ADDRESS FOR REPRINTS: Department of Pediatrics, University of Pittsburgh School of Medicine, 125 DeSoto Street, Pittsburgh, Pennsylvania 15213.
Screening
in Child
Health
Care:
Where
Are
We Now
and
Where
Are We Going?
A. Frederick North, Jr., M.D.
The preceding papers17 in this symposium
dis-cuss criteria for evaluating screening tests and
screening programs and demonstrate how these
criteria can be applied to several screening
techniques of particular current interest. This
paper will briefly review how a number of
proce-dures measure up to the suggested criteria for
screening tests and suggest some future directions
which must be pursued if screening is to be based
on science rather than on polemic.
WHERE ARE WE NOW?
Table I lists a number of diseases, functions and
tests which have been considered to be of use in
screening. For each of these it also gives my own
estimate of how well each disease meets the
crite-ria listed by Frankenburg2 and how well the
avail-able tests meet his criteria for effectiveness, direct
costs, costs of false positives, and costs of false
neg-atives. In the following paragraphs some of the
considerations which led to these judgments are
discussed.
Phenyketonuria
Despite its low frequency, the cost effectiveness
of screening for PKU is well demonstrated, tests
are adequately sensitive and specific, and with
ex-pert management the potentially high costs of
false-positive tests can largely be eliminated.3
Galactosemia
Though even rarer than PKU, current methods
make routine neonatal screening both feasible and
cost effective, provided that the test is combined
with routine PKU screening.8
Other Inborn Metabolic Errors
With the kind of regionalized facilities and
planning discussed by Scriver,3 testing for these
diseases can be added to routine neonatal
screen-ing at very little additional cost. Some of them
lend themselves to effective early treatment; with
others, genetic counsulhing is the only currently
available useful intervention.
Anemia
Iron deficiency anemia and its analogues in the
newborn period appear to meet all the criteria for
screening. Screening in the neonate will identify
1% to 5% of infants as needing special
manage-ment.9 Screening at about 12 months of age will
identify those infants whose dietary iron intake
has been too low or who are losing iron because of
ingestion of unmodified fresh cow’s milk1#{176}or other
less common causes. Those who have been normal
at 12 months probably are not again at risk for
anemia until the adolescent growth spurt, when
girls’ menses and boys’ growth in muscle mass can
again cause an imbalance in iron nutrition.
SckIe Cell Diseases
The acid agar gel electrophoretic technique’1
makes possible identification of newborn infants
with homozygous or mixed heterozygous sickle
cell disease. When affected infants are given
ex-cellent medical supervision-including prompt
antibiotic treatment of infections and early
identi-fication and treatment of aregenerative and
vaso-occlusive episodes-the expected 20% two-year
mortality of such infants can be greatly reduced.
By the end of the first year of life affected children
can be identified through symptoms or through
anemia screening, so screening by electrophoresis
is no longer necessary or desirable.
Hemoglobin S and C Traits
The only purpose of screening for these genetic
traits is genetic counselling, and the efficacy of
such counselling in these conditions has never
been established. The harm that can be done by
routine identification of these traits is beginning
adults have been unnecessarily frightened and
stigmatized. Screening for hemoglobin S and C
should be aimed at persons of reproductive age;
all persons screened should have been exposed to
an educational program which accurately
de-scribes the consequences of sickle cell trait and
the sickle cell diseases and the available
reproduc-tive alternatives; screening should be entirely
voluntary; every person screened should be given
the opportunity to obtain individual counselling
regarding the meaning of a positive or negative
test result. An accurate electrophoretic method
must be used, or persons with hemoglobin C will
be given false information about their chances of
having an affected offspring.
Urinary
Tract
Infection
In boys, the prevalence of infection is too low
and the screening period too short to warrant
rou-tine testing for bacteriuria; detection must
de-pend upon careful evaluation of suspicious signs
and symptoms. The case for routine bacteriuria
screening of girls is made by Kunin.4 It must be
noted, however, that the natural history of
un-treated bacteriuria is not sufficiently documented
to make the case for screening unequivocal.
Evi-dence that untreated bacteriuria is likely to have
ill effects is substantial, if still circumstantial. The
new dip-stick and dip-slide techniques for urine
culture make accurate and economical testing
practical in all practice settings.
Impaired Hearing
As is true for most of the “well established”
screening tests, evidence that routine screening
discovers important problems in otherwise
asymptomatic children is sparse, but screening
seems to “make sense” logically. Impaired
hear-ing can have a devastating effect on language
de-velopment, but this is most important in the first
years of life for which screening techniques are
least well developed. Screening newborn infants
with a calibrated noisemaker yields too many
false-positive and false-negative results to be
con-sidered a useful routine In the first
three years of life, monitoring of language
devel-opment with parent-answered questionnaires or
interview items will reveal important hearing
losses, but will not differentiate them from other
causes of delayed language development. After
age 3 to 4,34 pure tone audiometry is feasible, and
routine preschool testing seems logical. New
in-stances of hearing loss appear to be quite
uncom-mon after the first few school grades, so screening
every three to four years, along with careful
evalu-ation of symptomatic children, seems adequate.
Much more knowledge of epidemiology and
natu-ral history is needed before truly rational
screen-ing recommendations can be made.
Impaired
Visual AcuityIt should amaze and chagrin us all to realize
that after decades of routine vision screening for
millions of children, almost nothing is known
about the reliability or validity of the techniques
of screening for visual acuity. Ophthalmologists
will generally accept on referral any child whose
vision in either eye is less than 20/40, or who has
more than a two-line (or sometimes one-line)
dif-ference in acuity between the two eyes. No one
has reported what proportion of such “acceptable
referrals” actually benefit from early detection by
some improvement in their life function.
None-theless, screening “makes sense.” Questions and
observations on the development of eye-hand
coordination will detect more severe visual
im-pairment in the first three years of life. After ages
3 to 4, the Snellen illiterate E chart can be used
with most children. Any child with frank
strabis-mus at any age is considered “referrable.” The
functional importance of lesser degrees of muscle
imbalance or “phoria” is almost completely
un-known. During the school years, new incidence of
visual impairment is common enough so that
test-ing every two to three years seems reasonable.
Again, truly rational screening recommendations
await much more extensive and precise
knowl-edge.
Deviant Physical Growth
“Everyone knows” that height, weight and
head circumference must be measured and
chart-ed periodically. Yet, there are no studies which
show that such routine measurements are useful in
identifying children with otherwise unsuspected
health problems!’ None! However, such
measure-ments are logical; they “make sense” for
identify-ing children with failure to thrive, with endocrine
causes of deviant growth, or with hydrocephalus.
Acting on logic and faith, pediatricians
con-tinue to make routine measurements. Once made
(several times during the first year of life and
at decreasing intervals thereafter), it is
simi-larly logical that any interpretation will depend
on charting that compares the measurements of a
child with his own previous measurements and
with age appropriate norms. It would be nice if
we had at least one study to show that all these
ef-forts are as worthwhile as all of us think that they
must be.
Growth measurements are usually so reassuring
proba-bly be justified on this basis alone. Care must be
taken to ensure that the 6% of children who will,
by definition, fall outside the 3rd and 97th
percen-tiles are not subjected to costly or potentially
dan-gerous investigations unless there is evidence,
other than their statistically deviant size, that they
are growing abnormally.
Deviant Psychomotor Development
Like growth screening, screening for
psycho-motor development seems logical and sensible,
but its usefulness in detecting otherwise
unsus-pected and remediable problems can be
support-ed by very little data. Available screening tests are
not, with two exceptions,”6 known to be reliable
or valid. Neither diagnostic criteria nor effective
treatments have been established for most of the
conditions which lead to developmental delays.
No one has applied a screening test to a large
number of children and then determined how
many of the “abnormals” could be helped through
early identification and treatment. The possible
dangers of mislabeling a child as “slow” or
“re-tarded” are quite clear, but the benefits to be
derived from early identification through
screen-ing, while logically convincing, are not well
documented.
Still, many of the most important handicapping
conditions of children present with delayed or
de-viant development of motor, language, adaptive
or personal-social skills, and for many of these
(
cretinism, seizure disorders, grossly aberrentpar-enting practices, as examples) early detection and
intervention are of clinically, if not statistically, proven benefit.
The importance of making
some
routinedevel-opmental observations seems to outweigh the
uncertainties. The most practical current
ap-proach would seem to be to use an explicit
proto-col of relatively simple questions and observations
(such as the parent-reported items in the DDST’5
or DSI’6) to identify the large majority of children
whose development is clearly normal; to apply
more time-consuming formal screening tests (such
as the DDST or DSI) to those children who are not
clearly normal; and to follow the progress of all
except the most deviant children over a period of
many months before labeling any as deviant or
in-stituting elaborate diagnostic studies.
Appropri-ate developmental items can easily be
incorporat-ed into each health supervision visit; a minimum
schedule for systematic observations might be 4
months, 9-12 months, 18 months and 3 years. After
entry into preschool or school, reports of school
progress and behavior will probably identify most
instances of deviant development.
Glucosuria
Tradition and the simplicity of the dip-stick test
have conspired to make this determination
“rou-tine.” However, the very low incidence of
di-abetes and its very short screening time make
de-tection through routine screening very expensive;
dip-sticks yield a substantial number of
false-posi-tive tests;’7 and the benefits of early detection
through screening over routine detection through
symptoms are not substantial. Screening for
glu-cosuria in apparently healthy children cannot be
recommended.
Albuminuria
Though hallowed by tradition, this simple test
cannot be recommended for routine screening. As
many as 10% of children will have positive tests by
the dip-stick method,’7 and as few as one in 200 of
those with positive tests may have significant
dis-ease. Most children with urinary tract infection
cannot be identified by this test, and few, if any, of
the nephropathies which produce albuminuria
benefit from early detection and treatment. The
cost of even the most simple follow-up of the huge
number of false-positive test results is thus not
balanced by any benefit to the health of children
tested.
Cystic Fibrosis
This condition is rare, all screening tests
pro-duce false-positive results and are relatively
time-consuming, and treatment in an asymptomatic
state has no clear benefits. Careful sweat
electro-lyte determinations for children who are suspect
because of family history or symptoms will be just
as effective and much less costly than routine
screening.
High Blood Pressure
There is no evidence that children with blood
pressure measurements at the upper end of the
statistical distribution are at any special risk
of disease or that they will become hypertensive
adults.18’19 The cost and risk of unnecessary
diag-nostic studies and of mislabeling appears to
out-weigh any hypothetical advantage to be gained by
routine screening, although this proceduce may
gain more use as pediatricians learn more about
children who are at risk of disease which will
ap-pear only in adult life.
Elevated Serum Cholesterol
There is substantial but inconclusive evidence
that some children with elevated serum
cholester-ol levels are at high risk of developing coronary
TABLE I
USEFULNESS OF SCREENING TESTS#{176}
-C
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u n
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.
o
‘ ‘
.
a u
.
.
‘.‘
-‘
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.
“3
u
‘‘
b
o n. ‘
u
‘
Phenylketonuria + ± + + + + + + + + +
Calactosemia + ± + + + + + + ± + +
Other inborn errors
ofmetabolism + ± + ± ± + + + ± ? +
Anemia + + + + + + + + + + +
Sickle cell
diseases + + + ± + + ? + + + +
Hemoglobin S and C
traits ? + + ? + + ? + + + +
Bacteriuria +(?) + + + ? + + + + + +
Impairedhearing + + + + + + + ± + ? ?
Impairedvision + + ± + ? + + ± + ? +
Deviant physical
growth + + ? ± ? + + + + ? ?
Deviant psychomotor
development + + ? ± ? + ? + ? ? ?
Glucosuria + 0 + + 0 0 + + + ? ?
Albuminuria ? + ? ? 0 ? ? + + 0 +
Cystic fibrosis + ± + + ? + + ? ? ? +
High blood pressure ? ? 0 ? ? + ? ± + o +
Hypercholesterol-emia )
. 2. #{149}?. 2. 2 ? + ? ? +
Deviant behavior + + ? ? ? + 0 ? ? ? ?
Intestinal
para-sites ? + + + ? + + ? 0 ? ?
Dentaldiseases + + + + + + ± ± 0 + 0
Lead absorption ? ? ± P + + ± ± ± ? ?
Tuberculosis + 0 + + + + + + + 0 +
Occult stool blood ? + ? ? ? + + + + 0 ?
#{176}Key:+
,
problem or test appears to meet this criterion; ±,
problem or test appears to partially meet problem or test appears to fail this criterion; ? evidence appears insufficient for judgement.this criterion; 0
Deviant Behavior
Intestinal Parasites
but no evidence that dietary modification in
childhood might reduce this risk. Because of this,
routine screening cannot be recommended until
much more substantial evidence is available. It
has been recommended that children whose
fami-ly history includes coronary artery disease before
age 50 in the first cousin or closer relative be
screened, and if found to have type II
hyperlipo-proteinenia, be included in longitudinal studies of
the effect of dietary modification.2#{176}
Behavior problems in children and mental
ill-ness in adults are preeminent among child health
problems. Early identification and early
interven-tion have immense appeal, but neither effective
screening techniques nor effective interventions
have been established. Mislabeling a child as
“emotionally disturbed” can have devastating
ef-fects on the child and family. At present, no
rou-tine “screening” method can be recommended to
supplant or supplement sympathetic listening,
ob-servation and clinical judgment based on parental
reports.
There is no evidence that detection of
asympto-matic infestations improves the health of
individu-al children or affects the epidemiology of
infesta-tion. Screening tests are relatively expensive and
technically demanding. The economy and safety
of treatment for pinworms and ascaris makes it
diag-nostic studies are indicated for children with
symptoms suggestive of other parasites. Routine
screening cannot be recommended.
Dental Diseases
Dental caries are so prevalent that all children
over age 3 should be counselled to obtain routine
dental evaluation and preventive care. Children
under age 3 should be referred for dental care if
in-spection of the mouth reveals caries, infection or
malformation.
Increased
Lead
AbsorptionThe wide gaps in current knowledge
con-cerning lead toxicity and its epidemiology are
dis-cussed by Moriarty.6 Current standard wisdom
dictates that children living in dilapitated or
run-down housing in communities in which lead
poi-soning is known to be a problem should be
screened periodically between the ages of 1 and 5
years. For most communities, the free erythrocyte
protoporphyrin (FEP) determination appears to
offer substantial advantages over the extremely
costly and demanding blood lead determination as
a method of primary screening.”
Tuberculosis
Once ideally suitable for routine screening,
tu-berculosis has now become so uncommon that
routine skin testing can no longer be
recommend-ed. The reasons are fully discussed by Edwards.7
Testing of known tuberculosis contacts is now the
preferable method of case detection, and
screen-ing can only be justified for epidemiologic surveys
or in specific high-risk communities.
Occult Stool Blood
The significance of positive guaiac tests in
oth-erwise normal children, especially infants, is
high-ly questionable. More than half of infants tested at
3, 6, and 12 months had 2+ or higher tests at each
testing.’#{176} With this number of positives, routine
testing cannot be recommended.
The Screening Interview
Nothing has been learned in the past 70 years to
refute Osler’s maxim that 90% of diagnosis is based
on history. Unfortunately, little has been learned
in the same period to identify which questions
must be asked to identify unsuspected or
untreat-ed health problems among children of various
ages. No one has asked a standard set of questions
of children (or parents of children) of a given age
group and then analyzed the responses to
deter-mine which questions or combinations of
ques-tions led to the discovery of treatable health
prob-lems. Nor has anyone determined the relative
effi-ciency of printed questionnaires, automated
histo-ry taking machines, and face to face interviews in
eliciting pertinent information.22
The absolute importance of interview data in
discovering untreated problems is undeniable, but
until better data are available, physicians will
have to rely on their own judgment or the advice
of “experts” (see Table II) to determine which
data are worth obtaining.
The Screening Physical Examination
The current status of the physical examination
in screening is similar to that of the history or
in-terview. There is no doubt that physical
examina-tion can yield unsuspected findings, but there is
no systematic evidence about how often each
examination item detects signfficant unsuspected
findings in children of various ages. The yield of
significant new physical findings in previously
examined populations is known to be low.23,24
However, much more data will have to be
accum-ulated and analyzed before parents or physicians
will be persuaded that some kind of physical
examination is not an essential screening tool.
While awaiting such data and analysis,
physi-cians can safely conform with the current trend,
performing routine examinations less frequently
and delegating parts of the examination to
non-physician personnel. They can also modify their
routine examinations so that they are based on a
strategy of discovering unsuspected health
prob-lems (see Table II) rather than on “textbook”
rou-tines designed to diagnose rather than to discover
disease.
. Summary of Current Opinion
The “state of the art” as described in the
pre-ceding paragraphs is summarized in Table II.
These recommendations must be considered
ten-tative-more as hypotheses to be tested than as
es-tablished facts-and subject to modification by
new knowledge or experience. It is suggested that
this schedule of tests and observations will identify
the great majority of health problems that might
benefit from early detection but which, if not
spe-cifically sought out, might escape early detection
either because symptoms are absent or difficult to
recognize or because the medical significance of
easily observable symptoms may not be
recog-nized by parents or others.
WHERE ARE WE GOING?
Directions in Research
There are immense gaps in our knowledge
2
Screening Tests NB ,
Approximate Age of Evaluation
4 6 , 9 mo 12 mo 18 mo 2 yr 4 yr 6 yr 9 yr 12 yr 15 yr
+ 4-
4-+ 4- 4- 4- 4- + 4- 4- 4-
-+ 4- 4- 4-
4-II
+ + 4- + 4- + 4- + + + + + +
+ 4- 4.- 4- +
+* +* + +
+ + +
4- 4.- 4- 4-
4-4- + +
4-Illness or medication in pregnancy Family history of genetic disease Abnormalities of delivery
Social and economic factors affecting health and health care Mother’s perception of child as
“easy-difficult”-”good-bad” Psychomotor development Language development Evidence of sight and hearing Relationships with peers and sibs Exposure to lead
Exposure to tuberculosis Feeding or eating patterns Bowel movement patterns Allergic symptoms Seizure-like symptoms Lower urinary tract symptoms School progress
Dental care Sexual behavior
Drug, alcohol, tobacco use Child’s perception of self Immunization status
+ 4-
4-+ 4- 4-
4--+ 4-
4-+ 4- 4-
4-+ + + +
+ + +
+ +
+ + +
+ 4- 4- +
+ + + + + + + + + + + 4- + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Cardiorespiratory signs Gastrointestinal obstruction Visible congenital anomalies Hip dislocation
Vision and hearing behavior Neuromotor development Mother-child interaction Strabismus Serous otitis Scoliosis Breast development Genital development
Acne, Eczema and other skin
+ + + + + + +
+ 4- 4- 4- 4- + 4- 4- +
+ + + + + + + + + + + + + + + + + + + + + TABLE II
SUMMARY OF TENTATIVE SCREENING RECOMMENDATIONS
PKU and galactosemia#{176} Anemia
Sickle cell diseasestS Hemoglobin S and C traits Bacteriuria (girls only) Hearing
Vision
Physical growth Psychomotor development Lead absorbtion (high risk only) Tuberculosis (high risk only)
Interview Questions
Physical Examination Items
+ + + + + + + + + + +
+11 +1! + +
+ + + + +
+ 4- .- + 4-
4.-+ + + + + + + + +
+ + + + + + + + + + +
+ + + + + + + + + + +
+ + + + + + + +
+ ‘ Do at this age.
4-’ Do at this age if not done at previous scheduled age.
#{176}Otherinborn errors may be added with the development of adequate testing and follow-up services. tScreening should only take place when excellent comprehensive care can be given to all positives. tOnly persons with African, Mediterranean and certain Latin-American ancestry need be tested. ‘Testing should take place only with informed consent and when skilled counselling can be ensured. ITesting with calibrated noisemakers may be added at 9 or 12 months if skills and resources permit. #{182}Hearing should be tested yearly from ages 4 to 8.
techniques that are currently most widely
ac-cepted for screening. One important direction for
the near future is to carry out the relatively simple
research that will close some of these gaps. It
should, for example, be relatively easy to review
growth records of several hundred
“well-doc-tored” children to determine whether abnormal
growth patterns actually identify children with
treatable health problems, and if so, which
pat-terns do so and what frequency of measurements is
necessary to gain most of the possible benefits of
such early identification. Better deliniation of the
prevalence, incidence, distribution and natural
history of health problems in the child population
will be essential for more rational approaches to
screening.
Directions in Program Administration
Several current trends should continue to affect
the course and direction of administering and
pro-gramming screening.
1. The DemLse of Single Disease Screening Prograims. The concept of marginal costs is well
described by Scriver.3 It takes just about as much
effort and time to reach, screen and follow-up
children for a single problem as to do so for a large
number of problems. When each single-problem
program could be considered a pilot or
demon-stration it could be justified. But to attempt to
carry out separate community-wide programs for
vision, for hearing, for tuberculosis, etc., no longer
makes sense in terms of economics, convenience
or effectiveness.
2. The Integration of Screening With Medical Care. When screening is conducted outside the
physician’s office or clinic, there are immense
dif-ficulties in ensuring adequate follow-up. The
sim-plest way of overcoming these difficulties appears
to be to incorporate screening into office or
clinic-based health management. A large proportion of
the costs of screening can be by-passed when
screening takes place in the direct context of
gen-eral medical supervision and care.
3.
“Standardization
“ of Screening Schedules.New knowledge from research, experience from
EPSDT, and a broader awareness of the problems
and opportunities of screening among both
pro-fessionals and laymen should lead to a greater
con-census regarding the choice and scheduling of
screening techniques. “Utopian” proposals such
as those of the original Standards of Child Health
Care 25 have already been reduced in scope to
ap-proximate more closely what is both necessary
and practical, and publically supported
pro-grams will probably set a floor of basic
expecta-tions. Debates regarding the number and
fre-quency of health supervision visits for children
will focus more on the need for health education
and counselling, and less on the need for
“exam-inations and shots.” The proportion of child health
supervision devoted to “screening for disease”
will probably decrease, while the number of
problems systematically screened for and the
pre-cision of their detection increases.
4. Parent Participation. Parents will
increasing-ly participate in the formal screening process. As
methods for screening are simplified, they can be
taught not only to paraprofessionals but to
par-ents.
Parents already read tuberculin tests, complete
urinary symptom diaries, have been urged to
screen their children’s vision and hearing, and
re-port and describe a variety of symptoms. It seems
possible that nurses and aides will increasingly
teach mothers to measure and chart their
chil-dren’s growth, to complete “developmental
checklists,” to test vision and to assess diet rather
than perform these services directly. A system of
child health supervision that is less paternalistic
and more “do it yourself” may have many
advan-tages in addition to its obvious economy.
5. Better Instrumentation. As there is
increas-ing agreement on which observations and
mea-surements are desirable in routine health
supervi-sion, more attention can be paid to ensuring the
accuracy and reliability of the observations. The
trend will probably be away from large scale
inte-grated multiphasic screening centers and toward
small single function instruments which ca be
used in a variety of settings. The direct rea [ing
weighing scales, which greatly improves the
accu-racy and economy of weight measurements, is a
prosaic example. The phonocardioscan’6 is
re-ported to be more accurate in differentiating
be-nign heart murmurs from organic murmurs (in
school-age children) than are most clinicians. To
the extent that accurate weight determination or
accurate identification of heart murmurs proves
to be important in health screening of children,
in-struments such as these may make the
observa-tions more accurate and economical.
Directions in Testing
There are several areas in which both
knowl-edge and technology are developing at rates and
in directions that will soon make “routine
screen-ing” feasible. As such testing becomes technically
feasible, the question arises whether such routine
screening is socially desirable, cost effective or
both.
1. Fetal Screening. An increasing number of
per-formed on the fluid obtained by amniocentesis,
through ultrasound, and through blood tests
performed on the mother during pregnancy.’7
Unfortunately, only a few of the conditions
discov-ered through this method are remediable. If
abor-tion is accepted as suitable “therapy” in such
con-ditions, the cost effectiveness of routine prenatal
care is probably established. If abortion is
reject-ed, either by parents or by society, then the
bene-fits of such early detection are limited to those few
conditions for which intrauterine or immediate
neonatal treatment is effective (as severe
erythro-blostosis) and to the reassurance that can be given
by negative studies in pregnancies which are
ge-netically at risk. While the technology for
“am-nioscopy” or “fetuscopy” is well advanced,
cur-rent constraints on research involving the human
fetus will almost certainly delay its clinical use jn
fetal diagnosis for many years.
2. Infant-Mother Relationships. Increasing
evi-dence supports the concept that distorted
mother-infant relationships lead to a spectrum of
disabili-ty ranging from child abuse and neglect, through
failure-to-thrive syndromes, to more subtle
psy-chological impairment. It appears that such
#{231}lis-torted relationships can be improved through
counselling and other supportive intervention.
New methods of screening for such relationships
seem likely to develop based on questionnaires
such as that of Kempe,28 on maternal history as
de-scribed by Frommer,29 or on mother-infant
inter-action patterns such as those described by Klaus.3#{176}
3. The Child-Rearing Environment. Caldwell3’
described a scale for evaluation of home
environ-ments that validly predicted which children
would have low developmental or IQ scores and
which children would improve those scores in a
developmental child care program. It seems likely
that this scale can be refined and simplified into a
routine clinical screening instrument. If combined
with routine developmental screening, such a tool
might identify those homes and families in which
counselling and teaching in child-rearing
prac-tices might be expected to have its greatest
benefits in enhanced child development. Karnes3’
and others have shown that successful
child-rearing techniques can be taught, and Gutelius33
has shown that even a comparatively low-cost
in-tervention program can have substantial benefits.
4. Speech. It seems very likely that present
knowledge of speech development and its
varia-tions is adequate for the development of simple,
well-codified screening criteria that would
identi-fy those children with deviations which would
benefit from medical or educational intervention.
The speech of deaf children is different from that
of children with neurologically or anatomically
based dysarthria, from that of children who are
adequately learning dialectal pronunciations, and
from that of children with delays in normal
articu-lation which seem to “cure” themselves in the first
year or two of school. Most currently used
screen-ing criteria fail to differentiate the later two
con-ditions which have a good prognosis without
specific intervention, from other more serious
conditions.
5. New Technologies. Several instruments and
technologies may be adapted for screening in
the near future. An electroacoustic
tympa-nometer35 has been developed which is capable of
detecting decreased typanic membrane motility
due to fluid in the middle ear. Its usefulness in
screening for both acute and chronic middle ear
disease is currenfly being evaluated. An instrument
capable of carrying out a full optometric
refrac-tion (and writing a corrective optical prescription)
has been used in screemng school children
with highly promising resiilts.36 The technology
of ultrasound-already beIng used to assess
in-trauterine fetal growth and to diagnose congenital
heart disease-is developing so rapidly that
appli-cations in screening seem inevitable. As each of
these technologies yields a technically feasible
screening test, further studies will be necessary to
determine whether the test and the health
prob-lem meet the necessary criteria for routine
em-ployment.
6.
Adult RLik Factors. There is alreadywide-spread debate about the role of pediatric
screen-ing in identifyscreen-ing persons who are at increased risk
of developing certain health problems in adult
life. Identification of children with elevated blood
pressure or with elevated levels of serum lipids
have been suggested as approaches to reduction of
hypertension and coronary artery disease in adult
life. Obesity, smoking and psychiatric illness are
believed by many to have their origins in
child-hood and to be potentially controllable through
screening and intervention in childhood. There
will be mounting pressure to “do something”
about such problems, even though the evidence
that “something can be done” effectively is not
yet a hand. Widespread application of the criteria
outlined by Frankenburg’ will keep us from
pre-mature implementation of programs based on
insufficient knowledge, while concurrently
pur-suing the knowledge necessary to justify truly effective programs.
Some Current Priorities
With the impetus given to much more
Maintenance Organization development, by
man-dated screening of Medicaid-eligible children,
and by mandated screening for school children in
some states, there are several priorities for current
action.
1. Those planning screening programs must be
aware of the many limitations of current
knowl-edge and technology, and include in their
pro-grams only those methods which are of proven
benefit, or which have the highest probability of
substantial benefits in relation to costs.
2. All screening programs must be designed
with built-in continuing evaluation. Practical
methods and protocols for monitoring and
evalua-tion of programs are probably more important for
immediate progress than is the refinement of
screening techniques. Once practices have been
uncritically established, they are very difficult to
stop. Failure to weed out ineffective methods and
approaches may be a greater threat to the
effec-tive long-term development of screening in health
care than slow development of new techniques.
3. Substantial research effort should be devoted
to answering questions relevant to screening.
Many of the needed answers depend more on
ion-gitudinal clinical studies than on complex
labora-tory or epidemiologic techniques. The
longitudi-nal observation of a few hundred children could
yield a great deal of information about the
useful-ness of many accepted or proposed screening
techniques-most obviously questionnaire and
ex-amination items.
Recapitulation
When a patient brings a complaint to a
physi-cian, the physician is responsible to do his best
with the knowledge, skill, facilities and resources
that are currently available. When physicians,
through screening, take the initiative to discover
unsuspected health problems, they assume further
responsibilities. They must be sure that
knowl-edge, skills, facilities and resources are available
to do something useful about problems which are
discovered; and they must be sure that the total
benefits of discovery and intervention outweigh
the total costs. These considerations must pervade
all applications of both currently available
screen-ing methods and those which will be developed
and perfected in the future.
Screening and screening programs to date have
largely failed to fulfill the hope that early
detec-tion will lead to more effective early treatment
and to improved health status in the populations
served. Part of this failure is due to inadequate
knowledge and technology, but much can be
at-tributed to programs which have failed to
incor-porate basic principles described in the papers in
this symposium.
1. Screening must be part of a program that
en-sures effective treatment for problems discovered.
2. Tests used and problems sought must have
certain specific characteristics to be suitable for
incorporation in screening programs.
3. The dangers of mislabeling through
screen-ing must be avoided.
If future efforts are to be more successful than
those in the past, they will have to learn from and
correct the mistakes of the past. The following
lessons seem to be among the most important:
1. Screening is not and cannot be a substitute
for other elements of health care. Primary
preven-tion, care of episodic symptomatic illness,
man-agement of chronic illness and handicaps, and
health counseling and education can sometimes
be potentiated by, but never replaced by
screen-ing. Screening is one means of alerting people that
they may need medical care, it is not a system for
the delivery of medical care.
2. The existence of a relatively simple test does
not automatically justify its routine use in
screen-ing.
3. Screening provided in the setting of
compre-hensive health supervision is much more likely to
lead to effective intervention than is screening
provided in other contexts.
4. The cost of screening is greatly reduced
when a single administrative system is used to
carry out testing and follow-up for a number of
problems. Regionalization of specialized
labora-tory, administrative and diagnostic services can
improve effectiveness and economy.
5. All screening-whether in health supervision
or in special programs-must be evaluated
period-ically to be sure that it is having its intended
re-suits: improved health status through
identifica-tion and treatment of remediable problems.
REFERENCES
1. Lessler, K.: Screening, screening programs and the pedi-atrician. Pediatrics, 54:6()8, 1974.
2. Frankenburg, W. K.: Selection of diseases and tests in pediatric screening. PediatriCs, 54:612, 1974. 3. Scriver, C. R.: PKU and beyond: When do costs exceed
benefits? Pediatrics, 54:616, 1974.
4. Kunin, C. M.: Current status of screening children for urinary tract infections. Pediatrics, 54:619, 1974. 5. Allen, C. M., and Shinefield, II. R.: Automated
multi-phasic screening. Pediatrics, 54:621, 1974. 6. Moriarty, R. W.: Screening to prevent lead poisoning.
Pediatrics, 54:626, 1974.
7. Edwards, P. Q.: Tuberculin testing of children.
Pediat-rics, 54:628, 1974.
medi-cally high risk population at delivery. Amer. J.Dis. Child., 124:369, 1972.
10. Woodruff, C. W., Wright, S. W., and Wright, R. P.: The role of fresh cow’s milk in iron deficiency. Amer. J. Dis. Child., 124:18 & 26, 1972.
1 1. Pearson, H. A., et al.: Routine screening of umbilical cord blood for sickle cell diseases. JAMA, 227:420,
1974.
12. Hampton, M. L., et a!.: Sickle cell non-disease: A poten-tially serious public health problem. Amer. J. Dis. Child., 128:58, 1974.
13. Committee on Fetus and Newborn: Neonatal screening for hearing impairment. Pediatrics, 47: 1085, 1971. 14. Owen, G. M.: The assessment and recording of
measure-ments of growth of children: Report of a small con-ference. Pediatrics, 51:461, 1973.
15. Frankenburg, W. K., Goldstein, A. D., and Camp, B. W.: The revised Denver Developmental Screening Test: Its accuracy as a screening instrument. J. Pe-diat., 79:988, 1971.
16. Knobloch, H., Pasamanick, B., and Sherard, E. S.: A de-velopmental screening inventory for infants.
Pedi-atrics, 38:1095, 1966.
17. Kunin, C. M., Southall, I., and Paquin, A. J.: Epidemiolo-gy of urinary tract infections: Pilot study of 3,057 school children. New Eng. J. Med., 263:817, 1960. 18. Loggie, J. M. H.: Systemic hypertension in children and adolescents: Causes and treatment. Pediat. Clin.
N. Amer., 18:1273, 1971.
19. North, A. F.: Hypertension in children. J. Pediat.,
79:510, 1971.
20. Committee on Nutrition: Childhood diet and coronary artery disease. Pediatrics, 49:305, 1972. 21. Chisholm, J. J.: Screening for lead poisoning in children.
Pediatrics, 51:280, 1973.
22. Yarnall, S. R., and Wakefield, J. S.: Acquisition of the History Database, ed. 2. Seattle: Medical Comput-er Services Association, 1972.
23. Anderson, F. P.: Evaluation of the routine physician ex-amination of infants in the first year of life. Pediat-iics, 45:950, 1970.
24. Yankauer, A., and Lawrence, R. A.: A study of periodic school medical examinations: II. The annual incre-ment of new defects. Amer. J. Public Health, 46: 1553, 1956.
25. Standards of Child Health Care. Evanston, Ill.: Ameri-can Academy of Pediatrics, 1967.
26. Gari, A., et a!.: Auscultation of the heart by machine and by physicians. JAMA, 202: 143, 1967.
27. Milunski, A.: The Prenatal Diagnosis of Hereditary Dis-orders. Springfield, Ill.: Charles C Thomas, Pub-lisher, 1973.
28. Kempe, C. H., and Helfer, R. E.: Helping the Battered Child. Philadelphia: J. B. Lippincott, 1972. 29. Klaus, M. H., et al.: Maternal attachment: Importance of
the first post-partum days. New Eng. J. Med., 286:460, 1972.
30. Frommer, E. A., and O’Shea, C.: Antenatal identifica-tion of women liable to have problems in managing their infants. Brit. J. Psychiat., 123: 149, 1973. 31. Karnes, M. B., et al.: Educational intervention at home
by mothers of disadvantaged infants. Child Devel-op., 41:925, 1970.
32. Caidwell, B. M.: Descriptive evaluations of child devel-opment and of developmental settings. Pediatrics,
40:46, 1967.
33. Gutelius, M. F., et al.: Promising results from a cognitive stimulation program in infancy: A preliminary
re-port. Clin. Pediat., 11:585, 1972.
34. Rutter, M., and Martin, J. A. M.: The Child With De-layed Speech. Philadelphia: J.B. Lippincott, 1972. 35. Brooks, D. N.: An objective method of detecting fluid in
the middle ear. Int. Audiol., 7:280, 1968. 36. Safir, A., Kulikowski, C., and Deuschle, K.: Automatic
