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Recommendations for Preventive Pediatric Health Care

Bright Futures/American Academy of Pediatrics

Each child and family is unique; therefore,these Recommendations for Preventive Pediatric Health Care are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in satisfactory fashion.Additionalvisits may become necessary if circumstances suggest variations from normal.

Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits.

These guidelines represent a consensus by the American Academy of Pediatrics (AAP) and Bright Futures.The AAP continues to emphasize the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care.

Refer to the specific guidance by age as listed in Bright Futures guidelines (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008).

The recommendations in this statement do not indicate an exclusive course of treatment or standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Copyright ? 2014 by the American Academy of Pediatrics.

No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use.

INFANCY

EARLY CHILDHOOD

AGE1

2

Prenatal

3

Newborn

4

3-5 d

By 1 mo

2 mo

4 mo

6 mo 9 mo

12 mo

15 mo

18 mo

24 mo

30 mo

3y 4y

5 y

HISTORY

Initial/Interval

MIDDLE CHILDHOOD

6 y

7 y

8y

9y

ADOLESCENCE

10 y

11 y

12 y

13 y

14 y

15 y

16 y

17 y

18 y 19 y 20 y

21 y

MEASUREMENTS Length/Height and Weight

Head Circumference Weight for Length Body Mass Index5 Blood Pressure6

SENSORY SCREENING Vision

Hearing

7

8

DEVELOPMENTAL/BEHAVIORAL ASSESSMENT Developmental Screening9 Autism Screening10

Developmental Surveillance

Psychosocial/Behavioral Assessment Alcohol and Drug Use Assessment11

Depression Screening12

PHYSICAL EXAMINATION13

PROCEDURES14

Newborn Blood Screening15

Critical Congenital Heart Defect Screening16 Immunization17

Hematocrit or Hemoglobin18

Lead Screening19

Tuberculosis Testing21

Dyslipidemia Screening22

STI/HIV Screening23 Cervical Dysplasia Screening24

ORAL HEALTH25

ANTICIPATORY GUIDANCE

or 20

or 20

or

or or or

1. If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date at the earliest possible time.

2. A prenatal visit is recommended for parents who are at high risk, for first-time parents, and for those who request a conference. The prenatal visit should include anticipatory guidance, pertinent medical history, and a discussion of benefits of breastfeeding and planned method of feeding, per the 2009 AAP statement "The Prenatal Visit" ().

3. Every infant should have a newborn evaluation after birth, and breastfeeding should be encouraged (and instruction and support should be offered). 4. Every infant should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the hospital to include evaluation for

feeding and jaundice. Breastfeeding infants should receive formal breastfeeding evaluation, and their mothers should receive encouragement and instruction, as recommended in the 2012 AAP statement "Breastfeeding and the Use of Human Milk" (). Newborn infants discharged less than 48 hours after delivery must be examined within 48 hours of discharge, per the 2010 AAP statement "Hospital Stay for Healthy Term Newborns" (). 5. Screen, per the 2007 AAP statement "Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report" (). 6. Blood pressure measurement in infants and children with specific risk conditions should be performed at visits before age 3 years. 7. If the patient is uncooperative, rescreen within 6 months, per the 2007 AAP statement "Eye Examination in Infants, Children, and Young Adults by Pediatricians" (). 8. All newborns should be screened, per the AAP statement "Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs" (). 9. See 2006 AAP statement "Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening" (). 10. Screening should occur per the 2007 AAP statement "Identification and Evaluation of Children with Autism Spectrum Disorders" ().

11. A recommended screening tool is available at . 12. Recommended screening using the Patient Health Questionnaire (PHQ)-2 or other tools available in the GLAD-PC toolkit and at

. 13. At each visit, age-appropriate physical examination is essential, with infant totally unclothed and older children undressed and suitably draped. See

2011 AAP statement "Use of Chaperones During the Physical Examination of the Pediatric Patient" (). 14. These may be modified, depending on entry point into schedule and individual need. 15. The Recommended Uniform Newborn Screening Panel (), as determined by The Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening laws/regulations (), establish the criteria for and coverage of newborn screening procedures and programs. Follow-up must be provided, as appropriate, by the pediatrician. 16. Screening for critical congenital heart disease using pulse oximetry should be performed in newborns, after 24 hours of age, before discharge from the hospital, per the 2011 AAP statement "Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease" (). 17. Schedules, per the AAP Committee on Infectious Diseases, are available at: . Every visit should be an opportunity to update and complete a child's immunizations. 18. See 2010 AAP statement "Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and Young Children (0-3 Years of Age)" (). 19. For children at risk of lead exposure, see the 2012 CDC Advisory Committee on Childhood Lead Poisoning Prevention statement "Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention" ().

20. Perform risk assessments or screenings as appropriate, based on universal screening requirements for patients with Medicaid or in high prevalence areas.

21. Tuberculosis testing per recommendations of the Committee on Infectious Diseases, published in the current edition of AAP Red Book: Report of the Committee on Infectious Diseases. Testing should be performed on recognition of high-risk factors.

22. See AAP-endorsed 2011 guidelines from the National Heart Blood and Lung Institute, "Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents" ().

23. Adolescents should be screened for sexually transmitted infections (STIs) per recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases. Additionally, all adolescents should be screened for HIV according to the AAP statement () once between the ages of 16 and 18, making every effort to preserve confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually.

24. See USPSTF recommendations (). Indications for pelvic examinations prior to age 21 are noted in the 2010 AAP statement "Gynecologic Examination for Adolescents in the Pediatric Office Setting" ().

25. Refer to a dental home, if available. If not available, perform a risk assessment (). If primary water source is deficient in fluoride, consider oral fluoride supplementation. For those at high risk, consider application of fluoride varnish for caries prevention. See 2008 AAP statement "Preventive Oral Health Intervention for Pediatricians" () and 2009 AAP statement "Oral Health Risk Assessment Timing and Establishment of the Dental Home" ().

KEY = to be performed

= risk assessment to be performed with appropriate action to follow, if positive

= range during which a service may be provided

Summary of changes made to the

2014 Bright Futures/AAP Recommendations for Preventive Pediatric Health Care

(Periodicity Schedule)

Changes to Developmental/Behavioral Assessment ? Alcohol and Drug Use Assessment- Information regarding a recommended

screening tool (CRAFFT) was added.

? Depression- Screening for depression at ages 11 through 21 has been added, along with suggested screening tools.

Changes to Procedures

? Dyslipidemia screening- An additional screening between 9 and 11 years of age has been added. The reference has been updated to the AAP-endorsed National Heart Blood and Lung Institute policy ().

? Hematocrit or hemoglobin- A risk assessment has been added at 15 and 30 months. The reference has been updated to the current AAP policy ().

? STI/HIV screening- A screen for HIV has been added between 16 and 18 years. Information on screening adolescents for HIV has been added in the footnotes. STI screening now references recommendations made in the AAP Red Book. This category was previously titled "STI Screening."

? Cervical dysplasia- Adolescents should no longer be routinely screened for cervical dysplasia until age 21. Indications for pelvic exams prior to age 21 are noted in the 2010 AAP statement "Gynecologic Examination for Adolescents in the Pediatric Office Setting" ().

? Critical Congenital Heart Disease- Screening for critical congenital heart disease using pulse oximetry should be performed in newborns, after 24 hours of age, before discharge from the hospital, per the 2011 AAP statement, "Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease" ().

For several recommendations, the AAP Policy has been updated since 2007 but there have been no changes in the timing of recommendations on the Periodicity Schedule. These include:

? Footnote 2- The Prenatal Visit (2009):

? Footnote 4- Breastfeeding and the Use of Human Milk (2012): and Hospital Stay for Healthy Term Newborns (2010):

? Footnote 8- Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs (2007):

? Footnote 10- Identification and Evaluation of Children with Autism Spectrum Disorders (2007):

? Footnote 17- Immunization Schedules (2014): , , and

? Footnote 19- CDC Advisory Committee on Childhood Lead Poisoning Prevention statement "Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention" (2012):

? Footnote 22- AAP-endorsed guideline "Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents" (2011):

? Footnote 25- Preventive Oral Health Intervention for Pediatricians (2008): and Oral Health Risk Assessment Timing and Establishment of the Dental Home (2009): . Additional information from the policies regarding fluoride supplementation and fluoride varnish has been added to the footnote.

New references were added for several footnotes, also with no change to recommendations in the Periodicity Schedule:

? Footnote 5- Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report (2007):

? Footnote 13- Use of Chaperones During the Physical Examination of the Pediatric Patient (2011):

? Footnote 15- The Recommended Uniform Newborn Screening Panel ( mmendedpanel/uniformscreeningpanel.pdf), as determined by The Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening laws/regulations ( us.uthscsa.edu/sites/genes-r-us/files/nbsdisorders.pdf), establish the criteria for and coverage of newborn screening procedures and programs. Follow-up must be provided, as appropriate, by the pediatrician.

For consistency, the title of "Tuberculin Test" has been changed to "Tuberculosis Testing." The title of "Newborn Metabolic/Hemoglobin Screening" has been changed to "Newborn Blood Screening."

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