Pediatric Preventive Care 2018-09-28T23:05:55+00:00

2018 Pediatric Preventive Care Guidelines

MHQP’s 2018 guidelines were developed by a collaborative group of Massachusetts healthcare organizations. These are recommendations for providing preventive care to pediatric patients from the general population. These guidelines should not supplant clinical judgment or the needs of individual patients. These guidelines are intended as quality-practice recommendations and are not intended as a description of benefits, conditions of payment, or any other legal requirements of any particular health plan or payor. Each health plan or payor makes its own determination of coverage and benefits. In the event that these practice recommendations are inconsistent with any applicable laws or regulations, such laws or regulations take precedence.

Click here to access a PDF version of the Pediatric guidelines.

PERIODIC HEALTH EVALUATION

0-1 (Infancy)

  • Ages 1-2 weeks, and 1, 2, 4, 6, 9, and 12 months
  • Assess breastfeeding infants between 2-5 days of age.

1-4 (Early Childhood)

  • Ages 15, 18, and 24 months, and 3 and 4 years.

5-21 (Middle Childhood – Young Adult)

  • Annually

RECOMMENDED SCREENING AND ROUTINE LABS

0-1 (Infancy)

  • Once between ages 9-12 months.
  • At clinician discretion, conduct detailed assessment of infants at high risk for iron deficiency.
  • Consider screening at 15 and 30 months, based on risk factors.

1-10 (Early Childhood – Mid. Childhood)

  • Conduct assessment, including dietary iron sufficiency, at clinician discretion.
  • Screen those with known risk factors annually from ages 2 to 5.

11- 21 (Adolescence – Young Adult)

  • Starting at age 11, conduct risk assessment.
  • Screen all non-pregnant female adolescents for anemia every 5-10 years during well visit starting at age 12.
  • Annually screen for those with known risk factors.

RISK FACTORS
Excessive menstrual blood loss, low iron intake, or previous diagnosis of iron deficiency anemia.

RESOURCE
Bright Futures

1-4 (Early Childhood)

  • At every well visit starting at age 3 years.

5-21 (Mid. Childhood – Young Adult)

  • At every well visit.

0-1 (Infancy)

  • N/A

1-4 (Early Childhood)

  • Screen if at risk.

5-10 (Mid. Childhood)

  • Ages 5-8, screen if at risk.
  • Starting at age 9, screen child at least once if not previously screened.

11-21 (Adolescence – Young Adult)

  • Screen once if not screened previously, or risk factors have changed.

RISK FACTORS
Family history of premature cardiovasular disease (CVD), parent with known lipid disorder, overweight/obesity.

0-1 (Infancy)

  • Assess growth parameters using length, weight, and head circumference.

1-21 (Early Childhood – Young Adult)

  • Assess growth parameters using length/height and weight; include head circumference until 2 years of age.
  • Screen annually for healthy weight. Plot value on CDC’s growth and body mass index (BMI) charts specifically for ages 2-20 years.
  • Screen for obesity in children 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.
  • Counsel on the benefits of physical activity and a healthy diet to maintain a desirable weight for height.
  • Provide more focused evaluation and counseling for children with BMI ≥85th percentile or with significant increase in BMI percentile.

0-10 (Infancy – Mid. Childhood)

Massachusetts law requires lead screening according to the following schedule:

  • Initial screening between 9-12 months of age;
  • Annually at ages 2 and 3;
  • At age 4 if child lives in a city/town with high risk for childhood lead poisoning;
  • At entry to kindergarten if not screened before.

11-21 (Adolescence – Young Adult)

  • N/A

RESOURCE
Mass DPH Childhood Lead Poisoning Prevention Program

0-1 (Infancy)

1-21 (Early Childhood – Young Adult)

  • N/A

SENSORY SCREENING

0-1 (Infancy)

  • Assess newborn before discharge or at least by age 1 month.
  • Conduct subjective assessment at all other routine checkups.

1-17 (Early Childhood – Adolescence)

  • Conduct objective hearing screening at ages 4, 5, 6, 8, and 10 years. Conduct at older ages at clinician discretion. If test is performed in another setting, such as a school, it does not need to be repeated by the provider, but findings should be documented in child’s medical record.
  • If a language delay or a risk of hearing loss exists, conduct audiologic monitoring every 6 months until age 3 years.
  • Make subjective assessment at all other routine checkups.

18-21 (Young Adult)

  • N/A

0-1 (Infancy)

  • Assess newborn before discharge or at least by age 2 weeks using corneal light reflex and red reflex.
  • Evaluate fixation preference, alignment, and eye disease by age 6 months.

1-17 (Early Childhood – Adolescence)

  • Visual acuity test at ages 3, 4, 5, 6, 8, 10, 12, 15, and 18 years. Document in medical record if test is performed in another setting such as a school.
  • Screen for strabismus between ages 3 and 5 years.
  • Child must be screened at entry to kindergarten if not screened during the prior year per the Massachusetts Preschool Vision Screening Protocol.

RESOURCE
Massachusetts School Health Screenings

INFECTIOUS DISEASE SCREENING

11-21 (Adolescence – Young Adult)

General counseling regarding safe and healthy sexual behaviors:

  • Obtain sexual history and ask annually about involvement in sexual behaviors with sensitivity to sexual orientation.
  • Counsel to prevent sexually transmitted infections for all sexually active adolescents and young adults.
  • Counsel about responsible sexual behaviors.
  • Inform patients of the risk of unintended pregnancy and sexually transmitted infections.
  • Ask about use/motivation to use contraceptive methods.
  • Consider preconception counseling, if appropriate.

Chlamydia and gonorrhea:

  • Screen all sexually active female patients annually. Consider urine-based screening for female patients when a pelvic examination is not performed.

HPV:

  • Strongly recommend vaccination and counsel all patients regarding schedule of HPV vaccine.
  • See Pelvic Exam/Pap Test section for more information.

Syphilis:

  • Screen if at risk, considering STI risk factors, including living in an area with increased syphilis prevalence.

RISK FACTORS
History of and/or current sexually transmitted infection; having more than one sexual partner within the past 6 months; exchanging sex for money or drugs; and males who have sex with males.

RESOURCES
HPV Vaccine Resources for Clinicians  | Sexually Transmitted Infections (STI) Fact Sheets | Syphilis in Your Area

0-10 (Infancy – Mid. Childhood)

  • N/A

1-21 (Adolescence – Young Adult)

  • Counsel about risk factors for HIV infection.
  • Start risk assessment at age 11.
  • Confidentially screen all patients for HIV once between ages 15-21
  • Routine screening of all patients at increased risk.
  • Note that the CDC recommends annual testing for those at increased risk and routine HIV screening for all individuals 13 years of age and older.

RISK FACTORS
Injection drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and persons (men who have sex with men or heterosexual) who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

RESOURCE
HIV Screening Recommendations for Adults and Adolescents

0-1 (Infancy)

  • N/A

1-10 (Early Childhood – Mid. Childhood)

  • Perform anti-hepatitis C virus test after age 12 months in children with hepatitis C virus-infected mothers.

11-21 (Adolescence – Young Adult)

  • Periodic testing of all patients at high risk.

RISK FACTORS
Illicit injection drug use; long-term kidney dialysis; evidence of liver disease; a tattoo or body piercing by nonsterile needle; and high-risk sexual practices.

0-21 (Infancy – Young Adult)

  • Screen all patients at high risk.
  • Determine the need for repeat testing by the likelihood of continued exposure to infectious TB.
    • Administer tuberculin skin test (TST) for individuals with no past BCG vaccination for whom follow-up is certain.
    • Consider IGRA for individuals who have received BCG vaccination for whom follow-up is uncertain.

RISK FACTORS
Having spent time with someone with known or suspected TB; coming from a country where TB is very common; having HIV infection; having injected illicit drugs; living in U.S. communities where TB is more common (e.g., shelters, migrant farm camps, prisons); or spending time with others with these risk factors.

OTHER SCREENING

0-17 (Infancy – Mid. Adolescence)

  • N/A

18-21 (Adolescence – Young Adult)

  • Consider performing clinical breast exam every 1-2 years starting at age 20.

0-17 (Infancy – Mid. Adolescence)

  • N/A

18-21 (Adolescence – Young Adult)

  • Initiate pelvic exam and Pap test at age 21 or at the onset of sexual activity if patient is immune suppressed or HIV infected.

GENERAL COUNSELING AND GUIDANCE – PHYSICAL WELL-BEING​

  • Parents should not be present during counseling for adolescents and young adults ages 11-21.
  • Consider discussing transitioning to an adult physician between the ages of 18 and 21 years old.

0-1 (Infancy)

  • Ask about dietary habits, including food insecurity.
  • Promote breastfeeding as best form of infant nutrition.
  • Recommend breastfeeding for at least 1 year, if possible. Infants weaned before 12 months should receive iron-fortified infant formula. Whole milk can be given to children at age 1 year.
  • Counsel for breastfed infants to receive 400 IU of oral vitamin D drops daily beginning soon after birth and continuing until the daily consumption of fortified formula or milk is 500 mL. (16 ounces/2 cups).
  • Counsel not to restrict fat or cholesterol.
  • Refer eligible families to WIC for help with supplemental nutritional or other needs.

1-10 (Early -Middle Childhood)

  • Ask about dietary habits, including food insecurity.
  • Counsel about the benefits of a healthy diet, ways to achieve a healthy diet, and safe weight management. A healthy diet:
    • Emphasizes fruits and vegetables; whole grains; low-fat dairy; lean proteins, nuts and legumes.
    • Limits red meat, saturated and trans fat, and food and beverages with added sugar.
    • Follows appropriate portion size.
  • Advise whole milk until age 2 and then switch to low-fat milk beginning at age 2.
  • Refer eligible families to WIC for help with supplemental nutritional or other needs.

11-21 (Adolescence – Young Adult)

  • Ask annually about dietary habits, including food insecurity.
  • Counsel about the benefits of a healthy diet, ways to achieve a healthy diet, and safe weight management. A healthy diet:
    • Emphasizes fruits and vegetables; whole grains; low-fat dairy; lean proteins, nuts and legumes.
    • Limits red meat, saturated and trans fat, and food and beverages with added sugar.
    • Follows appropriate portion size.
  • Screen for eating disorders by asking about body image and dieting patterns.
  • Counsel to maintain adequate calcium and vitamin D intake.
  • Counsel against sugar-sweetened and caffeinated drinks.
  • Advise patients at risk of becoming pregnant to take a daily multivitamin containing .4 mg foliate.
  • Refer eligible families to WIC for help with supplemental nutritional or other needs.

RESOURCE
CDC MyPlate (available in multiple languages)

0-10 (Infancy – Mid. Childhood)

  • Advise that infants under 6 months of age should be kept out of direct sunlight.
  • Encourage limits of time in the sun during peak hours and encourage use of sunscreen, clothing, and hats to prevent sun exposure.

11-21 (Adolescence – Young Adult)

  • Encourage limits of time in the sun during peak hours and encourage use of sunscreen, clothing, and hats to prevent sun exposure.
  • Educate about skin cancer.
  • Discourage use of indoor tanning.
  • Starting at age 20, perform skin exams every three years, or more frequently at clinician discretion.

RISK FACTORS
Repeated sunburns early in life; family history; certain types and a large number of moles; light skin, light hair, and light eye color; sun-sensitive skin; and chronic exposure to the sun.

0-1 (Infancy)

  • Encourage opportunities for play time and other physical activity.

1-4 (Early Childhood)

  • Ask about play time and other physical activities.
  • Encourage opportunities for physical activity each day.
  • Encourage parents to be role models for physical activity.

5-21 (Middle Childhood – Young Adult)

  • Ask about frequency, type, and duration of play time and other physical activities.
  • Encourage daily physical activity (at least one hour a day).
  • Counsel on the importance of regular moderate-to-vigorous physical activity as a way to prevent illness in adult life.
  • Encourage parents to be role models for physical activity.

RESOURCE
Physical Activity for Children

0-1 (Infancy)

  • Counsel against bottle-propping when feeding infants and babies.
  • Counsel against bottles to bed.
  • Assess oral health at each visit and need for fluoride supplementation at 6 months based upon availability in water supply and dietary source of fluoride.
  • Encourage brushing with a soft toothbrush/cloth and water at age 6 months.
  • Encourage weaning from bottle and drinking from a cup by the first birthday.
  • Apply fluoride varnish to primary teeth of all infants and children every 6 months if not applied at dental home and every 3 months if at high risk for caries.

1-21 (Early Childhood – Young Adult)

  • Apply fluoride varnish to primary teeth for all children aged 1-5 every 6 months if not applied at dental home and every 3 months if at high risk for caries.
  • Assess oral health at each visit and need for fluoride supplementation up to age 14 based on availability in water supply and dietary source of fluoride.
  • Counsel on good dental hygiene habits, including brushing twice daily.
  • Counsel on the establishment of a dental home beginning at 12 months or after eruption of first tooth.
  • Counsel on use of mouth guards when playing sports.

TOOTH DECAY RISK FACTORS
Frequent sugar exposure, inappropriate bottle feeding, developmental defects of the tooth enamel, dry mouth, and history of previous caries.

0-1 (Infancy)

  • Advise that infants be placed on their backs when putting them to sleep until 1 year of age.
  • Advise that side positioning is no longer considered a safe alternative.
  • Counsel parents on safe sleeping practices, including ABC guidelines (Alone, on Back, in a Crib).
  • Encourage parents to discuss safe sleep practices with daycare providers.
  • Encourage proper sleep amounts (14-15 hours) for ages 3-11 months.

1-21 (Early Childhood – Young Adult)

  • Ask about sleep habits including chronic snoring.
  • Encourage proper sleep amounts by age group:
    • 4-12 moths: 12-16 hours
    • 1-2 years: 11-14 hours
    • 3-5 years: 10-13 hours
    • 6-12 years: 9-12 hours
    • 13-18 years: 8-10 hours
  • Discourage placement of computers, tablets, phones, and TVs in bedrooms.
  • Encourage parents to talk with daycare providers about safe sleep practices for their children.

RESOURCE
Safe Sleep Practices

0-1 (Infancy)

Provide annual age-specific safety and injury prevention counseling. For example:

  • Shaken-baby syndrome;
  • Bath and water temperature safety;
  • Smoke and carbon monoxide detectors in the home;
  • Childproofing the home (including use of window guards);
  • Falls;
  • First-aid and CPR knowledge; and
  • Poison Control Hotline: 1-800-222-1222.

1-4 (Early Childhood)

  • Provide annual age-specific safety and injury prevention counseling. For example:
    • Water, bike, and sports safety (including use of helmets);
    • Signs and symptoms of concussions;
    • Neighborhood safety (pedestrian, playground, strangers);
    • Lock-up of matches, guns, and poisons (Poison Control Hotline: 1-800-222-1222);
  • Emphasis on gun safety in the home and/or when visiting friends’ homes. Counsel about the dangers of having a gun, especially a handgun, in the home.

5-21 (Mid. Childhood – Young Adult)

  • Provide annual age-specific injury prevention and safety counseling. For example:
    • Water, bike, and sports safety (including use of helmets; mouth guards, and protective sports gear);
    • Signs and symptoms of concussions;
    • Neighborhood and after-school safety (strangers, home alone, job);
    • Relationships with peers and bullying; and
    • Potential risks of tattooing or body piercing.
  • Assess need for violence-prevention counseling.
  • Ask adolescents about partner violence.
  • Emphasize gun safety in the home and/or when visiting friends’ homes. Counsel about the dangers of having a gun, especially a handgun, in the home.

0-4 (Infancy – Early Childhood)

  • Counsel parents who smoke on the potentially harmful effects of smoking on fetal and child health and on the benefits of maintaining a smoke-free home. Refer parents to Quitworks or to their own PCP for help in quitting.

5-10 (Mid. Childhood)

  • Counsel parents who smoke on the potentially harmful effects of smoking on fetal and child health and on the benefits of maintaining a smoke-free home. Refer parents to Quitworks or to their own PCP for help in quitting.
  • Counsel patients not to begin using tobacco products, inlcuding e-cigarettes. Provide interventions, such as education and brief counseling, to prevent initiation of smoking.

11-21 (Adolescence – Young Adult)

  • Counsel parents who smoke on the potentially harmful effects of smoking and the use of tobacco products on fetal and child health and on the benefits of maintaining a smokefree home. Refer parents to Quitworks or to their own PCP for help in quitting.
  • Counsel patients not to begin using tobacco or any other substances such as e-cigarettes, smokeless tobacco, cigars, herbal substances.
  • Advise tobacco users to quit, especially patients who are pregnant.
  • Assess readiness to quit.
  • Assist tobacco users in quitting, especially patients who are pregnant. Provide brief counseling and refer to Quitworks. Note patients 18 and older (patients under 18 will need consent from guardian to enroll.
  • Arrange follow-up.

0-1 (Infancy)

  • Ask about use of safety belts and child safety seats.
  • Counsel that children should remain in rear-facing safety seats until they are at least 2 years old or until they reach either the height or weight limit of their rear-facing child safety seat.
  • Inform about danger of front-seat airbags for children aged 12 and under.
  • Counsel parents against driving under the influence of alcohol/drugs.

1-10 (Early – Middle Childhood)

  • Ask about use of safety belts and child safety seats.
  • Counsel that children should remain in rear-facing child safety seats until they are at least 2 years old or until they reach either the height or weight limit of their rear-facing child safety seat. Children must be in an appropriate child passenger safety restraint: forward-facing safety seat until they weigh 40 lbs; booster seat until they are 4’9” tall or at least 8 years of age.
  • Inform about danger of front-seat airbags for children aged 12 and under.
  • Counsel parents against driving under the influence of alcohol/drugs.

11-21 (Adolescence – Young Adult)

  • Counsel parents that children under age 12 and under who have outgrown their booster seats should always use a seat belt and ride in the back seat.
  • Ask about the use of safety belts and motorcycle helmets.
  • Inform about danger of front-seat airbags for children aged and 12 under.
  • Counsel against driving under the influence of alcohol/drugs or getting in a car with someone under the influence of alcohol/drugs.
  • Counsel against excessive speed and other risk-taking behaviors while driving, such as cell phone use.
  • Inform that cell phone use (including texting) while driving is prohibited for teens aged 17 and younger, and texting while driving is prohibited at all ages.

RESOURCES
Massachusetts Executive Office of Public Safety and Security Child Passenger Safety | Seat Check | Parent-teen driving contract

0-21 (Infancy – Young Adult)

  • Screen for signs of family violence, including: facial/body bruising; depression; anxiety; failure to keep medical appointments; reluctance to answer questions about discipline in the home; or frequent office visits for complaints not supported by medical evaluation of the child.
  • Screen for signs of child physical/sexual abuse.
  • For adolescents, counsel on safe and appropriate dating and relationships as well as strategies for avoiding or resolving conflicts with friends and peers.
  • Ask about relationships with peers and bullying.

RESOURCES
Identifying and Responding to Domestic Violence: Consensus for Recommendations for Child and Adolescent Health
Understanding Intimate Partner Violence
National Domestic Violence Hotline — 1-800-799-SAFE
National Child Abuse Hotline — 1-800-4-A-CHILD

GENERAL COUNSELING AND GUIDANCE – SOCIAL AND EMOTIONAL WELL-BEING

0-5 (Infancy – Early Childhood)

  • Screen mother for postpartum depression using the SWYC-MA at 6 months.
  • Consider screening mother and/or other caregiver for depression using the SWYC-MA until 5 years of age.

12-21 (Adolescence – Young Adult)

  • Screen for depression using the PHQ-A (12-17 years old), PHQ-9 (18-21 years old) or other age-appropriate validated screening tool. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

RESOURCES
SWYC-MA | PHQ-A | PHQ-2  | MCPAP

12-21 (Adolescence – Young Adult)

  • Screen for anxiety based on risk factors and individual patient presentation of disorder. Consider using the SCARED (8-18 years old), GAD-7 (18-21 years old) or other age-appropriate validated screening tool.
  • Ask about familial/environmental stress.

RISK FACTORS
Family or personal history of anxiety or depression, history of trauma, history of major life stresses, female gender, and temperament.

RESOURCE
SCARED | GAD-7

4-21 (Adolescence – Young Adult)

  • Ask parents about any academic or behavioral problems, including symptoms of inattention, hyperactivity, or impulsivity.
  • Screen for ADHD based on individual patient presentation of disorder using the Vanderbilt Assessment Scale or other age-appropriate validated screening tool.

RESOURCE
Vanderbilt Assessment Scale

10-11 (Mid. Childhood – Adolescence)

  • Ask parents about alcohol use, family history of alcoholism and substance abuse, and attitudes about alcohol and substance use.
  • Counsel parents about the harmful effects of alcohol misuse and substance abuse, including opiate-based prescription medications, and how to recognize abuse.
  • Advise pregnant women against any intake of alcohol during pregnancy and of the potential harmful effects of drug use on fetal development.

11-21 (Adolescence – Young Adult)

  • Ask about use of alcohol, drugs, and other substances (e.g., inhalants).
  • Ask about use of over-the-counter or prescription drugs for nonmedical purposes. Consider using a screening tool, such as the CRAFFT.
  • Counsel young adults that opiate-based prescription medications are highly addictive, and not safer to use than other substances.
  • Counsel not to drive under the influence of drugs or alcohol or ride with someone who is under the influence of alcohol or other substance.
  • Screen for alcohol misuse using a validated assessment tool such as CRAFFTDAST, or AuditC. Provide brief behavioral counseling to people engaged in risky or hazardous drinking behavior.

RESOURCES
MA Substance Abuse Information and Education Helpline | MA Prescription Dropbox Locations

0-1 (Infancy)

  • Discourage screen time except supervised video chats.

1-4 (Early Childhood)

  • Discourage screen time for children less than 2 years, and limit screen time to one hour per day for 2-4 year olds.
  • Ask about frequency of age-appropriate screen time, including TV, computer, and mobile electronic devices (e.g. handheld video games, cell phones) being viewed.
  • Discourage placement of computer and TV in bedroom.
  • Counsel on impact of screen time as a risk factor for becoming overweight, low school performance, and violent behavior.

5-21 (Middle Childhood – Young Adult)

  • Ask about frequency of age-appropriate screen time, including TV, computer, and mobile electronic devices (e.g. handheld video games, cell phones) being viewed.
  • Counsel on impact of screen time as a risk factor for low school performance, overweight, and violent behavior.
  • Place consistent limits on time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity, and other behaviors essential to health.
  • Designate media-free times together, such as dinner or driving, as well as media-free locations at home, such as bedrooms.
  • Discourage placement of computer and TV in bedroom.
  • Discuss limits on text messaging and cell phone use (e.g. no phone in bedroom near bedtime).
  • Encourage shutting down electronic devices before bedtime.
  • Discourage listening to loud-frequency sound on earphones.

RESOURCE
Media Use Plan

0-1 (Infancy)

  • Review opportunities for cognitive growth and language development through talking, singing, and reading aloud, and developing baby’s fine (e.g. play with toys or food) and gross (e.g. tummy time, practice walking) motor skills.
  • Counsel on avoiding background TV or related media

1-4 (Early Childhood)

  • Counsel that unstructured play is essential to the cognitive, physical, social, and emotional well-being development of children and adolescents.
  • Review the importance cognitive development by exposing children to language through talking, singing, and reading aloud.

5-10 (Mid. Childhood)

  • Counsel that unstructured play is essential to the cognitive, physical, social, and emotional well being development of children and adolescents.
  • Review that a child’s participation in sports or other physical activities can reinforce positive interaction skills and help ensure a positive self image.

11- 21 (Adolescence – Young Adult)

  • Encourage adolescents to maintain a balance of participation in extracurricular activities with demands of academics and/or work.
  • Screen adolescents for declining grades/attendance issues, signs of learning disorders, and social- adjustment concerns.

RESOURCE
SWYC-MA

0-1 (Infancy)

  • N/A.

1-4 (Early Childhood)

  • Screen at 18 and 24 months using validated tool such as M-CHAT-R or SWYC.

5-21 (Mid. Childhood – Young Adult)

  • Assess child for signs of autism and screen at clinician discretion.

RESOURCES
MA Autism Resources, Mental Health Legal Advisors Committee | M-CHAT-R | SWYC-MA