2004 Preventive Health Guidelines
2004 PEDIATRIC PREVENTIVE SCREENING GUIDELINES:
ASSESSMENT FOR HIGH RISK AND
GUIDE TO PROFESSIONAL CONSENSUS STATEMENTS
Overview
Since 1988, Oxford has endorsed, distributed and encouraged adherence to preventive
health guidelines in physician practice through education and outreach to its physicians
and Members. Ongoing research continues to identify optimal methods of addressing
preventable illnesses in the pediatric population. How “normal” and “high risk” is
defined often dictates the appropriate time to initiate screening.
To help physicians, parents and patients make informed decisions, Oxford includes
definitions of “normal” and “high risk” in its Pediatric Preventive Screening Guidelines.
In addition, where expert opinion or regional mandates differ, a synopsis of current
medical opinion has been charted to clarify where they differ and converge. In areas
where no clear consensus exists, Oxford supports decisions made in the context of the
physician-family relationship.
Recommendations for preventive pediatric healthcare are designed for the care of
children who have no manifestations of any important health problems and are growing
and developing in satisfactory fashion. Additional visits to the pediatrician may be
necessary if circumstances vary from the norm. A prenatal visit is recommended for
mothers who are at high risk, for first-time parents and for those who request a
conference. The prenatal visit should include anticipatory guidance and pertinent
medical history. Every infant should have a newborn evaluation after birth.
MS-04-1094
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002,
3/2003,03/2004
7294
Recommendations for Preventive Pediatric Healthcare (RE9939)
Committee on Practice and Ambulatory Medicine
Each child and family is unique. Therefore, Recommendations for Preventive Pediatric Healthcare 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. Additional visits may become necessary if circumstances
suggest variations from the norm.
These guidelines represent a consensus by the Committee on Practice and Ambulatory Medicine in consultation with national committees and sections of the American Academy
of Pediatrics (AAP). The Committee emphasizes great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care.
MS-04-1094
7294
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002, 3/2003,03/2004
1. A prenatal visit is recommended for mothers 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 the benefits of breastfeeding and planned method of feeding per the AAP statement, "The Prenatal
Visit" (1996).
2. Every infant should have a newborn evaluation after birth. Breastfeeding should be encouraged and instruction and support offered. Every breastfeeding infant should have
an evaluation 48-72 hours after discharge from the hospital to include weight, formal breastfeeding evaluation, encouragement, and instruction as recommended in the AAP
statement, "Breastfeeding and the Use of Human Milk" (1997).
3. For newborns discharged within 48 hours of delivery, the AAP statement, "Hospital Stay for Healthy-Term Newborns" (1995), is recommended reading.
4. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment separate from preventive care visits.
5. When a child comes under care for the first time, or if any items are not accomplished at the suggested age, the child’s schedule should be brought up to date at the earliest
possible time.
6. If the patient is uncooperative, rescreen within six months.
7. All newborns should be screened per the AAP task force on the Newborn and Infant Hearing statement, "Newborn and Infant Hearing Loss: Detection and Intervention"
(1999).
8. Parenting skills should be fostered at every visit.
9. At each visit, a complete physical examination is essential with infant totally unclothed, older child undressed and suitably draped.
10. These recommendations may be modified, depending upon entry point into the schedule and individual need.
11. Metabolic screening (e.g., thyroid, hemoglobinopathies, PKU, galactosemia) should be done according to state law.
12. The schedule, per the Committee on Infectious Diseases, is published annually in the January edition of Pediatrics. Every visit should be an opportunity to update and
complete a child's immunizations.
13. See the AAP Pediatric Nutrition Handbook (1998) for a discussion of universal and selective screening options. Consider earlier screening for high-risk infants (e.g.,
premature infants and low birth weight infants). See also "Recommendations to Prevent and Control Iron Deficiency in the United States." MMWR. 1998;47 (RR-3): 1-29.
14. All menstruating adolescents should be screened annually.
15. Conduct a dipstick urinalysis for leukocytes annually for sexually active male and female adolescents.
16. For children at risk of lead exposure, consult the AAP statement "Screening for Elevated Blood Levels" (1998). Additionally, screening should be done in accordance with
state law where applicable.
17. TB testing recommendations by the Committee on Infectious Diseases can be found in Red Book: Report of the Committee on Infectious Diseases. Testing should be done
upon recognition of high-risk factors.
18. Cholesterol screening for high-risk patients is recommended per the AAP statement "Cholesterol in Childhood" (1998). If family history cannot be ascertained and other
risk factors are present, screening should be at the discretion of the physician.
19. All sexually active patients should be screened for sexually transmitted diseases (STDs).
MS-04-1094
7294
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002, 3/2003,03/2004
20. All sexually active females should have a pelvic examination. A pelvic examination and routine pap smear should be offered as part of preventive health maintenance
between the ages of 18 and 21 years.
21. Age-appropriate discussion and counseling should be an integral part of each visit for care per the AAP Guidelines for Health Supervision III (1998).
22. From birth to age 12, refer to the AAP injury prevention program (TIPP) (as described in A Guide to Safety Counseling in Office Practice (1994).
23. Violence prevention and management for all patients is located in the AAP statement, "The Role of the Pediatrician in Youth Violence Prevention in Clinical Practice and
at the Community Level" (1999).
24. Parents and caregivers should be advised to place healthy infants on their backs when putting them to sleep. Side positioning is a reasonable alternative, but carries a
slightly higher risk of SIDS. Consult the AAP statement, "Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep
Position" (2000).
25. Age-appropriate nutrition counseling should be an integral part of each visit per the AAP Handbook of Nutrition (1998).
26. Earlier initial dental examinations may be appropriate for some children. Subsequent examinations are as prescribed by dentist.
Key:
• = to be performed
* = to be performed for patients at risk
S = subjective, by history
O = objective, by a standard testing method
¥ = the range during which a service may be provided with the dot indicating the preferred age
Special chemical, immunologic, and endocrine testing is usually carried out upon specific indications. Testing for other than newborns (e.g., inborn errors of metabolism, sickle
disease, etc.) is discretionary with the physician.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Copyright © 2000 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.
MS-04-1094
7294
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002, 3/2003,03/2004
Since publication of the 2002 catch-up schedule, no major changes have been made
regarding specific vaccines. However, included for reference this year is the
recommendation for children who fall behind or start their immunizations late. The new
schedule also begins to focus on the expansion of routine influenza immunization for
pediatric populations to reflect the shift toward immunization of all children between six
and 24 months of age.
The annual recommended childhood and adolescent immunization schedule of the
American Academy of Pediatrics, the Advisory Committee on Immunization Practices of
the Centers for Disease Control and Prevention, and the American Academy of Family
Physicians is issued for January to June 2004. A mid-year schedule will be released with
any new significant recommendations.
In October 2003, the ACIP recommended universal influenza immunization of all
children between six and 23 months of age and routine influenza immunization of all
household contact and out-of-home caregivers of children younger than 24 months. This
change by the ACIP from encouraging immunization to recommending it is under
consideration by the Centers for Disease Control and Prevention, the American Academy
of Family Physicians, and the American Academy of Pediatrics for the 2004–2005
influenza season.
Changes in the 2004 schedule include specification of the following minimum ages for
the final dose in the vaccine series: 1) diphtheria and tetanus toxoids and acellular
pertussis (DTaP) for those over four years of age; 2) Haemophilus influenzae type b
(Hib) conjugate vaccine for those over 12 months of age; 3) pneumococcal conjugate
vaccine for those over 12 months of age; and 4) hepatitis B (third or fourth dose) for
those over 24 weeks of age. The diphtheria and tetanus toxoids (Td) booster is now
recommended to be given between 11 and 12 years of age as opposed to 11-18 years of
age.
Summary of New York State Lead Screening and Follow-up Regulations, Part 67-1
and 67-3
Pediatric healthcare providers are required to:
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Screen all one- and two-year-olds for blood lead levels as part of well-childcare.
Assess other children six months to six years of age for risk of high-dose exposure
to lead (see Chapter 3, New York State Department of Health Physician's
Handbook on Lead Screening to determine risks for high-dose lead exposure) and
provide lead screening as indicated.
Ensure that all children six months to six years of age are appropriately screened
by inquiring about lead screening status when children present for emergent or
episodic care to nonprimary care providers.
MS-04-1094
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002,
3/2003,03/2004
7294

Provide parents with written documentation of blood lead testing. Providers may
use the New York State lead screening certificate, the revised immunization
record or another parent-held child health record to indicate proof of a blood lead
test.
 Provide risk reduction education and nutrition counseling to parents of children
with blood lead levels of ten micrograms per deciliter or greater (µg/dL or
mcg/dL).
 Provide follow-up testing to children with blood lead levels of 10 µg/dL or greater
in accordance with currently accepted medical standards and public health
guidelines.
 Confirm fingerstick blood lead levels equal to or greater than 15 µg/dL with a
venous sample.
 Provide a complete diagnostic evaluation, a detailed lead exposure assessment, a
nutritional assessment and a developmental screening to children with a lood lead
level 20 µg/dL or greater and provide medical treatment as indicated.
 Refer children who have a confirmed blood lead level of 20 µg/dL or greater to
the appropriate local or state health unit for environmental assessment and
management.

Notify the local health unit of a blood lead level result greater than 45 µg/dL
within 24 hours.
Connecticut
Anticipatory Guidelines and Lead Hazard Reduction
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Anticipatory guidance regarding lead hazard identification and risk reduction
measures should be a routine part of an ongoing educational approach for
pregnant women, children, and their families.
Family education and anticipatory guidance should be offered with awareness of,
and respect for, the cultural determination of health behaviors and attitudes in the
family and community.
Family education that takes place during a visit should be supplemented with
written materials in the family’s primary language at an appropriate reading level.
Universal Lead Screening
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At well-child visits, at age 12 months and again at age 24 months, healthcare
providers should screen all children using a blood lead test for elevated blood
lead levels.
Any child age 25-72 months of age, who has not previously been screened,
should also have a blood lead screening performed immediately, regardless of
risk.
MS-04-1094
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002,
3/2003,03/2004
7294


Additional blood lead screening is indicated for any child older than 72
months of age, with developmental delays, especially if associated with pica.
All children 6-72 months of age in HUSKY Part A Medicaid must be assessed
for risk, and at a minimum, screened at 12 months and 24 months of age.
Blood lead testing should also be considered for any child regardless of age with:
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Unexplained seizures, neurological symptoms, hyperactivity, behavior disorders,
growth failure, abdominal pain or other symptoms consistent with lead poisoning
or associated with lead exposure.
Recent history of ingesting, or an atypical behavior pattern of inserting, any
foreign object (even if the foreign object is unleaded) into a body orifice.
Risk Assessment

In addition to screening children at the recommended time intervals, healthcare
providers should assess children 6-72 months of age for risk of lead exposure
using risk assessment questions. The State of Connecticut Department of Public
Health Childhood Lead Poisoning Prevention Program, which can be reached at
860-509-7745 or
www.dph.state.ct.us/Publications/BCH/EEOH/recommandations.pdf, can provide
specific risk assessment questions.
Diagnostic Testing and Follow-up
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If a screening blood lead level is elevated (equal to or greater than 10 ug/dl),
confirm with diagnostic (venous) blood lead test with reference to CDC
guidelines.
Children with an elevated diagnostic blood lead test require additional follow-up
blood testing at appropriate intervals according to CDC guidelines.
Providers can contact one of Connecticut’s regional Lead Treatment Centers for
guidance and assistance with clinical management of a lead-poisoned child.
New Jersey
Childhood Lead Screening Requirements
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Verbally assess at six months of age and annually up to age six.
All children must be tested for blood lead levels (BLL) at least twice:
o At 9-18 months; preferably at 12 months
o At 18-24 months; preferably at 24 months
o Test any child at 27-72 months who has not been tested previously.
Report all results to parents.
MS-04-1094
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002,
3/2003,03/2004
7294

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o < 15ug/dL., orally
o >/= 15 ug/dL, in writing
Provide anticipatory guidance concerning preventive measures.
Perform follow ups:
o If BLL is >/= 10ug/dL, confirm/monitor BLL, test siblings, educate
parents, provide appropriate diagnostic tests and medical treatment.
o If BLL is >/= 20ug/dL, all of the above, and work with local health
department to ensure follow-up.
If at high risk:
o At </= two years, test at six months and
o At two years, test new exposure.
o If blood lead level is </= 10 ug/dL, see above.
MS-04-1094
Derived from American Association of Pediatricians, U.S. Preventive Services Task Force,
& New York, New Jersey, & Connecticut State Departments of Health.
Approved by Oxford Regional QM Committees 3/1992, 3/1994, 1/1995, 12/1997, 3/1999, 2/2000, 4/2001, 3/2002,
3/2003,03/2004
7294