Prevention consists of activities directed toward decreasing the probability of specific illnesses or dysfunctions in individuals, families and communities. It is the concept of reducing unwanted health outcomes by reducing or eliminating risk factors that might lead to those outcomes.

Prevention has three components: primary, secondary and tertiary prevention.

Primary Prevention

Activities aimed at intervention before pathological changes have begun and during the natural history of susceptibility. Immunization is an example of primary prevention.

Secondary Prevention

Activities aimed at early detection of disease and prompt treatment, to cure disease during its earliest stages or to slow its progression, prevent complications and limit disability when cure is not possible. A screening program is an example of secondary prevention.

Tertiary Prevention

Limiting the effects of disease and disability for people in the earlier stages of illness and providing rehabilitation for people who already have residual damage.

Immunization

An injury is the result of any type of trauma, whether intentional or unintentional. Injuries are preventable.

In terms of potential years of life lost, injuries are significant contributors to total mortality. They are among the leading causes of death and disability in children of all age groups and the leading cause in children >1 year of age.

Injuries

Definition

An injury is the result of any type of trauma, whether intentional or unintentional. Injuries are preventable.

Commonest Types of Injuries

Infants and Toddlers

Falls
Near-drowning
Burns, scalds
Poisonings

Older Children (8-15 Years)

Injuries related to bicycling and other sports

Youth (15-20 Years)

Firearms-related injuries

Injury Prevention Strategies

General

Preventing injuries requires effort from the total community
Preventing injuries requires a detailed history of exposure to potentially injurious activities within the family and at school
Identifying children and families at risk is a critical step in preventing injuries
The environment can be modified by construction (e.g., fences around water, safer roads) and by regulations (e.g., requiring seat belts and bicycle helmets)
A large part of preventing injuries is educating parents and caregivers about potential dangers to children and methods of avoiding injuries; this is an important role for the healthcare worker, particularly nurses (during well-baby clinics and illness visits)

Anticipatory Guidance and Counseling

The parents or caregiver should be educated about the following strategies to minimize the risk of injury.

Birth to 6 Months

Position child on back or side for sleeping (to prevent SIDS [sudden infant death syndrome])
Never leave child unattended in bathtub
Use approved infant car seat (properly restrained) to protect child in vehicle
Ensure that mattress fits snugly in crib and that it provides good body support (i.e., not made of feathers, not too soft); space between bars should be approved by CSA International (formerly the Canadian Standards Association)
Because children like to put things in their mouths, keep small, hard objects that could be swallowed out of reach, and avoid toys with small parts that could come off while in the child's mouth

6-12 Months

Never leave child unattended in bathtub
Use approved infant car seat in vehicles
Cover electrical outlets
Keep electrical cords and plugs out of reach or covered to prevent burns from chewing exposed cords or putting plugs in mouth
Keep cleaning solutions, solvents and medications out of reach of a crawling infant (i.e., in upper cupboards)
Avoid use of walkers, which represent a significant cause of injury
Protect steps and stairways with gates
Avoid peanuts, peanut butter, seeds and round candies
Advise older children not to share small food items or objects (e.g., gum, peanuts, pennies) with an infant
When child is near water, ensure that he or she is wearing a life jacket and is under continual supervision

1-2 Years

Never leave child unattended in bathtub
Set temperature on hot water tank at 54°C to prevent scalding
Supervise child while he or she is close to vehicular traffic
Use approved infant car seat in vehicles
Turn pot handles away from edge of stove
Keep poisonous substances locked up or out of reach
Advise older children not to share small food items or objects (e.g., gum, peanuts, pennies) with an infant
When child is near water, ensure that he or she is wearing a life jacket and is under continual supervision

2-5 Years

Never leave child unattended in bathtub
Ensure that child uses a seat belt when in a vehicle
Ensure that child wears a helmet while bicycling or skateboarding
Avoid transporting children 2-5 years of age on ATVs and snowmobiles
Keep matches and lighters out of reach
Keep poisonous substances locked up or out of reach
Advise older children not to share small food items or objects (e.g., gum, peanuts, pennies) with a younger child
When child is near water, ensure that he or she is wearing a life jacket and is under continual supervision

5-10 Years

Ensure that child wears a helmet for bicycle, ATV, snowmobile and skateboard use
Ensure that child uses a seat belt when in a vehicle
Teach child how to prevent playground injuries and how to use playground equipment safely
When child is near water, ensure that he or she is wearing a life jacket and is under continual supervision
Ensure that child receives instruction about water safety and swimming skills
Teach child to avoid contact with strangers

10-15 Years

Provide guidance about risk-taking behavior (particularly alcohol and substance abuse)
Provide guidance about sexual activity, including how to say No to unwanted touching
Provide instruction about gun safety
Provide instruction about boating safety
Ensure that young adolescent uses a seat belt when in a vehicle
Ensure that young adolescent wears a helmet for bicycle, ATV, snowmobile and skateboard use
Ensure that young adolescent receives instruction about water safety and swimming skills

15-20 Years

Provide guidance about risk-taking behavior (particularly alcohol and substance abuse)
Provide guidance about sexual activity, including how to say No to unwanted touching
Provide instruction about gun safety
Provide instruction about boating safety
Ensure that young adult uses a seat belt when in a vehicle
Ensure that young adult wears a helmet for bicycle, ATV, snowmobile and skateboard use

Home Safety

Ensure that house is equipped with fire alarms and fire extinguishers
Establish exit routes, and ensure that all members of the family are aware of them
Ensure that firearms and ammunition are stored safely
Ensure that dangerous chemicals are stored safely, particularly if there are small children in the home

Well-Child Care

Well-Child Visit

Purposes

Immunization
Parental support regarding feeding, safety and nurturing of children
Screening for developmental or physical problems
Parental education, counseling and anticipatory guidance

Components of Well-Child Visit

Review the child's health record and the family record, so that you are aware of previous health concerns and can plan what should be done during the current visit.

Review the child's immunization record. Ensure that consent for immunization is on file.

Discuss with the parents or caregiver the child's health and progress:

Current general health
Achievement of developmental milestones
Feeding habits
Sleeping habits
Behavior
Relationships with family members

Perform a physical examination. Observe the following aspects:

Nutritional status
Character of cry (in infants <6 months of age)
Color
Vision
Hearing
Activity level
Any other aspect, as dictated by concerns raised in the history

In addition, examine:

Hair, scalp, fontanels
Eyes, ears, nose, mouth (including dentition), throat
Lungs, heart
Abdomen, genitalia
Limbs, specifically muscle tone, motion, symmetry and hips (for congenital dislocation; in newborn period and at every visit up to 12 months of age)
Skin
Growth measurements
Observe for achievement of major developmental milestones

Remain alert for ocular misalignment, vision disorders, tooth decay, and child abuse or neglect.

Growth Measurement

Measurement of a child's weight, height and head circumference is most important in the health assessment process, because growth is a major characteristic of childhood. Atypical growth patterns can be indicators of pathologic processes.

Correct measuring techniques and accuracy are essential if the measurements are to be useful in evaluating growth. In addition, the measurements must be appropriately recorded on a growth chart and compared to norms for the child's age and to his or her previous growth pattern. If the child's measurements consistently follow the relevant growth curve, the growth pattern is considered normal.

A graph gives an easily understood pictorial display of the child's growth and should alert the observer early to deviations from normal.

Failure to thrive should be suspected if the child's growth curve drops by two or more major percentiles. In this situation, the child is considered at high risk. See "Failure to Thrive," in chapter 17, "Hematology, Endocrinology, Metabolism and Immunology."

Abnormal Growth Problems

Any child with growth or developmental problems should be referred to a physician.

Weight

Above-normal weight combined with normal height: consider over-nutrition
Above-normal weight combined with below-normal height: consider a genetic cause (e.g., Down's syndrome) or endocrine problems (e.g., hypothyroidism, Cushing's disease)
Below-normal weight combined with normal height and head circumference: consider under-nutrition, failure to thrive, iron deficiency, psychosocial deprivation, hypothyroidism
Below-normal weight combined with below-normal height and head circumference: consider organic cause (e.g., renal failure, iron deficiency, lea intoxication, immune deficiencies, inborn errors of metabolism, HIV infection)

Height

Above-normal height combined with normal weight and head size: in 90% of cases, this combination of growth parameters represents a familial tendency; the rate of growth is normal, although the absolute percentile value is greater than normal; may also be caused by excess production of growth hormone, hyperthyroidism or Marfan's syndrome
Above-normal height, weight and head size: consider a pathologic process (e.g., acromegaly) or a chromosomal disorder (e.g., Klinefelter's syndrome)
Below-normal height: consider a pathologic process (e.g., deficiency of growth hormone, hypothyroidism, chronic anemia), a chromosomal disorder (e.g., Turner's syndrome) or failure of a major organ system (e.g., GI, renal, pulmonary or cardiovascular)

Head Circumference

Disproportionate Microcephaly

Head size that is small relative to the child's height and weight is often an indicator of a pathologic process
Below-normal head size combined with normal weight and height: consider craniosynostosis, prenatal insult (e.g., maternal drug or alcohol abuse), maternal infection, complications during pregnancy or birth, chromosome defects
Disproportionate microcephaly requires immediate evaluation (at the time of diagnosis)

Disproportionate Macrocephaly

If the head size is large relative to the child's height and weight, close attention must be given to the physical examination and assessment of developmental status-look for associated physical findings such as a bulging fontanel or split sutures, neurologic abnormalities or delays in reaching developmental milestones
Above-normal head size combined with normal weight and height: consider primary hydrocephalus, hydrocephalus secondary to associated disease of the central nervous system, primary megalocephaly or megalocephaly secondary to associated disease of the central nervous system or to a metabolic storage disease (e.g., Krabbe's disease)

Evaluation

A three step approach should be taken in evaluating a child with an abnormal growth curve.

Check the growth data for accuracy.
If a growth problem is substantiated, assess the child closely for associated symptoms, abnormal findings on physical examination or delays in development.
Any abnormality in a child's rate of growth requires further assessment. Consult a physician for advice. Children with suspected growth abnormalities who are otherwise normal should be followed closely to determine their growth rate.

Appropriate Screening

The idea of screening for early detection of disease is appealing, but it is valuable only if the following conditions pertain:

The disease can be diagnosed reliably by a simple, acceptable test
Effective treatment is available
The benefits outweigh the costs

The following situations are those in which screening is thought to be useful in child care.

Phenylketonuria (PKU)

All newborns should be screened for PKU by means of a capillary blood sample before discharge from the hospital
For any newborn who undergoes this type of screening at less than 24 hours of age, the screening test must be repeated between 2 and 7 days of age

Congenital Hypothyroidism

All newborns should be screened for TSH level by means of a dried capillary blood sample in the first week of life
If child was born in hospital, verify that this type of screening was done before discharge

Hemoglobin Screening

The prevalence of anemia is high among Aboriginal children 6-24 months of age. In addition to ethnic background, other risk factors for anemia are prematurity and low birth weight, breast-feeding beyond 6 months of age, lack of access to or inability to consume iron-fortified products, diet of cow's milk only in the first year of life and low socioeconomic status.

The Canadian Task Force on Preventive Health Care (formerly Canadian Task Force on the Periodic Health Examination 1994) recommends that screening for hemoglobin level be performed at 6-12 months of age, optimally at 9 months (Table 3-1). Hemoglobin should be monitored more frequently in children in whom anemia has been identified and treatment has begun.

Table 3-1: Normal Hemoglobin Levels in Children
Age	Hemoglobin Level (g/L)
1 month	115--180
2 months	90--135
3--12 months	100--140
1--5 years	110--140
6--14 years	120--160

See "Iron Deficiency Anemia in Infancy," in chapter 17, "Hematology, Endocrinology, Metabolism and Immunology."

Developmental Screening

In monitoring the health of children, developmental assessment is an important function that should not be neglected. Such assessment is done by making inquiries of the parents or caregiver and by clinical observation of the child's achievement of major age-appropriate milestones.

Assess achievement of developmental milestones for all children at every opportunity, or at least at the 2-, 4-, 6-, 12- and 18-month well-child visits and at 4-5 years of age, during pre-school entry assessment.

The earlier developmental delays are detected, the sooner an intervention can be undertaken. Hopefully, early intervention will minimize the long-term impact on the child. It is critical that steps be taken to alleviate developmental problems before the child reaches school age.

The Canadian Task Force on Preventive Health Care (formerly Canadian Task Force on the Periodic Health Examination 1994) recommends that the Denver Developmental Screening Test (DDST) be excluded from the periodic health examination of asymptomatic children.

However, formal developmental testing (e.g., DDST, as well as other testing tools that are available) may be helpful if a concern about developmental delay is either expressed by the parent or caregiver or suspected by the healthcare professional. (For information on the DDST, see Appendix 3-1, "Developmental Testing," below, this chapter)

Any child with suspected delay(s) should be referred promptly to a physician for assessment.

Hearing Screening

Hearing impairment is one of the most important causes of speech delay, educational difficulties and behavioral difficulties. Early intervention can help to prevent significant speech and educational delays. Therefore, the most important time to screen is during infancy. Unfortunately, this is also the most difficult time to test a child's hearing.

The parents or caregiver should be asked about the child's hearing ability as part of every well-child visit. In addition, the clinician should observe the child's response(s) to sounds.

Formal hearing screening by such methods as tympanometry or pure-tone audiometry is reserved for high-risk (e.g., repeated ear infections or strong family history) or symptomatic children.

The Canadian Task Force on Preventive Health Care (formerly Canadian Task Force on the Periodic Health Examination 1994) does not recommend routine formal testing of asymptomatic children for hearing impairment in the pre-school years. Furthermore, such testing is of little benefit in asymptomatic older children and adolescents.

Temporary conductive hearing loss secondary to otitis media or serous otitis media with effusion is common in Aboriginal communities and may persist for long periods of time (months). Consultation with a physician is important for management of chronic otitis media with hearing loss.

See Appendix 3-2, this chapter, for details of hearing screening.

Vision Screening

The Canadian Task Force on Preventive Health Care (formerly Canadian Task Force on the Periodic Health Examination 1994) recommends that all well-child visits during the first 2 years of life include an eye examination to check for abnormalities of vision. This examination should include inspection of the eyes for abnormalities and the corneal light reflex test. Infants should also be examined for strabismus (by means of the cover-uncover test) in the first year of life (see also "Strabismus [Squinting]," in chapter 8, "The Eyes").

The Task Force also recommends that initial screening of visual acuity be undertaken in the pre-school period (3-5 years of age). If visual acuity on Snellen charts is 20/30 or less, optometric assessment is advised.

See Appendix 3-3, this chapter, for details of vision screening. For more detail on pediatric eye care, see chapter 8, "The Eyes."

When Screening Does Not Work

Urine

Routine urinalysis is not recommended for asymptomatic children.
Scoliosis
The natural history of scoliosis is not well understood, and treatments have not been well evaluated. The screening test itself is not very sensitive or specific. Any abnormalities in posture, spinal symmetry or curvature identified by the child or the child's parents or caregiver should be referred to a physician for assessment.
Observe the spine in adolescents who present for other reasons.

Pre-Sschool Entry Assessment

It is important that all children undergo a detailed pre-school assessment in preparation for starting school. The purpose of the assessment is to ensure readiness for school and to identify and correct any health problems that might interfere with the child's performance in school.

The assessment is generally done at 4-5 years of age, before the child enters kindergarten.

It is best to organize one or more special clinics in the spring of each year to carry out pre-school entry assessments for all children of the appropriate age living in the community. This allows time for any medical, surgical or social referrals to be made before school starts in the fall.

Components of the Pre-School Entry Assessment

It is important that a parent or the main caregiver accompany the child for this visit.

Review of child's past health history, as well as the family's health history
Review of present health status

Brief Physical Examination

Eyes, ears, nose, throat, teeth
Respiratory system
Check for cardiac murmurs
Abdomen
Genitalia
Musculoskeletal system

Screening

Growth: measure height and weight, and plot on growth chart
Vision: Goodlite illiterate "E" chart or random dot "E" chart
Hearing
Speech: gross screening for articulation
Developmental screening: full DDST if indicated by concerns expressed by the parents or caregiver or by a healthcare professional
Hemoglobin, urinalysis: should be done selectively for children whose medical history indicates a past or ongoing problem such as anemia or urinary tract infection
Review of immunization status: obtain appropriate consents and update immunizations according to accepted schedule; refer to regional and provincial schedules and to the Canadian Immunization Guide, 5th edition (Health Canada 1998)

Health Counseling for Parents or Caregiver as Necessary

Offer nutritional counseling
Recommend provision of intellectual stimulation (e.g., exposure to books and reading)
Provide anticipatory guidance about developmental milestones
Provide information about resources available for school-age children (e.g., dental care, audiology, optometry, speech therapy)
Allow time to discuss the results of the assessment with the parents or caregiver and to let them raise concerns or ask questions
Initiate referrals to specific healthcare professionals or agencies as required to address any identified health problems (with parental approval and consent)
Record all information on the child's personal health history and immunization record and in general file as necessary
Instruct the parents or caregiver to notify the school of any identified health problem that might have implications for the child's school attendance or performance

Specific Issues for Preventive Care of Adolescents

See chapter 19, "Adolescent Health."

Appendix 3-1: Developmental Testing

Denver Developmental Screening Test (DDST)

The DDST manual (Frankenburg et al. 1986), which explains the standardized method of administering and interpreting each test item in the DDST, is available in all nursing stations and health centers. The healthcare provider should read this manual before attempting to administer the test.

The DDST is intended as an assessment tool for counseling and planning. It is not an intelligence test; rather, it shows how the child is developing in relation to other children of the same age. Some activities outlined in the DDST will have to be adjusted for cultural relevance.

The DDST takes 15-30 minutes and considers development in four areas:

Large muscles (arms, legs)
Small muscles (hands, eyes)
Words and language
Ability to care for self and relate to others

If properly trained, the CHR can administer this test to advantage, because language and cultural barriers will be avoided. It may also be advantageous to perform the DDST in the child's home or other familiar surroundings.

The parents or another familiar adult should stay with the child during the test and should answer questions about the child's activities at home.

Calculate the child's age carefully so that the line recording results is drawn accurately. Adjust age line to account for weeks of prematurity.

To determine the highest level of development reached, the test should always include some items that are beyond the child's present development level.

The results are confidential and form part of the child's health record. They should be discussed with the parents or caregiver, and ways in which the parents or caregiver can stimulate the child's development should be explained.

Follow-up, consultation and referral should be carried out as indicated by the results.

Appendix 3-2: Hearing Screening

Perform gross hearing screening for all children during child health clinics. Gross screening includes questioning the parents or caregiver about the child's hearing ability, observing the response to a sound stimulus (e.g., clapping hands) in a younger child and pure-tone audiometric screening in the older pre-schooler ( 3 years of age) if a concern has been raised about hearing.

Infants and Pre-School Children

Age	Procedure	Method	Normal Response
Newborn to 2 months	Startle response (Moro reflex)	Produce a loud noise near the child's ear (e.g., clap hands or slap table surface)	Child is startled, jumps at the noise, blinks, widens eyes, cries
3--5 months	Ability to track sound stimulus	Produce a noise (e.g., ring bell, call child's name, sing)	Child's eyes shift toward sound; child responds to mother's voice or coos when he or she is engaged
6--8 months	Sound recognition	Produce noise out of child's line of vision (e.g., ring bell, call child's name, sing)	Child turns head in response to sound; responds to name; babbles in response to verbalization
8--12 months	Sound localization	Call child's name or say words from outside child's field of vision	Child localizes to source by turning head or body toward sound; may try to imitate words
12--24 months	Speech development (normal for age)	Engage child in conversation or question parent or caregiver about speech

Toddlers and Pre-Schoolers (3-5 Years of Age)

Pure-Tone Audiometry Using Play Response

Procedure

Demonstrate method to child: put on ear phones, pretend to hear a sound, say "I hear it" and, at the same time, place a block in a box or a plastic ring on a ring holder.
Place ear phones correctly on child.
Give a block or ring to the child.
Produce a tone at 50 dB and 1000 Hz, and guide child's hand to place block in box or ring on ring holder.
After practice, when child seems to understand the procedure and responds correctly, proceed with the screening.
Set audiometer at 25 dB and 1000 Hz and present tone in left earphone.
If child responds correctly, proceed to test 2000, 4000 and 6000 Hz at 25 dB.
Switch to right ear and present 1000, 2000, 4000 and 6000 Hz at 25 dB.
Record results on audiography sheet (child should be able to hear all frequencies at 25 dB).
Retest, later in the day, frequencies for which response was "doubtful."
Children who do not hear all frequencies should be referred for further assessment by a physician.

Appendix 3-3: Vision Screening

General Principles and CPS Guidelines

Screen all children for vision abnormalities. Screening should include inspection of the eye structures for abnormalities, the corneal light reflex test, the cover-uncover test in the younger infant or child, and visual acuity testing in older children 3 years).

The Canadian Paediatric Society has made the following recommendations for vision screening (Community Paediatric Committee, CPS 1998).

Newborn To 3 Months of Age

A complete examination of the skin and external eye structures, as well as the conjunctiva, cornea, iris and pupils, is an integral part of the physical examination of all newborns, infants and children.
The retina should be inspected (by means of the red reflex) for opacities of the lens (cataracts) and signs of posterior eye disease (retinoblastoma).
Failure of visualization or abnormalities of the red reflex are indications for referral to an ophthalmologist.
Corneal light reflex should be tested to detect ocular misalignment.

6-12 Months of Age

Conduct examination as for newborn to 3 months of age.
Observe ocular alignment to check for strabismus. The corneal light reflex should be central and the cover-uncover test normal.
Observe fixation and following.

3-5 Years of Age

Conduct examination as for newborn to 3 months of age.
Conduct visual acuity testing.
Any child with visual acuity less than 20/30 should be referred for optometric assessment.

6-18 Years of Age

Visual acuity should be assessed (e.g., by Snellen chart) every 2 years until 10 years of age, then every 3 years until 18 years of age.
Any child with visual acuity less than 20/30 should be referred for optometric assessment.

Suggested Screening Techniques for Infants and Pre-School Children

Birth To 4 Months of Age (Near-Visual Acuity)

Observe child and ensure that the following occur:

Regards face (of examiner or mother) in line of vision
Follows object or light to midline
Follows object or light past midline
Follows object or light through 180°
Grasps rattle when offered
Reaches toward an object placed in line of vision

3-4 Months of Age and Over

As for children 1-4 months of age, but add tests for strabismus.

Tests for Strabismus (SQUINT)

Procedure for Corneal Light Reflex Test

Sit at child's eye level.
Hold a light source (penlight) 13 inches (32 cm) away from the child, in front of your own nose.
Ask child to focus on the light, if child is old enough to understand and follow the instruction.
Observe position of the light reflex of each cornea and of the eyes.

Responses

Normal: both eyes are focused in same position, and the light reflects off the same area of the cornea, usually slightly to the nasal side of the pupil center
Abnormal: eyes are not aligned in position, and the light reflexes are asymmetric, i.e., coming off different areas of the cornea; this may indicate squinting

If response is abnormal for the corneal light reflex test, perform the cover-uncover test to further assess for strabismus.

Procedure for Cover-Uncover Test

Perform this test only if the child is able to cooperate.

Cover one eye with an opaque object (a large plastic spoon-shaped cover designed for this purpose may be available; otherwise, improvise).
Instruct or try to get the child to fix his or her gaze on a light source (held in front of him or her) with the uncovered eye.
Quickly remove the cover from the covered eye, and observe the position of that eye.
Repeat steps 1, 2 and 3 for the other eye.

For further explanation, see "Strabismus (Squinting)," in chapter 8, "The Eyes."

Responses

Normal: both eyes are focused in the same position
Abnormal: covered eye will deviate and may swing back into alignment when the cover is removed; in more obvious cases, the eye will remain deviated after the cover is removed or always appears deviated

Referral

Children with abnormal responses on the corneal light reflex test and the cover-uncover test should be seen as soon as possible by a physician. Referral to an ophthalmologist may be necessary.

Visual Acuity Testing

Visual acuity of 20/30 or less requires referral for further optometric assessment.

3-5 Years of Age

If the child is able to comprehend instructions, use the Goodlite illiterate "E" chart or the random dot "E" chart. This test is preferably administered in the child's own language.

6-18 Years of Age

If the child knows the alphabet, use a Snellen chart. Otherwise, use the symbol or "E" charts.

Previous Chapter

Subject Index

Pediatric Clinical Practice Guidelines List of Chapters

Next Chapter


	Last Updated: 2005-03-17		Important Notices