Structured Abstract
Routine Preschool Screening for Visual and Hearing Problems
Prepared by John W. Feightner, MD, MSc, FCFP, Department of Family Medicine,
The University of Western Ontario
These recommendations were finalized by the Task Force in March 1994
Contents
Objective
To make recommendations for routine screening for visual deficits and hearing
impairments in asymptomatic Canadian preschool children. These recommendations
specifically refer to care given during periodic health examinations (PHEs)
in primary care settings and are for use by health professionals and health
care planners.
Burden
of Suffering
Visual Defects
On the basis of data from two Ontario communities, the prevalence rate
of visual deficits in the preschool population is estimated to be 10% to
15%. Estimates for amblyopia range from 1.2% to 5.6% with similar estimates
for strabismus. The prevalence of combined amblyopia and strabismus
is estimated to be in the region of 5%.
Hearing Deficits
Hearing problems in preschool children are best divided into short-term,
transient problems that resolve and persistent problems. The latter
category is composed primarily of persistent middle ear effusion and sensorineural
deficits. The prevalence of short-term problems is approximately
15% while for persistent problems it is closer to 3%.
Options
Visual charts are used to assess visual acuity. Refractive errors can be
corrected with eye glasses.
Impairments can be ascertained using the whisper test, pure tone audiometry,
mobility of the tympanic membrane, and acoustic reflexometry. Treatment
options include ventilation tubes for preschool children with recurrent
otitis media.
Outcomes
Sensitivity, specificity, and positive and negative predictive values for
the visual and hearing tests. Treatment outcomes include improvement in
vision and hearing and adverse effects of language development delays.
Evidence
MEDLINE was searched up to March 1993 using the keywords hearing disorders;
vision disorders; child, preschool; mass screening; guideline; and Canada.
Recommendations were graded as:
|
A
|
Good evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
B
|
Fair evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
C
|
Poor evidence regarding inclusion or exclusion of the condition
in a PHE, but recommendations may be made on other grounds. |
|
D
|
Fair evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
|
E
|
Good evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
Quality of evidence was rated according to 5 levels:
|
I
|
Evidence from at least 1 properly randomized controlled
trial (RCT). |
|
II-1
|
Evidence from well-designed controlled trials without randomization. |
|
II-2
|
Evidence from well-designed cohort or case-control analytic
studies, preferably from more than 1 centre or research group. |
|
II-3
|
Evidence from comparisons between times or places with
or without the intervention. Dramatic results in uncontrolled experiments
could also be included here. |
|
III
|
Opinions of respected authorities, based on clinical experience,
descriptive studies or reports of expert committees. |
Values
The 13-member Task Force of experts in family medicine, geriatric medicine,
pediatrics, psychiatry and epidemiology used an evidence-based method for
evaluating the effectiveness of preventive health care interventions. Recommendations
were not based on cost-effectiveness of options. Patient preferences were
not discussed.
Background papers providing critical appraisal of the evidence and tentative
recommendations prepared by the chapter author were pre-circulated to the
members. Evidence for this topic was presented and deliberated upon in
1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993.
Consensus was reached on final recommendations.
Benefits,
Harms, and Costs
A combined program of visual inspection, assessment of visual acuity, and
evaluation of steroacuity had a negative predictive value of 98.7% for
amblyopia, strabismus, and/or high refractive errors. A similar program
had a positive predictive value of 72%. A Swedish study assessing monocular
visual acuity, steroacuity, and use of a cover test found a positive predictive
value of 84% for all visual acuity problems with 43% for visual acuity
problems that required treatment. Eye glasses effectively treat refractive
errors; treatment for amblyopia is more controversial and inconclusive.
A cohort study found that 6 to 12 months after screening, screened children
had 50% fewer vision problems and 75% fewer severe vision difficulties
than did unscreened children.
For hearing difficulties, 2 cohort studies using 2 different criteria
sets found tympanometry had a sensitivity and specificity of 48% and 89%,
and 78% and 68% respectively. One small study found no differences in language
development when children were given ventilation tubes after recurrent
otitis media. One cohort study found no differences in hearing deficits
between 2 groups, 1 of which had screening and the other who did not have
routine hearing screening. Another cohort study found that < 0.3% of
the population had hearing deficits.
Recommendations
Recommendation grade [A, B, C, D, E] and level of evidence
[I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations
in support of individual recommendations are identified in the guideline
text.
-
There is fair evidence to include visual acuity testing for visual deficits
in the PHE of preschool children [B,
II-2].
-
There is fair evidence to exclude history taking and clinical examination
(pure tome audiometry, tympanometry, acoustic reflexometry) to detect hearing
impairment in the PHE of preschool children [D,
II-1, II-2].
Validation
This report was externally peer reviewed. The United States Preventive
Services Task Force and the American Academy of Pediatrics recommend all
children be tested for amblyopia and strabismus once before entering schools
(3 to 4 years of age); routine vision acuity testing is not recommended.
The American Academy of Ophthalmology, the American Academy of Pediatrics,
and the American Association of Pediatric Ophthalmology and Strabismus
recommends that all children be given eye and vision screening at birth
and 6 months, 3 years, and 5 years. The American Academy of Family
Physicians states that it has insufficient evidence to evaluate routine
universal screening in children. The American Academy of Pediatrics recommends
pure audiometry screening at 4 and 5 years of age. The American Speech
and Language Hearing Association recommends routine annual pure tone audiometry
for children from 3 to 10 years of age.
Sponsors
The Canadian Task Force on Preventive Health Care
developed this guideline with funding from Health Canada.
Selected
References
Source Document
Link to Full Text of this
review
Link to Summary Table of Recommendations of this review
Link to Selected References list of this review
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