Developmental Screening in Children: Promoting Healthy Development and Catching Problems Early

Jacqueline Sedgwick, MD, MPH


July 17, 2012

In This Article

Screening Recommendations

Nutritional and Environmental Issues

Nutritional and environmental issues, such as iron deficiency anemia and lead poisoning, affect a child's health and ability to learn.[5,9] Nutritional and environmental issues may begin in the prenatal setting; adequate prenatal nutrition and healthcare for women with high-risk conditions, such as gestational diabetes, provide infants with a healthy start in life. Breastfeeding should be promoted for all infants, unless a contraindication is present.[9]

Iron deficiency. Iron deficiency occurs in up to 15% of toddlers in the United States. Iron deficiency anemia and lead exposure during infancy and childhood have been found to have long-lasting detrimental effects on neurodevelopment.[11]

Children should be universally screened for iron deficiency anemia at approximately 1 year of age. If the child is found to have mild anemia, standard clinical practice is to provide iron supplementation and repeat hemoglobin testing in 1-3 months. For all infants with anemia, measuring serum ferritin and C-reactive protein or reticulocyte hemoglobin is recommended.[11]

Because of the cost and difficulties of acquiring venous blood from toddlers, standard clinical practice is to evaluate further children with severe anemia, those with a family history of hematologic illness, or infants who have a follow-up hemoglobin level less than 10.0 g/dL. Treatment will depend on the diagnosis. If iron deficiency anemia is diagnosed, management is iron supplementation and dietary education.[11]

Exposure to lead and other chemicals. Risk assessment or screening for lead exposure should be done at 1 year of age unless local prevalence indicates that earlier screening is advisable. Lead testing also should be considered whenever a young child has persistent anemia, lives in housing built before 1977 (when lead was banned from being used in housing paint), or has developmental delay.[9]

It is also prudent to ensure that patients are not exposed unnecessarily to other chemicals that can affect their health, such as pesticides on a field worker's clothing. This can be mitigated by having the parent change clothes before returning home (see "Center for Environmental Research and Children's Health" under "Web Resources" at the end of this article).

Nutrition. Every physical examination is an opportunity to monitor the child's growth and offer nutritional advice. Families who are having difficulty providing food for their children should be referred to such agencies as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which is intended to safeguard the health of low-income pregnant, postpartum, and breastfeeding women; infants; and children up to age 5 years. WIC provides nutritious foods to supplement diets and information on healthy eating, including breastfeeding promotion and support. Assistance from the Supplemental Nutrition Assistance Program (formerly known as "food stamps") also may be available for low-income families; currently, only 56.7% of eligible families are receiving such assistance.[4]

Physical and Mental Health Problems, Including Developmental Delay

According to the 2009-2010 National Survey of Children with Special Health Care Needs, approximately 11.2 million children (ie, children in 1 in 5 households in the United States) have special healthcare needs.[12] During periodic physical examinations, all children should be screened for vision, hearing, speech, and developmental delays; chronic health problems; and functional disabilities, including motor, communication, cognitive, and socioemotional problems.[9]

Children with chronic physical and mental health issues, a history of in utero substance abuse exposure, high lead levels, child abuse, neglect, domestic violence, and developmental delay are generally eligible for early intervention services, as part of the Individuals with Disabilities Education Act (IDEA) Part C (birth to age 3 years) or part B (3 to 5 years).[12,13] These programs are state-required multidisciplinary services for children with developmental delays or at risk for delays.[12,13] Early intervention services offer the child and family treatment and support, giving the child the best chance to reach his or her potential.

Developmental surveillance should be incorporated into every well-child care visit.[9,14] The American Academy of Pediatrics[14] identifies 5 components of developmental surveillance:

  1. Eliciting and attending to parental concerns;

  2. Documenting and maintaining a developmental history;

  3. Making accurate observations of the child;

  4. Identifying risk and protective factors; and

  5. Maintaining an accurate record documenting the child's development.

If a parent or clinician determines that a child is at risk for a developmental problem, specific standardized screening should be implemented.[14] This may be conducted in the medical home; by referral to a behavioral pediatrician; or by referral to programs that offer early intervention services, such as Babies Can't Wait, state-funded programs for persons with disabilities (for example, the Lanterman Developmental Disabilities Services Act is part of California law that funds Regional Centers), or Early Head Start. In children with a positive screening result for a developmental problem, further developmental and medical evaluations are warranted to identify the specific disorder and refer for early intervention and family support services.[14]

Currently, on the basis of the available scientific evidence, the American Academy of Pediatrics does not have enough evidence to support the implementation of communitywide routine screening for autism. At this time, the American Academy of Pediatrics recommends careful assessment and surveillance of all preschoolers who present with impairments in language or social or cognitive skills development for autism spectrum disorders. None of the currently available autism screening tests has been shown to have sufficient accuracy (ie, high sensitivity, high specificity, and high predictive value) in population-wide screening programs.[15] In addition, neither proven therapies nor preventive measures exist for the universal treatment of children with autism.[15] At this time, the World Health Organization recommends careful surveillance and assessment of all preschoolers for impairments in their development of language, social function, or cognitive skills, with further evaluation of these high-risk children using available standardized testing whenever a problem is suspected.[15]

Family Problems and Social Support Issues

In the United States, up to 12% of all pregnant and postpartum women experience depression in a given year.[16] The consequences of maternal depression include negative effects on the cognitive, social, emotional, and behavioral development of their child.[16]

All parents of infants should be screened for depression (Appendix, Table 1) and offered intervention or referral to promote parental well-being and a healthy parent/child relationship.[9] The US Preventive Services Task Force[17] has endorsed a 2-question screen for depression:

Over the past 2 weeks:

  1. Have you ever felt down, depressed, or hopeless? and

  2. Have you felt little interest or pleasure in doing things?"

One "yes" answer is a positive screening result. Responses to a positive screening result range from reassurance to support and referral, depending on available resources, severity of depression, and duration of the parent's symptoms.[16]

Children need cognitive stimulation to learn. Creating a dialogue with the family about ways they can help their child to learn and helping families who have inadequate resources and social support to identify community resources should be incorporated into routine well-child visits.[9] Such programs as Early Head Start and Head Start are federally funded community-based programs for low-income families with infants, toddlers, and preschoolers. They are designed to enhance the development of young children, and to promote healthy family functioning and school readiness through the provision of educational, health, nutritional, social, and other services. Currently in the United States, only 47.6% of children 3-4 years of age attend preschool,[4] and local Head Start programs may have insufficient funding to provide services to all eligible children.

Apart from these programs, parenting classes may be offered through the local adult school or community college. Libraries often have programs for children and their families, as do such organizations as the YMCA or YWCA. Your practice also may want to participate in Reach Out and Read, an evidence-based literacy promotion program for primary care providers (see "Web Resources").

Bright Futures recommends screening for domestic violence and violence exposure.[9] Whenever problems are identified, referral to appropriate agencies, including law enforcement and child protective services, is mandated.[9] Development of a support system for your practice -- including agreements with local service providers, such as public health nurses, social workers, and mental health professionals -- can facilitate assisting families with these issues. Early intervention services offer patient and family support, giving children the best chance to reach their potential.


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