Pediatric screening reviewed for efficacy

Guidelines for vision, hearing and scoliosis screenings differ from HHS, AAP.

Long a mainstay of pediatrics, screening for conditions and functional deficits has come under greater scrutiny in recent years, as more evidence as to the effectiveness and safety of screening measures begins to appear in the literature.

“For a long time, we performed screenings because they just seemed like a good idea,” said William T. Gerson, MD, an Infectious Diseases in Children Editorial Board member. “But we’ve always been worried about their effectiveness and the consequences of a patient being labeled in a way that could follow them for the rest of their lives. That could have repercussions that far outweigh the actual health issue. Now that we have evidence and outcome measurements attached to screening, different organizations and agencies have reviewed the evidence and made recommendations.”

One such agency, The U.S. Preventive Services Task Force, was appointed by the Department of Health and Human Services and comprises several non-federal primary care specialists with expertise in evidence-based medicine, including family physicians, pediatricians, OB/GYNs, nurses and behavioral health specialists. The panel conducts broad literature reviews of preventive health measures, including pediatric screenings, and makes recommendations as to their efficacy and usefulness.

In 2004, the Task Force issued recommendations on three of the most common screenings performed in the pediatric setting — vision, hearing and scoliosis. But the American Academy of Pediatrics recommendations on these screenings differ slightly.

“It is important to remember that the Task Force and the AAP have distinctly different perspectives on primary care practice,” Gerson said. “The Task Force is mandated to explicitly review the scientific data, with emphasis on evidence-based practice, outcome and effectiveness studies. For most areas in general pediatric practice, research along these lines are in their infancy.”

However, “the AAP, in their guidelines, acknowledges the Task Force as a significant partner, but takes a larger, expert driven approach to the development of practice parameters. For the general pediatrician, the AAP guidelines are the most sensible to adopt. The Task Force guidelines allows the research arms of clinical pediatrics to determine those areas of care that require the development of more satisfactory evidence,” Gerson said.

Screening recommendations

For vision, the Task Force recommends screening to detect strabismus, amblyopia and refractive error exclusively in children younger than age 5. In its review, the panel did not find any evidence that vision screenings resulted in improved visual acuity, but found fair evidence to suggest vision screenings have “reasonable accuracy” in detecting strabismus, amblyopia and refractive error.

The Task Force noted a single study that found intensive eye screening performed six times between ages 8 and 37 months, was sufficient to decrease the prevalence of amblyopia. Furthermore, they emphasized that treatment of strabismus and amblyopia could improve visual acuity and reduce long-term amblyopia.

There were no risks associated with vision screenings, and the benefits of screening were likely to outweigh any harms, the researchers noted noted.

The AAP differs in its vision screening guidelines, recommending universal screening at ages 3, 4, 5, 6, 8, 10 and once during the early, middle and late adolescent phases.

“If you don’t find amblyopia by age 5, the chances of fixing the condition are slim to none,” Gerson said. “But in the older ages we continue to do a universal vision screening for acuity.”

The Task Force recommends universal hearing screening for all newborn infants. Noting that half of children with hearing loss lack identifiable risk factors, Task Force recommendations assert that only universal screening is effective for detecting children with permanent congenital hearing loss. Because of this, “several states mandate screenings in the hospital nursery before the infant is discharged,” Gerson said.

The AAP recommends that pediatricians perform a hearing screening in the first three months of an infant’s life in order to meet the goal of universal detection of hearing loss. The AAP further recommends universal follow-up screenings at 4, 5, 6, 8 and 10-year visits. After age 10, selective screenings should only be performed if hearing issues persist.

Finally, the Task Force recommends against routine screening for idiopathic scoliosis in asymptomatic adolescents. In its review, the Task Force failed to find sufficient evidence that screening detected scoliosis any earlier than when the condition was detected without screening. The typical forward bend test was found to be “variable,” and among those adolescents who were indentified during community screenings, follow-up was poor. While the Task Force noted the surgery is often beneficial, the most aggressive forms of scoliosis that require surgery are likely to be identified without screening.

Furthermore, the Task Force found that scoliosis screening could lead to moderate harms, including unnecessary braces and referrals to specialty care.

The AAP differs in its scoliosis guideline, having endorsed in 2007 a statement by B. Stephens Richards III, MD, and Michael G. Vitale, MD, which did not explicitly recommend school screening programs but encouraged their continuation where they exist, and stated that any endorsing organization would not support a recommendation against screening.

“I suspect that most pediatricians will continue to screen for scoliosis despite that Task Force’s recommendation against it,” Gerson said. “We look at every patient’s back anyway. We wouldn’t leave off a whole part of the body.” –by Andy Moskowitz