4496 PDH 11/06

Clinical Practice Guidelines for Pediatric Health

Empire BlueCross BlueShield has a commitment to provide its members with quality and
appropriate preventive health care services by distributing guidelines on clinical practice
to our network physicians. These guidelines have been compiled by Empire from
recommendations of the American Academy of Family Physicians (AAFP), the American
Academy of Pediatrics (AAP), Advisory Committee on Immunization Practices (ACIP), U.S.
Preventive Services Task Force (USPSTF) and the Centers for Disease Control and
Prevention, and apply to the care of healthy children. Additional testing should be
conducted depending on a childs condition, family history and past medical problems.
This information is being provided as guidelines for your consideration and should be
considered minimum standards of care. All participating physicians are expected to
exercise independent professional judgment in the evaluation and treatment of their
patients and the rationale for variation from these nationally recognized
recommendations should be legibly documented. Periodically, Empire Quality
Improvement nurses audit the medical records of our members to determine whether
appropriate care has been provided. That determination is based on the quality and the
content of the medical record documentation.
Continuity and Coordination of Care
If a patient requires referral to one or more specialists, it is imperative for the primary
care physician to coordinate that care. Maintaining coordination and continuity includes
timely, effective and confidential exchange of patient information between the primary
care physician and any referral specialists providing ongoing care for the patient. In
addition, it includes careful monitoring of medication usage. Primary care physicians and
referral specialists should keep each other apprised of a patients clinical status.
Frequency of Well-Child Visits
The American Academy of Pediatrics recommends Well-Child visits according to the schedule
below. Empire's preventive health benefits allow for annual well visits through age 21.
Age Frequency
Prenatal A visit with the pediatrician when a woman is in
her third trimester is recommended for first-time
parents, for parents who are at high risk and for
those who request a conference.
Newborn Every infant should have a newborn
evaluation after birth.
Every breast-feeding infant should have an
evaluation 48 to 72 hours after discharge
from the hospital.
Infancy 2 to 4 days (for newborns discharged in less than
48 hours after delivery)
By 1 month; at 2 months, 4 months,
6 months, 9 months, 12 months
Childhood 15 months, 18 months, 24 months,
annually from ages 3 through 6;
at 8 years; at 10 years
Adolescence Annually from ages 11 through 21.
January 2004
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November 2006
Clinical Practice Guidelines for Pediatric Health 2
Well-Baby Care
Pediatric Prenatal visit
At least one prenatal visit to the pediatrician is recommended during the third trimester for first-time
parents, for parents who are at high risk and for those who request a conference. The prenatal visit
should include anticipatory guidance, pertinent medical history and a discussion of the benefits of
breast feeding and the planned method of feeding. Ideally, both the expectant mother and father
should attend. This provides an opportunity to discuss the topics listed above and to explain
physician practice arrangements.
Newborn
An initial assessment of the newborn is necessary during the postpartum period before discharge
from the hospital. Breast-feeding should be encouraged and instruction and support offered. Every
breast-feeding infant should have an evaluation 48 to 72 hours after discharge from the hospital to
include weight, formal breast feeding evaluation, encouragement and instruction as recommended
by the AAP.
Screening for hypothyroidism, phenylketonuria, other congenital errors of metabolism and
hemoglobinopathies is necessary for all newborns, as mandated by New York and New Jersey State
law. Other selected screenings should be done and documented as indicated by family history or
prenatal conditions (e.g., cystic fibrosis, hearing impairment, syphilis or maternal substance abuse).
Well-Baby Assessment
Infants between birth and 15 months of age should have a comprehensive health assessment within
the first three visits. Initial and follow-up Well-Child visits should include legible documentation of
health and developmental history, physical exam, health education and anticipatory guidance. The
Well-Child assessment should include legible documentation of:
History Physical Examination
Birth history (including birth weight) Length
Family history Weight
Illnesses and hospitalizations Head circumference (until 2nd birthday)
Nutritional history Eyes (strabismus/vision)
Growth Red reflex
Development Ears
Immunization history Dental assessment
Heart and lungs
Abdomen
Genitalia
Hips and feet
Skin
Femoral pulse (check once)
Neurological development
Height, weight and head circumference should be documented on growth chart or in progress notes
with the corresponding percentiles.
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Clinical Practice Guidelines for Pediatric Health 4
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Clinical Practice Guidelines for Pediatric Health 8
Well-Child Care
Children 16 months to 21 years of age should have a comprehensive health assessment at the first
Well-Child visit. Initial and follow-up visits should include legible documentation of health and
developmental history, physical exam, health education and anticipatory guidance (see table 1). The
comprehensive health assessment should include legible documentation of the following:
History
Interim history of illness or injury
Hospitalizations
Drug sensitivities/allergies
Review of systems
Family history
Psychosocial history (a questionnaire may be used)
Current problems and treatment
Nutritional history
School history; after-school activities and employment
Immunization history
Growth and development
Behavioral history, including habits, use of tobacco, alcohol,
inhalants or other drugs (beginning at age 8 years)
Sexuality and sexual activity, including preference/orientation (beginning at age 8 years)
Physical
Height and weight (with percentiles)
Ears, nose and throat
Mouth (teeth and gums)
Heart and lungs
Abdomen
Genitalia (Tanner Stages beginning at age 5 years)
Rectal region
Extremities (observe gait)
Skin
Neck (thyroid and lymph nodes)
Eyes (vision/strabismus)
Blood pressure (in children > 3 years)
Femoral pulse (check once between 16 months and four years)
Neurological development (including developmental assessment)
Pelvic exam and Pap test (in females who are sexually active or who are 18 years or older)
Scoliosis screen (beginning at age five years)
For patients 11 to 21 years of age, physicians may refer to Empires Clinical Practice Guidelines for
Adolescent Health.
Clinical Practice Guidelines for Pediatric Health 9
Routine Screening in Well-Child Care
Test Frequency
Hemoglobin and Hematocrit Once in the first year; once in early childhood; for menstruating
females, testing should be based on clinical judgment.
Sickle Cell/Hemoglobin
Electrophoresis All at-risk patients (a required part of newborn
screening in New York State and New Jersey).
Mantoux Skin Test (PPD) Only children deemed at increased risk of exposure to persons
with tuberculosis should be considered for periodic Mantoux
skin testing. Also, new entrants to day-care facilities and
secondary level schools should be tuberculin skin tested.
Cholesterol Screen children with a family history of cardiovascular disease
or hypercholesterolemia.
Dental First visit within six months of eruption of first tooth and no later
than first birthday. Every six months thereafter or as indicated
by provider.
Hearing (using a standard
testing method) Once at age 4 years then every two to four years.
Hypertension Annually from age 3 years.
Vision (using standard
testing method) Every two years starting at age 4 years.
Sexually Transmitted Disease Query and document in all sexually active adolescents; in areas
with a high incidence of problems, such as congenital syphilis,
include screening, history and counseling.
Lead Blood Test Starting at 6 months of age and at each regular office visit
thereafter, the provider should document assessment of the
childs risk for high-dose exposure. All children should be
tested at 1 year and 2 years of age as required by the New York
and New Jersey State Department of Health. Also, the provider
should discuss childhood lead poisoning interventions with
the childs parent or guardian. The guidance and risk
assessment should emphasize the sources and exposures of
greatest concern in the childs community. Because lead-based
paint has been used in housing throughout the United States,
in most communities it will be necessary to focus on housing
as a source of lead exposure. Other sources of lead exposure
may include some makeup products, some traditional
medicines, soil and some toys. At a minimum, the following
types of questions should be asked and the answers should
be documented:
Clinical Practice Guidelines for Pediatric Health 10
Does your child
live in or regularly visit a house with peeling or chipping
paint built before 1980? (This could include a day-care
center, preschool, the home of a baby-sitter or relative, etc.)
live in or regularly visit a house built before 1980 with
recent, ongoing or planned renovation or remodeling?
Have a brother or sister, housemate or playmate being
followed or treated for lead poisoning?
Live with an adult whose job or hobby involves
exposure to lead?
Live near an active smelter, battery recycling plant or
other industrial setting likely to release lead?
Ask any additional questions specific to situations that exist
in a particular community. If the answers to all questions are
negative, a child is considered at low risk for high-dose lead
exposure. If the answer to any question is positive, a child is
considered at high risk for high dose lead exposure.
Clinical Practice Guidelines for Pediatric Health 11
Table 2
References
American Academy of Pediatrics Committee on Infectious Diseases. Update on Tuberculosis Skin
Testing of Children. Pediatrics. 1996;97:282284. http://pediatrics.aappublications.org
Advisory Committee on Immunization Practices (ACIP) www.cdc.gov/nip/acip
American Dental Association website: www.ada.org/public/index.asp
Centers for Disease Control. Recommended Childhood Immunization Schedule-United States, 2006.
http://www.cdc.gov/nip/recs/child-schedule.pdf
Centers for Disease Control. Childhood Lead Poisoning Prevention Program. December 22, 2005.
http://www.cdc.gov/nceh/lead/lead.htm
Department of Health and Mental Hygiene. http://www.nyc.gov/html/doh/home.html
Recommendations for Preventive Pediatric Health Care (RE9939), Committee on Practice and
Ambulatory Medicine, American Academy of Pediatrics. 2000.
U.S. Preventive Services Task Force (USPSTF). http://www.ahrq.gov/clinic/uspstfix.htm
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the
Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Clinical Practice Guidelines for Pediatric Health 12 4496 PDH 11/06