EPSDT Care for Kids Screenings:
Children from Birth to 24 Months
Winter 2001

EPSDT CARE FOR KIDS is an Iowa Medicaid program that provides children from low-income families with good health care.

Why do Iowa kids need EPSDT? In 1997, even though Iowa had one of the highest proportions of working parents of any state, 13% of our children younger than 18 lived in households whose incomes were below the federal poverty level. Today, right here in Iowa, the highest rate of poverty -- 16% -- is found among our most vulnerable citizens, children younger than five (Kids Count, Annie E. Casey Foundation, http://www.aecf.org).

During the first two years of life, good health care can help create a sound foundation for a child's development. EPSDT recommends that a child have 9 health care visits during these years. Each visit offers you an ideal opportunity not only to monitor the child's development, but also to provide information and encouragement to the child's parents.

EPSDT SCREENING
The components of EPSDT -- Early and Periodic Screening, Diagnosis, and Treatment -- are summarized below. For a detailed and highly useful description of each of these components, you can review your EPSDT Provider Manual. If your office participates in the EPSDT program, you have a copy of this manual. Often, it is kept with billing information; your office manager can probably locate it. Or you can find a copy online:

Provider Manual: Physician Services

Provider Manual: Screening Centers

A child's first postnatal visit takes place before the newborn leaves the hospital. At this visit, you can ensure that the child has received a hepatitis B immunization, had a hearing assessment, been evaluated for hyperbilirubinemia, has good cardiopulmonary function, and is growing well. This is also a good time to talk with the parents, observe parent-infant attachment, and monitor for signs of stress within the family.

The two-week visit focuses on the child's feeding patterns and growth. A breast-fed baby should regain its birth weight by 2 weeks of age. Bottle fed babies should gain an ounce a day. It is also important to assess how the parents are adjusting to their new family member.

2-, 4-, and 6-month visits focus on the infant's neuromotor development, gains in length and weight, and sleep patterns. Babies on formula typically double their weight by about the third month; breastfed babies, by about the fourth month. During these visits, you will plot the baby's growth, including head circumference. You will also give the child these immunizations:

Diphtheria, tetanus, and acellular pertussis (DTaP)
Haemophilus influenza B (HIB)
Hepatitis B
Pneumococcal conjugate vaccine (Prevnar)
Poliomyelitis (IPV)

9- and 12-month visits are an opportunity to review good nutrition with parents as their baby transitions from breast or bottle to solid foods. Cow's milk can cause microhemorrhage in the gastrointestinal tract, so infants should not be given cow's milk until they are a year old. During these visits, the child can complete the hepatitis B vaccine series. A hematocrit or assessment of hemoglobin level is required at 9-12 months; lead assessment at 12 months; and a skin test for TB at 12 months for children at high risk. Refer the child for an initial dental exam at 12 months.

15- to 18-month visits allow for the assessment of the child's social and verbal development. At 15 months, the child should be inoculated for measles, mumps, and rubella (MMR), be given the DtaP booster, and the pneumococcal conjugate vaccine (Prevnar).

The 24-month visit allows you to assess the child's growth and development. No immunizations are usually given at this visit. Talk with parents about their child's growing independence, and how to provide effective guidance and discipline.

EPSDT SCREENING FOR CHILDREN FROM BIRTH TO 24 MONTHS
These recommendations are for children who are growing and developing as they should, who are receiving competent parenting, and who have no significant health concerns.

*  Should be carried out for children who are at risk.

»  Range at which service may be provided, with º indicating preferred age.

¹Prenatal care is an essential component of early childhood health care.

²Intermittant care - When an older infant enters your care, or if a child misses visits, it is important to bring the child's care up to date as quickly as possible.

³Sleep positioning of infants should be discussed with caregivers. Infants should sleep on their backs. Side positioning is an alternative, but it does carry a slightly higher risk of SIDS.

Screening components

Medical history.
Take a child's medical history at the first visit, and update this at subsequent visits. Include medical history, social history, family history, and a review of symptoms. Record keeping should demonstrate that appropriate histories have been taken.

Measurements.
Basic measurements provide an essential baseline for assessing a child's growth. To avoid errors, record all measurements as you take them.

Use the National Center for Health Statistics (NCHS) Growth Charts for the appropriate age and gender (online at http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm).

Special charts are also available for specific populations, such as Non-Caucasian children, children born preterm, and children with Down syndrome (see http://depts.washington.edu/nutrpeds/fug/growth/specialty.htm). These special charts are used in combination with the NCHS charts.

For each child, measure:

Height

• Recumbent length (child younger than 24 months or <35.5 inches tall) - Lay the child on a horizontal measuring board. This board should have a fixed headboard and sliding footboard securely attached at right angles to the surface. Record the measurement to the nearest 1/8-inch.

• Standing height (child 24 months old and older or >35.5 inches tall) - Measure using a standing height board or stadiometer. Children less than 35.5 inches tall should be measured on the recumbent board. Again, record the height to nearest 1/8-inch. (Don't use measuring rods attached to scales. The surface the child stands on is not stable, and the rod hinge has tendency to loosen, so measurements are inaccurate.)

Weight. Use a balance beam scale with sliding, non-detachable weights. Recalibrate the scale once a year. Infants can be weighed on an infant scale, or on a cradle that attaches to the adult scale. Weigh infants who are wearing a minimal amount of clothing. Record the weight to the nearest ounce.

Head circumference. Measure an infant's head circumference at each visit until the child is two years old. Use a non-stretchable measuring tape. Begin just above the nose between the eyebrows, travel over the ear with the tape, around the back of the head where it is widest, and then over the other ear and back to where you began.

If any measurements cannot be taken, document why -- for example, "child uncooperative" or "child unable to fully extend legs for measurement of height." For additional information about measurement, see insert page 1.

Vision. At each visit, examine a child's eyelids and orbits, eye muscle balance, pupils, red reflex, and motility. Ask caregivers about any family history of such disorders as congenital cataracts, retinoblastoma, and metabolic or genetic conditions that affect vision. Beginning at age three, use objective tests to assess the child's vision.

Hearing. All babies born in Iowa should receive objective hearing screening shortly after birth (see the winter '99 issue of this newsletter. A child who has not had a hearing screen by the age of 3 months should be referred to an audiologist who specializes in infant hearing screening.

Neonatal screening identifies children with congenital hearing loss, but children can also experience progressive hearing loss. For this reason, you should also refer a child to an audiologist for screening if you find:

• Congenital anomaly of the ear, nose, throat, or kidney
• Delayed onset of speech
• Family history of hearing loss
• Lack of response to pure tone testing at any level
• Parental concern about the child's hearing

Development and behavior. No specific tool is required for assessing a child's development, mental health, and behavior. Clinical assessment begins with taking the child's history, performing the physical exam, and observation. At each visit, it is a good idea to ask parents, "Do you have any concerns about your child's learning, behavior, or development?" In some cases you may also administer a Denver Development Screening Test (DDST); however, public health nurses often do DDST screening. If you review their results, you do not need to repeat the screening, but you need to document your review of their evaluation.

Physical exam. Examination of an unclothed child should be appropriate for the child's age, and consistent with professional standards and judgement. For example, a female child would not be given a pelvic exam unless it was medically indicated. Briefly document normal findings; describe abnormal findings as fully as necessary.

Required EPSDT procedures

Metabolic screening. About 99% of Iowa newborns receive metabolic screening for branched-chain ketoacidemia, hypothyroidism, galactosemia, phenylketonuria, hemoglobinopathies, and congenital adrenal hyperplasia. For this reason, Medicaid does not require specific documentation. In some situations, however, you may want to determine or confirm a child's status.

Children born before 1987 who have racial or ethnic backgrounds that put them at risk for hemoglobinopathies should be offered screening and genetic counseling. Documentation is needed only if testing is ordered.

Immunizations. Review the child's status and provide immunizations as appropriate [see "Recommended Childhood Immunizations," insert page 2.]

Hemoglobin/hematocrit. Take one hemoglobin/hematocrit during the child's first year, and in each of the following intervals:

6 months if needed for WIC
9-12 months for children who: Qualify for EPSDT, have low socioeconomic status, had a birth weight of less than 1500 grams, were given whole milk before the age of 6 months, or were given low-iron formula

Test for anemia at any age if medically indicated, or if a child's history indicates inadequate iron in diet, blood loss, or family history of anemia.

Lead testing. During a five-year period that ended in 1998, 93,229 Iowa children younger than six were tested for lead poisoning. Of these, 12.3% were identified as lead-poisoned, nearly three times the national average. As a result, the Iowa Department of Public Health (IDPH) recommends routine blood lead testing of all children younger than 6 years. As per CDC recommendations, you should assess the risk of lead exposure when a child is six months old.

If you determine the child is at high risk, you should perform blood lead testing when the child is one year old, every six months thereafter until they are two years old, and then yearly through the fifth birthday. Children at low risk should have blood lead assessed at 12 months. State regulations require blood lead testing for all children younger than 6 years of age who are enrolled in Medicaid. In addition, Iowa law requires that all blood lead-testing results, for both children and adults, be reported to IDPH. For more information about identifying and managing children with lead exposure, see the summer '99 issue of this newsletter.

Tuberculin testing. Annual testing is recommended for high-risk groups, and documentation in these cases is needed. This can be billed for in addition to the screening charge.

Anticipatory guidance. Anticipatory guidance is an important part of each visit. Documentation, while not required, ideally notes topics discussed and the responses of the child or caregiver. You will find developmentally appropriate topics for such guidance in the Bright Futures Pocket Guide -- Guidelines for the Health Supervision of Infants, Children, and Adolescents, online at http://www.brightfutures.org/pocket/. The American Academy of Pediatrics Health Supervision Guidelines III is another useful resource.

Nutrition. At each visit, determine whether the child is getting adequate nutrition. You can also offer caregivers basic information about nutrition. For children enrolled in the WIC program, a simple review with the caregiver is adequate, and provides the information needed for documentation: Feeding amounts and methods for infants; variety and quantity for normally developing children.

Oral health. Oral health screening should include gathering a basic dental history and inspection of the child's mouth and teeth. Ask if an infant is being allowed to fall asleep with the bottle, and talk about infant caries. Recommend that the child begin receiving regular dental care at age one year. Document your inspection of the child's mouth and teeth; make age-appropriate referrals. For more information, see the fall '99 issue of this newsletter.