lead levels Erythrocyte(or zinc) protoporphyrin is insensitive to modestelevations in blood lead levels and lacks specificity.Blood lead concentration is more sensitive than

Screening for Blood Lead Levels

erythrocyte protoporphyrin for detecting modestlead exposure, but its accuracy, precision, andreliability can be affected by environmental leadcontamination Therefore, venous blood lead leveltesting is preferred to capillary sampling Screeningquestionnaires may be of value in identifyingchildren at risk for elevated blood lead levels butshould be tailored for and validated in specificcommunities for clinical use.

n Treatment options in use for elevated blood leadlevels include residential lead hazard-control efforts(i.e., counseling and education, dust or paintremoval, and soil abatement), chelation, andnutritional interventions In most settings,

education and counseling is offered for childrenwith blood lead levels from 10 to 20 µg/dL Someexperts have also recommended nutritional

counseling for children with blood lead levels in thisrange Residential lead hazard control is usuallyoffered to children with blood lead levels ≥20µg/dL, while chelation therapy is offered to childrenwith blood lead levels ≥45 µg/dL

n Community-based interventions for the primaryprevention of lead exposure are likely to be moreeffective, and may be more cost-effective, thanoffice-based screening, treatment, and counseling.Relocating children who do not yet have elevatedblood lead levels but who live in settings with highlead exposure may be especially helpful

Screening for Blood Lead Levels

Community, regional, and national environmentallead hazard reduction efforts, such as reducing lead

in industrial emissions, gasoline, and cans, haveproven highly effective in reducing populationblood lead levels

This USPSTF recommendation was first published in:

Pediatrics 2006;118:e2514-2518.

Screening for Blood Lead Levels

Clinical Considerations

n Dental disease is prevalent among young children,particularly those from lower socioeconomicpopulations; however, few preschool-aged childrenever visit a dentist Primary care clinicians are oftenthe first and only health professionals whomchildren visit Therefore, they are in a uniqueposition to address dental disease in these children

n Fluoride varnishes, professionally applied topicalfluorides approved to prevent dental caries in youngchildren, are adjuncts to oral supplementation.Their advantages over other topical fluoride agents

Prevention of Dental Caries in

Preschool Children

Summary of Recommendations

The U.S Preventive Services Task Force

(USPSTF) recommends that primary care

clinicians prescribe oral fluoride supplementation

at currently recommended doses to preschoolchildren older than 6 months of age whose

primary water source is deficient in fluoride

Grade: B Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against routinerisk assessment of preschool children by primarycare clinicians for the prevention of dental disease

Grade: I Statement.

Prevention of Dental Caries in Preschool Children

(mouth-rinse and gel) include ease of use, patientacceptance, and reduced potential for toxicity

n Dental fluorosis (rather than skeletal fluorosis) is themost common harm of either oral fluoride orfluoride toothpaste use in children younger than 2years in the United States Dental fluorosis istypically very mild and only of aesthetic

importance The recommended dosage of fluoridesupplementation was reduced by the AmericanDental Association in 1994, which is likely todecrease the prevalence and severity of dentalfluorosis The current dosage recommendations arebased on the fluoride level of the local community’swater supply and are available online at

www.ada.org The primary care clinician’s

knowledge of the fluoride level of his or her

patients’ primary water supply ensures appropriatefluoride supplementation and minimizes risk forfluorosis

This USPSTF recommendation was first published in:

Am J Prev Med 2004;26(4)326-329.

Clinical Considerations

n This USPSTF screening recommendation appliesonly to infants who do not have obvious hipdislocations or other abnormalities evident withoutscreening DDH represents a spectrum of anatomicabnormalities in which the femoral head and theacetabulum are aligned improperly or grow

abnormally DDH can lead to premature

degenerative joint disease, impaired walking, andpain Risk factors for DDH include female gender,family history of DDH, breech positioning, and inutero postural deformities However, the majority ofcases of DDH have no identifiable risk factors

n Screening tests for DDH have limited accuracy Themost common methods of screening are serialphysical examinations of the hip and lower

extremities, using the Barlow and Ortolani

procedures, and ultrasonography The Barlowexamination is performed by adducting a flexed hipwith gentle posterior force to identify a dislocatable

Screening for Developmental Dysplasia

of the Hip

Summary of Recommendation

The USPSTF concludes that evidence is

insufficient to recommend routine screening fordevelopmental dysplasia of the hip in infants as a

means to prevent adverse outcomes Grade: I

Statement.

hip The Ortolani examination is performed byabducting a flexed hip with gentle anterior force torelocate a dislocated hip Data assessing the relativevalue of limited hip abduction as a screening toolare sparse and suggest the test is of little value inearly infancy and is of somewhat greater value asinfants age.

n Treatments for DDH include both nonsurgical andsurgical options Nonsurgical treatment withabduction devices is used in early treatment andincludes the commonly prescribed Pavlik method.Surgical intervention is used when DDH is severe

or diagnosed late or after an unsuccessful trial ofnonsurgical treatments Evidence of the effectiveness

of interventions is inconclusive because of a highrate of spontaneous resolution, absence of

comparative studies of intervention versus

nonintervention groups, and variations in surgicalindications and protocols Avascular necrosis of thehip is the most common and most severe potentialharm of both surgical and nonsurgical interventionsand can result in growth arrest of the hip andeventual joint destruction with significant disability

References

1 Lehmann HP, Hinton R, Morello P, Santoli J

Developmental dysplasia of the hip practice guideline:technical report Committee on Quality Improvement,and Subcommittee on Developmental Dysplasia of the

Hip Pediatrics 2000;105(4):E57.

Screening for Hip Dysplasia

2 Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant

M Developmental dysplasia of the hip: a new approach

to incidence Pediatrics 1999;103(1):98-99.

3 Barlow T Early diagnosis and treatment of congenital

dislocation of the hip J Bone and Joint Surgery.

1962;44:292-301

4 Standing Medical Advisory Committee Screening for

the detection of congenital dislocation of the hip Arch

Dis Child 1986;61(9):921-926.

5 Cashman JP, Round J, Taylor G, Clarke NM Thenatural history of developmental dysplasia of the hipafter early supervised treatment in the Pavlik harness A

prospective, longitudinal followup J Bone Joint Surg Br.

2002;84(3):418-425

6 Konigsberg DE, Karol LA, Colby S, O’Brien S Results

of medial open reduction of the hip in infants with

developmental dislocation of the hip J Pediatr Orthop.

Clinical Considerations

n Screening adolescents for idiopathic scoliosis isusually done by visual inspection of the spine tolook for asymmetry of the shoulders, scapulae, andhips A scoliometer can be used to measure thecurve If idiopathic scoliosis is suspected,

radiography can be used to confirm the diagnosisand to quantify the degree of curvature

n The health outcomes of adolescents with idiopathicscoliosis differ from those of adolescents withsecondary scoliosis (ie, congenital, neuromuscular,

or early onset idiopathic scoliosis) Idiopathicscoliosis with onset in adolescence may have amilder clinical course.1

n Conservative interventions to treat curves detectedthrough screening include spinal orthoses (braces)and exercise therapy, but they may not significantlyimprove back pain or the quality of life for

adolescents diagnosed with idiopathic scoliosis

Summary of Recommendation

The U.S Preventive Services Task Force

(USPSTF) recommends against the routine

screening of asymptomatic adolescents for

idiopathic scoliosis Grade: D Recommendation.

Screening for Idiopathic Scoliosis in Adolescents

Screening for Idiopathic Scoliosis in Adolescents

n The potential harms of screening and treatingadolescents for idiopathic scoliosis include

unnecessary follow-up visits and evaluations due tofalse positive test results and psychological adverseeffects, especially related to brace wear Althoughroutine screening of adolescents for idiopathicscoliosis is not recommended, clinicians should beprepared to evaluate idiopathic scoliosis when it isdiscovered incidentally or when the adolescent orparent expresses concern about scoliosis

Reference

1 Weinstein SL, Dolan LA, Spratt KF, Peterson KK,Spoonamore MJ, Ponseti IV Health and function of patients with untreated idiopathic scoliosis: a 50-year

natural history study JAMA 2003;289(5):559-567.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,

MD June 2004 http://www.preventiveservices.ahrq.gov

as familial hypercholesterolemia in some

individuals Multifactorial dyslipidemias are due torisk factors including environmental factors (obesity,diet) or currently unidentified genetic factors Thisrecommendation applies to all asymptomaticindividuals from birth to age 20

n Because normal lipid levels have been stronglyassociated with the risk of coronary heart disease(CHD) events in adulthood, and early

identification and lipid-lowering intervention incertain populations of adults can prevent CHDevents, much attention has been directed at

screening individuals for dyslipidemia at young ages

Screening for Lipid Disorders in Children

Summary of Recommendation

The U.S Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against routinescreening for lipid disorders in infants, children,

adolescents, or young adults (up to age 20) Grade:

I Statement