• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Health Screening of Children

Posted on: Sunday, 31 October 2004, 03:00 CST

Dr Linda Miller reviews the latest thinking in child health screening

Screening for physical and developmental problems in early childhood is most important. Child health surveillance clinics are also recognised as an ideal opportunity to identify a range of family needs. Feeding, sleep and behavioural problems as well as maternal postnatal depression are often revealed.

Failure to thrive

Failure to thrive is defined as abnormally low growth velocity, and affects five to 10 per cent of children in the community.

Plotting an infant's height and weight is a useful tool to ensure the child is thriving and an opportunity to observe mother-child interaction.

Never underestimate the parental stress that can be caused by inaccurately labelling a child as failing to thrive. It is important to know the limitations of charts and take into consideration prematurity or low birth weight. If growth velocity is normal, a baby may be small because of parental small stature.

Accurate charts

The growth reference group of the Royal College of Paediatricians concluded that the UK 1990 reference charts are superior to older charts. The Tanner-Whitehouse and Gairdner-Pearson charts should no longer be used.

By redefining failure to thrive as falling across two or more channels and correcting for 'catch up and catch down' growth, the detection of true cases should be improved.

The Child Growth Foundation has charts specifically for Asian children.There are charts for children with Down's and Turner's syndromes. There are no reliable head circumference charts for use beyond infancy.

Food intake

Failure to thrive is more often due to inadequate intake than physical illness. Simple causes such as misunderstandings relating to mixing feed, late weaning or unusual diet and nutrition ideas may be responsible. There is evidence that some children with failure to thrive lack the normal responses to hunger and satiety cues, and high energy snacks may improve their nutritional status.

Eating behaviour

Many parents of toddlers report behavioural problems at mealtimes. Limiting the duration of meals and emphasising praise for good eating habits may be sufficient. It is important that meals are sociable occasions and children see family members eating together. Fruit juices may be filling and milk or water should be recommended as an alternative. Adding butter and cream to foods and offering a variety of foods may help.

Hip screening

The incidence of congenital dislocation of the hip is 1-2 in 1,000.

The routine tests for checking babies' hips for subluxation or dislocation are subject to interpretation by the practitioner.

Routinely using ultrasound on the hips of all babies can eliminate late presentation of developmental dysplasia of the hip. Of the hip abnormalities found on ultrasound persisting beyond six weeks, only 20 per cent had been detected by clinical examination.This confirms the limitations of clinical examination as a screening test.

In Southampton, a study used selective screening with ultra- sound with or without X-ray and orthopaedic examination; the incidence of late diagnosis of developmental dysplasia of the hip was also reduced.

In terms of manpower and equipment, intensive screening is costly and requires good organisation. However such costs have been shown to be offset by the reduction in later morbidity and surgery.

Referral for scanning

Until ultrasound screening of all neonates is universally available, certain groups should be selected for scanning. Any child with a positive or equivocal hip examination should be referred.

Those with asymmetry of creases, femoral shortening with hips and knees flexed or restricted abduction should also be referred.

Hearing

The aim of screening for childhood hearing problems is to detect those with permanent, congenital hearing impairment. Early diagnosis and intervention can significantly help speech and intelligibility. The infant distraction test has a low yield of 26-28 per cent; the effectiveness is 34 per cent.

Neonatal testing

Neonatal screening can improve on this; the effectiveness is 85 per cent. The auditory brainstem response is measured using skin electrodes to record electrical activity originating in the auditory nerve and brainstem pathways in response to sound stimuli. This takes 12-40 minutes and is performed by an audiometrist on a sleeping baby.

The technique is sensitive but is affected by prematurity. Otoacoustic emissions, a quicker technique, is less sensitive but can be used as a neonatal screen by less highly trained staff.

When universal neonatal screening is introduced it will replace the infant distraction test, but targeted follow-up at eight months should include those at high risk. Babies missed by neonatal screening should also be tested at this stage.

School entry screening should continue.This can detect mild or unilateral sensorineural as well as conductive hearing losses.

Chemical screening

Screening for phenylketonuria and hypothyroidism are effective as long as adequate, clearly defined systems are in place for following up positive results.

Post-natal screening for sickle cell disorders and cystic fibrosis meet the criteria for screening programmes and there are plans to introduce screening tests.

Vision

Major visual defects are rare, about 4 per 10,000. Minor vision problems such as squint and refractive error affect 5-10 per cent of children.

Clinical examination at birth and six weeks is essential for detecting cases of retinoblastoma and congenital cataracts. Parental concerns about a baby or child's vision should be investigated, and causes other than visual defects may become apparent.

Tracking the eye movements in babies under one year in social situations can be used to identify autism. Instead of making eye contact, autistic babies focus on mouths and objects.

School entry remains an ideal opportunity for further screening for visual defects. As the visual system does not completely develop until the age of eight, lesions on the lids or around the eyes impinging on the visual field should be treated.

The aim of screening for childhood hearing problems is to detect those with permanent hearing impairment

"Measuring height and weight of infants offers a good opportunity to observe mother-child interaction

GP referral

Refer any child with:

* Speech or hearing concerns.

* Developmental or behavioural problems.

* Repeated ear infections.

* Any cases of head injury.

* cases of hypoxia.

* Bacterial meningitis.

* cases of measles.

* Any suspicion of a squint at the eight-month check.

Some causes of failure to thrive

* Feeding difficulty.

* Breastfeeding difficulties, sleeping through feeds.

* Oromotor problems.

* Over-dilution of feeds.

* Dietary restraint.

* Physical problems.

* Cystic fibrosis.

* Pyloric stenosis, malabsorbtion or intolerance of cows' milk protein.

* Cardiac problems.

* Gastro-oesophageal reflux, inflammatory bowel disease, giardia.

Dr Miller is a GP in West London

Copyright Haymarket Business Publications Ltd. Oct 8, 2004

Source: GP

More News in this Category