Search

Objective. The aims of this study were to determine the impact of expanded newborn screening using tandem mass spectrometry (MS/MS) on the overall detection rate of inborn errors of metabolism in Germany and to assess the outcome for the patients that were diagnosed. Methods. During the period of study, 250 000 neonates in a German population were investigated for 23 inborn errors of metabolism by electrospray ionization-MS/MS. The overall value of the screening program was estimated by 1) complete ascertainment of all positive tests; 2) definite assignment of all diagnoses including reconfirmation at 12 months; and 3) clinical follow-up of all detected patients in an overall interval of 42 months. The mean observation period was 13.5 months per child. Results. In 106 newborns, confirmed inborn errors of metabolism were found. The disorders were classified as 50 classic forms and 56 variants. A total of 825 tests (0.33%) were false-positives. Seventy of the 106 newborns with confirmed disorders were judged to require treatment. Six children developed symptoms despite treatment. Three children had died. Among 9 children who became symptomatic before report of the results of screening, in 6 the diagnosis had been made in advance of the screening report. In evaluation of the screening program, 61 of the 106 identified children (58% of true-positives, or 1 of 4100 healthy newborns) were judged to have benefited from screening and treatment, because the diagnosis had not been made before screening. None of these infants had died and none developed psychomotor retardation or metabolic crisis during the follow-up period. Conclusions. The screening by MS/MS for up to 23 additional disorders has approximately doubled the detection rate compared with that achieved by the conventional methods used in Germany. This strategy represents valuable preventive medicine by enabling diagnosis and treatment before the onset of symptoms. Pediatrics 2003;111:1399-1406; mass screening, metabolism, inborn errors, neonatal screening, outcome assessment, preventive medicine, spectrometry, mass, electrospray ionization., ABBREVIATIONS. FAO, fatty acid oxidation; CI, confidence interval; MCAD, medium-chain acyl-CoA dehydrogenase; MS/MS, tandem mass spectrometry; PKU, phenylketonuria. The application of electrospray ionization-tandem mass spectrometry (MS/MS) to newborn screening for [...]

Objective. To evaluate whether congenital adrenal hyperplasia (CAH) patients can be detected by newborn screening before the occurrence of life-threatening salt wasting and whether the prevalence, specificity, and sensitivity are adequate enough for a routine screening procedure. Design. From 1998, a 2-year regional pilot screening for CAH was performed. In 1998, cutoff levels for 17OHP were primarily based on birth weight, and in 1999 on gestational age. In addition, nationwide, all newly diagnosed patients with CAH were reported to the Dutch Pediatric Surveillance Unit to compare screened CAH patients with CAH patients in the area without screening. Results. In 2 years, 176 684 newborns were screened and 15 CAH patients (7 males/8 females) were detected. Therapy was started at the median age of 7 days. In the area without screening, 223 307 infants were born and 19 CAH patients (10 males/9 females) were reported to the Dutch Pediatric Surveillance Unit. Therapy was started at the median age of 14 days. The mean (standard deviation) serum sodium concentration was 134.5 (3.4) mmol/L in the area of screening versus 124.5 (10.8) mmol/L in the area without screening. The overall prevalence was 1:11 764. In 1998 and 1999, the specificity was 99.76% and 99.97%, respectively. The positive predictive value was 4.5% and 16%, respectively. To date, no false-negative cases have been detected. Conclusion. Severe salt wasting can be prevented by neonatal screening. The prevalence, specificity, and sensitivity allowed addition of screening for CAH to the routinely performed national neonatal screening program. Pediatrics 2001;108:1320-1324; congenital adrenal hyperplasia, costs, neonatal screening, specificity, sensitivity, cutoff levels., ABBREVIATIONS. CAH, congenital adrenal hyperplasia; 17OHP, 17-hydroxyprogesterone; SW, salt-wasting; NSW, nonsalt-wasting; DPSU, Dutch Pediatric Surveillance Unit; PPV, positive predictive value. Congenital adrenal hyperplasia (CAH) is, in >90% of the patients, [...]

A blood test using immunoreactive trypsinogen (IRT) followed by a genetic test appears to offer several advantages over using the IRT test alone. Researchers compared the true negative and true positive results found using the IRT/DNA test on 104,308 newborns and the IRT test alone on 220,862 newborns. The number of true positive results tended to be higher and the number of false positive results was lower using the IRT/DNA test. Fifty-five percent of the infants testing positive with the DNA test carried two copies of the delta-F508 mutation., Objectives. To evaluate neonatal screening for cystic fibrosis (CF), including study of the screening procedures and characteristics of false-positive infants, over the past 10 years in Wisconsin. An important objective evolving from the original design has been to compare use of a single-tier immunoreactive trypsinogen (IRT) screening method with that of a two-tier method using IRT and analyses of samples for the most common cystic fibrosis transmembrane regulator (CFTR) ([Delta]F508) mutation. We also examined the benefit of including up to 10 additional CFTR mutations in the screening protocol. Methods. From 1985 to 1994, using either the IRT or IRT/DNA protocol 220 862 and 104 308 neonates, respectively, were screened for CF. For the IRT protocol, neonates with an IRT [is greater than or equal to] 180 ng/mL were considered positive, and the standard sweat chloride test was administered to determine CF status. For the IRT/DNA protocol, samples from the original dried-blood specimen on the Guthrie card of neonates with an IRT [is greater than or equal to] 110 ng/mL were tested for the presence of the [Delta]F508 CFTR allele, and if the DNA test revealed one or two [Delta]F508 alleles, a sweat test was obtained. Results. Both screening procedures had very high specificity. The sensitivity tended to be higher with the IRT/DNA protocol, but the differences were not statistically significant. The positive predictive value of the IRT/DNA screening protocol was 15.2% compared with 6.4% if the same samples had been screened by the IRT method. Assessment of the false-positive IRT/DNA population revealed that the two-tier method eliminates the disproportionate number of infants with low Apgar scores and also the high prevalence of African-Americans identified previously in our study of newborns with high IRT levels. We found that 55% of DNA-positive CF infants were homozygous for [Delta]F508 and 40% had one [Delta]F508 allele. Adding analyses for 10 more CFTR mutations has only a small effect on the sensitivity but is likely to add significantly to the cost of screening. Conclusions. Advantages of the IRT/DNA protocol over IRT analysis include improved positive predictive value, reduction of false-positive infants, and more rapid diagnosis with elimination of recall specimens. Pediatrics 1997;99:819-824; cystic fibrosis, newborn screening, immunoreactive trypsinogen, population incidence, DNA testing., ABBREVIATIONS. CF, cystic fibrosis; IRT, immunoreactive trypsinogen; DNA, deoxyribonucleic acid. Cystic fibrosis (CF) is one of the most common autosomal recessive diseases in the Caucasian population, with incidence estimates ranging [...]

Screening tests for newborns to detect congenital adrenal hyperplasia (CAH) may increase early detection and treatment. CAH can cause the body to waste salt, which can be fatal, and cause increases in sex hormones. Researchers compared the effectiveness of CAH screening of 420,960 newborns to doctors' observation and detection of CAH cases. Screening provided early detection in 60% of CAH patients. Thirteen patients with CAH were identified, of whom eight were not detected by doctors' observations. Early detection of CAH can lead to prompt treatment to prevent fatal salt losses from the body., Objective. Comparative study of the incidence of classic 21-hydroxylase deficiency congenital adrenal hyperplasia (21ase-def CAH) and clinical findings of affected infants diagnosed via newborn screening versus case survey only in the Emilia-Romagna region of Italy. Methods. Neonatal mass screening (from March 1980 to September 1983--Period A, and from March 1991 to August 1995--Period C) and case survey study (from 1980 to June 1995; case survey alone from October 1983 to February 1991--Period B) were performed by the Regional Referral Center for Neonatal Screening for Endocrine-Metabolic Disease with a laboratory (Central Laboratory, S. Orsola Hospital, Bologna) and clinical (First Pediatric Clinic, University of Bologna, S. Orsola Hospital, Bologna) component. A population-based sample of 420 960 newborns consecutively born in the Emilia-Romagna region from March 1980 to August 1995 were studied. Spot 17-OH-progesterone (nmol/L blood) was tested by the radioimmunoassay method after sample extraction during Period A and by fluoroimmunometric time resolved method without sample extraction during Period C. Serum 17-OH-progesterone (ng/dL or nmollL) was tested by the radioimmunoassay method (Diagnostic Product Corporation Kit, Los Angeles, CA). The case survey was performed by means of a questionnaire sent to all regional centers dealing with pediatrics, neonatology, endocrinology, and pediatric surgery. Results. Thirteen classic 21ase-def CAH were diagnosed by means of neonatal screening (combined A and C periods). One true and one questionable false-negative cases were identified. The incidence of classical 21hydroxylase deficiency for the white population was 1:15 518 (95% confidence limits 1:9249-1:28 400) by neonatal screening plus case survey, 1:18105 (95% confidence limits 1:10 365-1:35 041) by neonatal screening alone and 1:25 462 (95% confidence limits 1:12 925-1:59 043) by case survey alone. The sensitivity and specificity of screening for classic CAH were 83% and 99.8% for Period A and 90% and 99.2% for Period C, respectively. The percentage of salt-wasting forms and the male/female ratio were higher during the neonatal screening period than during the case survey only. Sixty-one percent of classic CAH patients benefited from a prompt diagnosis. Nonclassical 21ase-def CAH cases detected via screening and case survey were also reported. Conclusions. Even in a region with adequate neonatal services, clinical diagnosis alone of classic CAH might be delayed or misinterpreted and salt-wasting crises could cause neonatal deaths. CAH screening is thus an effective tool for diagnosing affected male infants without a family history of CAH and for preventing salt loss. However, to achieve maximal benefit from screening, quick procedures are necessary for notification of positive results and beginning prompt treatment. The possibility of false-negative cases indicates that clinical observation should never be abandoned, even with ongoing screening programs. Pediatrics 1996;98:362-367; Congenital adrenal hyperplasia, 21-hydroxylase deficiency, neonatal screening, case survey., ABBREVIATIONS. 21ase-def CAH, congenital adrenal hyperplasia due to 21-hydroxylase deficiency; 1 [alpha]a-OHP, 17 [alpha]-hydroxyprogesterone; BW, birth weight; GA, gestational age; ACTH, adrenocorticotropin hormone. After the methodology had been defined by [...]

More comprehensive screening of adolescents and universal screening of young adults for cholesterol levels may reduce high cholesterol levels among urban African-Americans. Researchers studied 260 African-American teenagers and young adults for family histories of high cholesterol and personal histories of risk factors for high cholesterol levels. Professional recommendations for selective screening using total cholesterol may be inadequate. Total cholesterol combined with high-density lipoprotein cholesterol measurements may better detect people at risk for increased low-density lipoprotein cholesterol (LDL-C). High levels of LDL-C may cause fatty deposits to form inside arteries., Objective. The National Cholesterol Education Program (NCEP) and the American Academy of Pediatrics recommend selective screening to detect children and adolescents with hypercholesterolemia. We compared the effectiveness of these guidelines with other potential screening strategies in urban African-American adolescents. Subjects and Methods. Two hundred sixty African-American adolescents and young adults (192 females and 68 males; age range, 12 to 20 years) who were free from illnesses or medications that disrupt lipid metabolism were included in the study. Participants completed a questionnaire regarding their smoking habits, blood pressure, contraceptive pill use, and family history of early heart disease and high cholesterol and had their blood lipids, lipoproteins, and apolipoproteins measured (152 fasting and 108 nonfasting). Results. Nineteen percent of participants reported family histories of hypercholesterolemia; 26% reported family histories of premature heart disease; and 8% had family histories of both hypercholesterolemia and premature heart disease. Therefore, 37% of these participants would have been targeted for cholesterol screening, compared with the 25% predicted by the NCEP. Less than 50% of the participants with low-density lipoprotein cholesterol (LDL-C) levels greater than 110 or 130 mg/dL would have been detected by selective screening. Total cholesterol was superior as a screening test to apolipoprotein B in predicting LDL-C levels greater than 110 mg/dL (sensitivity, 92% vs 59%). However, total cholesterol minus high-density lipoprotein cholesterol showed better positive predictive value (100%) at LDL-C levels greater than 110 mg/dL than total cholesterol in the fasting (80%) and total groups (90%). Conclusions. In this population, selective screening with total cholesterol, as recommended by the NCEP, has such poor sensitivity and positive predictive value that other options may be superior. As an alternative, we recommend the measurement of high-density lipoprotein cholesterol together with total cholesterol at the initial screening step in adolescents and universal screening for those older than 16 years to capture a greater proportion of young adults with increased LDL-C. Furthermore, we recommend using the less stringent treatment guidelines established by the Adult Treatment Panel II for premenopausal women and men younger than 35 years for older adolescents and young adults. Pediatrics 1996; 98:383-388; cholesterol screening, African-Americans, adolescents., ABBREVIATIONS. NCEP, National Cholesterol Education Program; AAP, American Academy of Pediatrics; LDL-C, low-density lipoprotein cholesterol; apo, apolipoprotein; HDL-C, high-density lipoprotein cholesterol; CNMC, Children's National Medical Center; PPV, positive predictive value; [...]

The Rochester criteria for the evaluation of infants with fever may accurately identify infants who are unlikely to have serious bacterial infections (SBI). The Rochester criteria, also called the low-risk criteria, relies upon physical examination, patient history, and laboratory test results. Researchers studied 1005 healthy-looking infants with fevers who were two months old or younger. Of these patients, 511 satisfied the low-risk criteria while 494 did not. Laboratory testing identified SBI in 1% of infants categorized as low-risk. Twelve percent of infants who were not categorized as low-risk were diagnosed with SBI. Almost 99% of infants identified as being at low-risk will not have SBI. Based upon these findings, infants with fever who are two months old or younger and fit the low-risk criteria should be managed by observation only.

Both liquid umbilical cord blood and dried heel puncture blood seem to be effective laboratory methods for neonatal screening for hemoglobin disorders. A large hospital laboratory analyzed cord blood samples and a state public health laboratory analyzed dried blood samples from 6,904 newborns. The two laboratory tests agreed for 6,862 (99.4%) of the 6,904 matched blood samples. The results identified 27 infants with potential disease and 596 with potential disease carrier status. In 42 pairs, differences for potential disease occurred with umbilical cord blood samples. Errors involving potential disease carrier status occurred with 15 cord blood samples and 14 dried blood samples. Indeterminate results requiring repeated testing occurred in 92 of cord blood tests, compared to only 23 of the dried blood tests. Clerical problems and test limitations accounted for most of the laboratory errors.

Universal screening for hearing impairment among infants may not be beneficial. The National Institutes of Health (NIH) recommends that all infants be screened for hearing impairment within the first three months of life, preferably before leaving the hospital at birth. Early hearing loss can affect speech and language development, academic achievement, economical potential and self-esteem. However, the validity of diagnostic tests, high numbers of false positive results and cost of treatment make universal screening programs inappropriate. Available diagnostic equipment is difficult to use and test results are hard to interpret. One test cannot detect low frequency hearing loss and the other often generates false positive results in the first 48 hours of life. Universal screening would cost about $200,000,000 per year, which may be an unnecessary expense given the lack of evidence on suitable treatments and early intervention.

Universal screening of children under the age of one for lead poisoning may not be as appropriate or cost-effective as selective screening. Many regions of the US have a very low prevalence of elevated blood lead (BPb) levels. Data from 1984 indicated that about 17% of all preschool children had elevated BPb levels, but fewer suburban children than urban children had high levels. Little evidence is available on the efficacy of recommended interventions such as house dust control and childhood behavioral changes, especially at the lower end of the lead poisoning threshold. BPb level laboratory tests are of limited accuracy and can result in false test results. Universal testing is an invasive, costly procedure that may cause lost work time and anxiety for parents. However, no at-risk children would be missed. Selective screening that surveys episodes of lead exposure may be more effective.

To evaluate the usefulness of preoperative screening for coagulation disorders in children, we prospectively studied laboratory and bleeding histories in 1603 children undergoing tonsillectomy. All patients had preoperative laboratory screening with a complete blood count, prothrombin time, activated partial thromboplastin time, and bleeding time. Persistent abnormalities on repeat testing 1 week later were investigated further by a standardized schema. A subset of 129 patients, including all those bled perioperatively or had laboratory abnormalities, completed a standard historical questionaire. Thirteen patients had persistent laboratory abnormalities diagnostic of lupus inhibitor (5), non-lupus inhibitor (6), mild hemophilia A (1), and vonWillebrand disease (1). Two patients had persistently prolonged activated partial thromboplastin times undefined cause. Fourteen patients (10.8%) interviewed reported positive bleeding histories. Of these, five, including the patient with vonWillebrand disease, had persistent laboratory abnormalities. History alone failed to detect the patient with hemophilia A. For patients with inhibitors or prolonged activated partial thromboplastin times of unknown cause, surgery was delayed until the coagulation abnormalities resolved, and there was no perioperative bleeding. The patient with vonWillebrand disease had severe postoperative bleeding despite treatment with cryoprecipitate. In predicting perioperative bleeding, history and laboratory screening had a high specificity but a very low positive predictive value due to poor sensitivity and a low prevalence of bleeding. Some children with bleeding disorders may be identified first during routine preoperative coagulation testing, and replacement therapy or delay or cancellation of surgery may reduce or prevent perioperative hemorrhage. However, the large number of false positive laboratory tests and bleeding histories, coupled with the relative rarity of inherited and acquired coagulopathies, raises doubts about the overall value of routine screening. Pediatrics 1992;89:691-695

The American Academy of Pediatrics has recommended a screening program for hypercholesterolemia, or increased blood cholesterol levels, in adolescents with a high risk of developing this blood lipid disorder. The risk of hypercholesterolemia and blood cholesterol levels were assessed in 1,001 adolescents during routine health assessment at three urban teen clinics. Of the study group, 38.2 percent were Hispanic, 33.5 percent white, 15.4 percent black, and 11.3 percent Asian. The adolescents had an average age of 15.6 years and 52 percent were female. Subjects were assigned to two groups based on their cholesterol level. Cholesterol levels above 200 milligrams per deciliter (mg/dL) were considered high. The 1985 criteria for cholesterol screening established by the American Academy of Pediatrics were effective in identifying 30 of 64 teenagers with hypercholesterolemia, able to detect cases in only 47 percent (sensitivity), and to confirm the absence of the condition in 74 percent (specificity). The criteria set in 1988 identified 40 of 64 adolescents with hypercholesterolemia and had a sensitivity of 62 percent and specificity of 60 percent. The combined use of the 1985 and 1988 criteria identified 44 of 64 teenagers with hypercholesterolemia, and was 69 percent sensitive and 53 percent specific. These findings show that a large number of adolescents with hypercholesterolemia will not be identified if cholesterol screening is based on the 1985 and/or 1988 criteria developed by the American Academy of Pediatrics. It is thus suggested that cholesterol screening should be performed in all adolescents, not only those with a high risk of hypercholesterolemia. (Consumer Summary produced by Reliance Medical Information, Inc.)

Hypercholesterolemia, or increased blood levels of cholesterol, contributes to the development of atherosclerosis, the accumulation of lipids and cell matter within the blood vessels. Although screening for hypercholesterolemia is routinely performed in adults, the need for cholesterol screening in children has not been established. The American Academy of Pediatrics has expressed specific concerns about cholesterol screening in children, including the inadequate standardization of screening equipment, daily and seasonal changes in cholesterol levels, unnecessary use of drug therapy in children with transiently elevated cholesterol levels, and possible adverse effects of drug and diet therapy on growth and development. Cholesterol screening was recommended only for children older than two years of age with a family history of lipid disorders or early heart attack. However, a recent study showed that a large number of children with hypercholesterolemia would not be identified by these criteria. It was thus recommended that all children older than two years of age be screened for total cholesterol. The results of cholesterol screening of 1,665 children by four pediatricians over a 12-month period were assessed. Half the children had cholesterol levels above 156 mg/dL, and 10 percent had levels above 197 mg/dL, but these statistics varied with age and sex. Cholesterol levels decreased with age up to the teenage years and then increased, with similar changes tending to occur two years earlier in girls. Siblings tended to have similar increases in cholesterol levels, particularly when cholesterol levels were much higher than normal. These findings suggest that cholesterol screening of children in the office setting is useful, although reference cholesterol values in childhood should be specified by sex and age. In addition, siblings of children with high cholesterol levels should be screened. (Consumer Summary produced by Reliance Medical Information, Inc.)

Neuroblastoma is a malignant, bleeding tumor consisting of neuroblasts, which are cells that produce cells of the sympathetic nervous system. This malignancy is the most common solid cancer in young children, affecting almost 28 million children per year for the first five years of life, in the United States. The outcome and treatment of this cancer depends on the stage of the disease and the age of the patient at diagnosis. One-third of patients are diagnosed at an early stage of the disease, and they have a survival rate of 85 percent. The other two-thirds are patients with advanced disease; those with metastasis (spreading of the cancer to other areas) have a survival rate of less than 20 percent. Thus, early diagnosis of neuroblastoma is associated with improved survival. Age is also a factor; infants diagnosed with widespread disease have a 50 percent or greater survival rate, whereas older children with metastases have a survival rate of less than 10 percent. It remains unclear whether screening for neuroblastoma before the age of one year is effective, medically or economically. The Quebec Neuroblastoma Screening Project is assessing the effectiveness of screening infants for neuroblastoma in reducing the death rate due to this cancer. All infants born in Quebec within a five-year period will be screened at three weeks and six months of age. The methods used to screen for neuroblastoma are described, and are based on the detection of homovanillic acid and vanillylmandelic acid, which are secreted by the tumor. During the first six months of screening at the three-week stage, nine of 41,673 screened infants had positive results and were referred for further evaluation. The tumor was confirmed in four of the nine infants, no tumor was found in another four, and one infant instead had a calcified adrenal gland. Another three infants were diagnosed with neuroblastoma before they reached three weeks of age. There was one confirmed case of neuroblastoma in which the tumor did not secrete homovanillic acid and vanillylmandelic acid, and screening results from this patient were negative. (Consumer Summary produced by Reliance Medical Information, Inc.)

Urinalysis or chemical analysis of the urine for various elements is considered to be an important screening method in children who are admitted to the hospital. The effectiveness of urinalysis in detecting urinary tract infections was assessed in children admitted to a hospital day-care unit or admitted overnight to medical or surgical services between June and November 1987. Urinalysis was essential for diagnosis or treatment in 543 of 2,695 children admitted to the hospital; these test results were not included in the study. Urinalysis was performed on 145 children admitted to the day-care unit and 587 inpatients (of the remaining 2,152 hospitalized children). Of the 732 urinalysis tests, the results were abnormal in 149 cases, including 23 percent of the children admitted overnight and 10 percent admitted to the day unit. The number of abnormal urinalysis tests was similar in surgical and medical inpatients. Urinalysis was effective in detecting pyuria or pus in the urine in 90 patients, hematuria or blood in the urine in 66 patients, and urinary tract infection in 6 patients. Follow-up tests were performed in 38 percent of the children with abnormal urinalysis results. Abnormalities persisted in 58 percent those who had additional urinalysis tests, although most subsequent abnormal results were not further investigated. The total cost of initial urinalysis and additional diagnostic studies of 732 patients over a two-month period was $23,465, with the cost for every diagnosis of urinary tract infection calculated at $3,911. These findings show that hospital bylaws requiring routine urinalysis upon admission are often ignored; unfortunately, the data also indicate that most abnormal results and repeated abnormal results are not further investigated. At this medical center, urinalysis was a costly screening test, which provided limited benefit in detecting kidney disease. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infants with fever who are younger than two months of age may still require full laboratory testing to determine if bacterial infection is present. One-month-old infants with fever may require hospitalization and antibiotics. Three recent research studies address the evaluation and care of infants with fevers. Before adopting the recommendations of these studies, several issues must be considered. The appearance of an infant cannot be used as a criterion for ruling out bacterial infection unless standardized by experienced professionals using objective measures. Diagnostic criteria used to evaluate infants with fever must be tested for applicability in various medical settings and as applied by different medical professionals. Both the negative predictive value and the sensitivity of the low-risk criteria must be assessed. The Pediatric Research in Office Settings network study will address the aforementioned issues and the results will guide the evaluation and management of infants with fevers.

Screening infants and young children for developmental disabilities can facilitate early treatment and may reduce long-term disability. Screening is defined as a brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment. Pediatricians should make themselves familiar with screening techniques of young children and establish rapport with children's families. Screening of children for developmental disabilities has focused more on younger children since the passage of the Individuals with Disabilities Education Act.

Public health efforts should be aimed at removing the remaining sources of lead exposure, rather than at universal screening of children for lead poisoning. Between the 1970s and the 1990s, clinical lead poisoning essentially disappeared. The reason for the decline in blood lead levels nationwide was the elimination of environmental sources of lead including the removal of lead from gasoline. The the neurological and behavioral effects of lead are measurable at extremely low exposure levels, but a recommendation to screen all children may not be an effective preventive measure. Current technology cannot accurately measure blood lead levels in the 10 to 15 microgram/deciliter range and national screening may identify children who are not at risk of lead poisoning. State governments should concentrate on inspecting dwellings built before 1950 in which children may live and screening children who live in high-risk communities.

Neuroblastoma is a type of cancer involving a bleeding tumor; it is one of the most common malignancies occurring in young children in the United States. The outcome of treatment for this cancer depends on the stage of the disease and the age of the patient at the time of diagnosis. Early detection of neuroblastoma has improved the survival rate of afflicted patients. In Japan, infants are required to undergo routine screening for neuroblastoma. The Quebec Neuroblastoma Screening Study was established to assess the effects of screening infants for neuroblastoma on the rate of death due to this cancer. The neuroblastoma tumor secretes large amounts of metabolic products that can easily be measured in urine samples. However, screening may only be useful if the cancer follows a typical pattern of development, consisting of restricted tumor growth followed by metastases, or spreading of the tumor to other sites. But tumors in neuroblastoma appear to develop in a heterogeneous manner, and may regress spontaneously. Screening for neuroblastoma would detect mainly patients with benign, slow-growing or regressing tumors rather than rapidly growing, malignant tumors. Hence, survival rates based on screening may appear better than those determined from clinically detected tumors. Neuroblastoma tumors are classified into different forms, which vary in genetic characteristics, prognosis, and the specific metabolites they produce. Tumors detected by screening tend to have a better prognosis than tumors detected clinically. Results available so far suggest that screening infants for neuroblastoma would be premature and possibly inefficient from an economic standpoint. (Consumer Summary produced by Reliance Medical Information, Inc.)

Background. Maternal domestic violence (MDV) screening by pediatricians is not well-studied. Objectives. To determine the practicality and dynamics of routine MDV screening in a private pediatric office and to determine the rate of MDV in Upper Cape Cod, Massachusetts. Setting. A 3-pediatrician, private pediatric office in Falmouth, Massachusetts. Participants. Mothers of children aged 1 month to 10 years scheduled to undergo a well-child visit between February 7 and July 7, 2000. Intervention. Completion of an 11-item questionnaire related to violence. Results. Seven hundred sixty-six families were scheduled for well visits. Five hundred ninety-two eligible mothers presented to the office. Five hundred fifty-three completed questionnaires were returned (71.2%). The rate of MDV was 2.5% in current relationships (95% confidence interval [CI]: 1.4-4.3), 14.7% in past relationships (95% CI: 11.9-18.0), and 16.5% overall (95% CI: 13.5-19.9). Increased incidence of MDV was associated with the following variables: 1) harm to a child (odds ratio [OR]: 57.3, 95% CI: 7.3-1232.4), 2) being in a relationship other than a first marriage (OR: 4.6, 95% CI: 2.7-7.8), 3) having been previously asked about MDV (OR: 3.5, 95% CI: 2.1-6.1), 4) having 4 or more children (OR: 3.1, 95% CI: 1.6-6.1), 5) Women, Infants, and Children's program eligibility (OR: 3.0, 95% CI: 1.8-5.0), 6) having public insurance (ie, Medicaid or Children's Medical Security Plan) (OR: 2.2, 95% CI: 1.3-3.7), 7) a history of failure to present for a scheduled well-child visit (no-show; OR: 2.0, 95% CI: 1.0-4.2) and 8) anonymous questionnaire completion (OR: 1.7, 95% CI: 1.0-2.9). Thirty-two and one-half percent (32/91, 95% CI: 25.6-46.0) of mothers with a history of MDV recall having previously been asked about this by a health professional, compared with 16.9% overall (93/551, 95% CI: 13.9-20.3). Eighty-two and eight tenths (82.8) percent (457/552, 95% CI: 79.3-85.8) of mothers favored pediatricians asking about MDV. Discussion. This information was gathered within the context of normal work hours in a busy office. No additional staff were required. Hence, routine MDV screening appears feasible. The results suggest that a documented history of child abuse in a family makes it very likely that the mother has also been abused. However, child abuse among abused mothers is probably underreported. Furthermore, because most mothers favor domestic violence screening, concerns about lack of acceptance of maternal screening at pediatric visits seem to be unfounded. Screening may actually increase satisfaction with care. In addition, families who do not show up for appointments are at higher risk. Therefore, screening only at well visits will miss an important group. Conclusions. Maternal domestic violence screening at well-child visits is practical in a private pediatric office setting. Current rates of screening are low; however, most mothers favor such screening. Furthermore, MDV screening should also be offered on a catch-up basis for those who miss well-child visits, as is currently recommended for immunizations. Pediatrics 2001;108(3). URL: http:// www.pediatrics.org/cgi/content/full/108/3/e43; maternal domestic violence, pediatrician, office screening.

Objective. Mandated state newborn screening programs for the approximately 4 million infants born each year in the United States involves the following 5 components: 1) initial screening, 2) immediate follow-up testing of the screen-positive newborn, 3) diagnosis confirmation (true positive versus false positive), 4) immediate and long-term care, and 5) evaluation of all of the components of the system, including process and outcomes measures. Smooth functioning of this system requires pretest education of the parents as well as education and involvement of all health care providers who interact with the newborn screening system. Although extensive literature is available concerning public health aspects, technical standards/protocols, and discussion of the interfaces among the 5 components of the system, little information is available regarding physician awareness, involvement, and interactions with the system. The objective of this study was to determine, through a survey, primary care pediatricians' satisfaction with their state's newborn screening program. This was reflected in survey questions that asked how pediatricians were notified of the results of newborn screening tests that were performed on infants in their practice. Methods. Two thousand questionnaires were sent to primary care pediatricians in all 50 states and the District of Columbia regarding their practices in retrieving statewide newborn screening results. Of the 2000 surveys, 574 (29%) responses from primary care pediatricians who care for at least 1 to 5 newborns each week form the basis of this report. Also reported are the commentaries of the physicians concerning their specific practices, overall assessment of the system, and ideas for improvement. Results. Physicians reported their general satisfaction with the newborn screening system's ability to retrieve screen-positive infants for follow-up testing. However, communication and partnership with the primary care pediatrician regarding accessibility and timely retrieval of newborn screening test results was deemed less than optimal. Thirty-one percent of respondents indicated that notification for screen-positive test results was greater than 10 days, whereas 26% indicated that they do not receive the results of screen-negative tests and need to develop office procedures (contact birth hospital or state laboratory) to obtain results. Twenty-eight percent indicated that they do not actively seek results of newborn screening for their patients and presume that "no news is good news." Barriers to retrieving test results included that infants were born at hospitals where the physician does not have privileges, there were new transfers to the practice, infants were born in other states, personnel time was needed to track results, and there was a lack of a cohesive communication/reporting system that includes the primary care physician as an integral partner in the newborn screening communication process. Ninety-two percent of physicians would welcome an enhanced state system with direct communication to the primary care pediatrician as well as the birth hospital. Conclusion. Pediatricians recognize and endorse the benefits of newborn screening and believe that they play an important role in the efficient functioning of the system. An enhanced physician partnership with the newborn screening program will enable the timely follow-up of the screen-positive newborn for confirmatory testing. All test results need to be communicated to the pediatrician in a timely and efficient manner: 7 days for screen-positive results and 10 to 14 days for all results. Newborn screening test results of new patients who enter the practice should be available at the time of the first well-infant visit, ideally by 2 weeks of age. The majority of primary care pediatricians acknowledge the need to establish office protocols for the retrieval of newborn screening test results and would welcome an enhanced direct communication system with the state newborn screening program. Pediatrics 2001;108(8). URL: http://www. pediatrics.org/cgi/content/full/108/8/e22; newborn screening, pediatrician survey.

Objective. To create an obsessive-compulsive disorder subscale (OCS) of the Child Behavior Checklist (CBCL) and to determine its internal consistency, sensitivity, specificity, and positive and negative predictive power to identify obsessive-compulsive disorder (OCD) in children and adolescents. Methods. Three samples of equal size (n = 73) of children and adolescents, matched for age, gender, and race, were selected for these analyses: 1) a clinically ascertained OCD group, 2) a psychiatrically treated group whose records revealed no evidence of OCD, and 3) a general population control group. An OCS was created by applying factor analysis to 11 CBCL items. Examinations of internal consistency, sensitivity, specificity, and positive and negative predictive value were undertaken. Results. Of 11 items hypothesized to predict OCD, 8 items were retained after factor analyses (smallest factor loading: 0.49) and used to calculate OCS scores. The retained items displayed excellent internal consistency (Cronbach's [Alpha] coefficient = 0.84). OCD participants had significantly higher OCS scores than either psychiatrically treated or general population control groups. With the use of the 2 cutoff scores closest to the true rate of OCD in the overall sample, sensitivity was 75.3% to 84.9%, specificity was 82.2% to 92.5%, positive predictive value was 70.5% to 83.3%, and negative predictive value was 88.2% to 91.6%. Conclusion. The performance of the proposed CBCL OCS compares favorably with that of the only previously studied screening instrument for OCD, the Leyton Obsessional Inventory-Child Version. Unlike the Leyton Obsessional Inventory-Child Version, the CBCL is already in widespread use as a screen for most other forms of psychopathology. As the performance of the CBCL OCS will need to be replicated in other sample populations, data with various cutoff levels are provided to enable investigators and clinicians to tailor its use to specific study populations. Pediatrics 2001;107(7). URL: http://www.pediatrics.org/cgi/content/full/107/7/e14; Child Behavior Checklist, obsessive-compulsive disorder, screening.

Objective. To develop a brief screening tool that will allow emergency department (ED) staff to rapidly and accurately detect suicide risk in child and adolescent patients. Design. Cross-sectional survey. Participants. One hundred forty-four children and adolescents, mean age of 13.6 years, presenting to an urban university teaching hospital pediatric ED for primarily psychiatric reasons. Data Collection. As part of a quality improvement initiative, we developed a 14-item screening survey (the Risk of Suicide Questionnaire [RSQ]) that was administered by a triage nurse to all pediatric mental health patients on admission to the ED. All patients were subsequently administered the 30-item Suicide Ideation Questionnaire (SIQ) by a mental health clinician, which served as the criterion standard assessment of suicidality. Other information collected included demographic and clinical characteristics. Main Outcome Measures. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), and area under the receiver operating characteristic curve for responses to individual and combinations of RSQ items, relative to determinations of suicidality by the criterion standard SIQ. Results. Four of the items from the RSQ had a predictive c statistic of 0.87, a sensitivity of 0.98, and a NPV of 0.97. Little improvement in predictive ability was obtained by including other RSQ items (c statistic for the most predictive 4-item model = 0.87; c statistic for tire model containing all 14 items = 0.90). Among all possible combinations of 4 RSQ items, the combination of items inquiring about current suicidal behavior, past suicidal ideation, past self-destructive behavior, and current stressors yielded the highest sensitivity (0.98), NPV (0.97), and c statistic (0.87), as assessed by the criterion standard SIQ. Conclusions. A brief 4-item screening tool can be used by nonmental health clinicians to accurately detect suicidality in children and adolescents who visit an ED. Early and accurate identification of suicidality is a critical first step that could lead to better treatment and improved health outcomes for children and adolescents with mental health concerns. Pediatrics 2001;107:1133-1137; suicidal behavior, suicidal ideation, screening tool, emergency medicine, suicide risk, children, adolescents., ABBREVIATIONS. ED, emergency department; RSQ, Risk of Suicide Questionnaire; SIQ, Suicide Ideation Questionnaire; PPV, positive predictive value; NPV, negative predictive value. The rate of suicide among adolescents in the United [...]

Objective. To determine the internal consistency and 1-week test-retest reliability of the Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD), the CAGE-AA (CAGE questions adapted for adolescents), and 4 modified items from the Drug and Alcohol Problem QuickScreen (DAP-4) among adolescents. Methods. Fifteen- to 18-year-old medical patients (n = 173) completed screening tests during a routine medical visit and then again I week later. Internal consistency for each test and retest was calculated using Cronbach's [Alpha], and 1-week test-retest reliability was calculated by using Winer's unbiased estimate of the intra-class correlation coefficient (r). Results. The SSI-AOD has good internal consistency ([Alpha] = .83) and the CAGE-AA questions acceptable internal consistency ([Alpha] = .60). Alpha varied with gender and race, and item analysis indicated the CAGE-AA test could be improved. As expected, the DAP-4 had a lower [Alpha] score (.46). All screening instruments studied had high 1-week test-retest reliabilities (range r = .82-.90). Conclusions. The SSI-AOD is a reliable substance abuse screening instrument among adolescent medical patients. The CAGE-AA questions must be further revised and tested before their use can be recommended. The DAP-4 questions are likely measuring different, but important, constructs. Pediatrics 2000;105:948-953; substance abuse, screening, adolescents, CAGE, DAP, reliability., ABBREVIATIONS. AOD, alcohol and other drug (use); TIP, treatment improvement protocols; SSI-AOD, Simple Screening Instrument for Alcohol and Other Drug Abuse; DAP, Drug and Alcohol Problem (QuickScreen); POSIT, Problem Oriented [...]

Pediatricians may wish to ask women about domestic violence when they bring their children for a check-up. In a study of 154 women who brought their child for a check-up, 47 (31%) said they had experienced domestic violence when asked. Twenty-five had experienced domestic violence within the past 2 years. Two cases of child abuse were reported that the doctor had not previously known about. Before these doctors began asking every woman about domestic violence, only one woman in the past four years had reported it., Objective. Children exposed to domestic violence (DV) can experience a variety of adverse effects such as behavior disorders, developmental delay, and child abuse. Recently, the American Academy of Pediatrics recommended that all pediatricians incorporate screening for DV as a part of anticipatory guidance. To date, however, there is little information on how likely women are to disclose DV or whether there are any benefits to screening in the pediatric office setting. The purpose of our pilot study was to gain an understanding of whether screening for DV in the pediatric office setting could be helpful to abused women and their children. Methods. During a 3-month period, 92% of the women who accompanied their children for a well-child visit to a hospital-based suburban pediatrician were asked about violence in the home with a six-question screening tool. Results. Of the 154 women screened, 47 (31%) revealed DV at some time in their lives. Twenty-five women (17%) reported DV within the past 2 years and were reported to the mandated state agency. There were 5 episodes of child abuse reported of which two had not been previously reported. Interestingly, there were 5 women injured during their most recent pregnancy and who had separated from their abusive partner, but no legal action had been taken to protect them from their partner's return. There was no significant difference in the incidence of DV reported in families with Medicaid (37%) versus private insurance (20%). Before routine DV screening in our office, only one previous DV report had been made in 4 years. Conclusions. Our preliminary results suggest that many women will reveal DV when screened in the pediatric office setting. Also, there is a subgroup of women, those with young children who have recently separated from their partners, who may particularly benefit from DV screening. Pediatrics 1999;104:874-877; domestic violence, child abuse, screening., ABBREVIATIONS. DV, domestic violence; AAP, American Academy of Pediatrics; KDVT, Kentucky Domestic Violence Team. Domestic violence (DV) is a major health concern with as many as 10% to 40% of [...]

Conclusions There is a lack of good quality research into the natural history of the target conditions, the disabilities associated with them, and the efficacy of available treatments. This evidence [...]

Objective. Although previous studies have documented the feasibility and benefits of universal newborn hearing screening in selected hospitals, none have reviewed the effectiveness of regionally mandated participation of large numbers of hospitals with variable levels of motivation to succeed. The purpose of this study was to measure hospital participation and overall screening success in a statewide program for universal newborn hearing screening and to track improvements in program establishment and outpatient follow-up over time. Methods. Four Colorado hospitals began voluntarily performing hearing screening before hospital discharge on all newborns in 1992. By 1996, 26 Colorado hospitals were participating in universal newborn hearing screening. The publication of screening results from these early years served as a catalyst for legislation requiring increased hospital participation in establishing universal screening programs. Data systems were subsequently developed to improve statistical tracking and follow-up. Eight years' worth of cumulative study data as well as the results from calendar year 1999 (the year of greatest hospital participation) were reviewed for collective measures of successful screening and follow-up. Three hospitals did not initiate newborn hearing screening programs until after the study period ended in 1999. Of the 57 hospitals that were screening newborns in 1999, the chosen method of screening at 52 hospitals was automated auditory brainstem response testing; 3 hospitals used otoacoustic emission testing, and the remaining 2 hospitals used 2-stage screening. Hearing loss was defined as a threshold of 35 decibels or greater in 1 or both ears at the time of confirmatory testing. Results. During the full 8-year study period, 1992 to 1999, 148 240 newborns were screened. A total of 291 infants who were born during the study period received a diagnosis of congenital hearing loss. In this cohort of 291 children, the cumulative frequency of bilateral hearing loss was 71% (range: 48%-94% by calendar year), the frequency of sensorineural hearing loss was 82% (range: 67%-88%), and the frequency of 1 or more risk factors was 47% (range: 37%-61%). During calendar year 1999, a total of 63 590 births were recorded at 60 birthing hospitals in Colorado. The families of 263 (0.4%) of these newborns refused newborn hearing screening. Of the remaining 63 327 newborns, 87% (55 324 infants) were screened for hearing acuity before hospital discharge, a far greater percentage than the 19% of all newborns screened during the first 5 years of voluntary hospital participation, and approaching the American Academy of Pediatrics's recommendation of 95% of newborns completing hospital-based testing in a successful screening program. As a result of this statewide hearing screening program, congenital hearing loss was diagnosed in 86 Colorado newborns during 1999, representing an occurrence rate of approximately 1 affected child in every 650 newborns. In this group of 86 infants, 59 had bilateral sensorineural hearing loss, 17 had unilateral sensorineural hearing loss, 4 had bilateral conductive hearing loss, and 6 had unilateral conductive hearing loss. Mild hearing loss was present in 6 infants, moderate hearing loss was present in 42 infants, severe hearing loss was present in 33 infants, and profound hearing loss was present in the remaining 5 infants. Only 32 of the 86 affected newborns in 1999 had 1 or more risk factors for heating loss subsequently identified. After failing an initial hospital-based screening at 1 of the 57 participating hospitals in 1999, 2.3% of infants screened (1283 newborns) were referred for follow-up testing, easily exceeding the standard of Conclusions. Universal screening for congenital hearing loss is demonstrated to be feasible in a large regional effort of legislatively mandated participation. The success of such an endeavor is dependent on educational efforts for community professionals, commitment on the part of program planners, and data systems that more accurately track and recall infants who fail initial hospital-based screening. Pediatrics 2002;109(1). URL: http:// www.pediatrics.org/cgi/content/full/109/1/e7; universal newborn hearing screening, congenital hearing loss, sensorineural hearing loss, deafness, hard of hearing.

Objective. Given the directive of the American Academy of Pediatrics to test children for tuberculosis (TB) only if they are at high risk for the disease, we sought to determine how well a risk assessment questionnaire can predict a positive tuberculin skin test (TST) result among children seen in a medical office setting. Methods. In a prospective observational study, we identified 31 926 children who received well-child care in 18 pediatric offices of the Kaiser Permanente Northern California Region from August 1996 through November 1998 and who were due to receive a routine TST (Mantoux method) as part of universal screening. Parents were asked to complete a questionnaire about risk factors for TB infection that included demographic information. The TST result at 48 to 72 hours was compared with questionnaire responses to identify responses that were most highly associated with a positive TST result at both the 10-mm and 15-mm cutoffs. A concurrent study was conducted to determine whether parents can recognize induration. Results. This population was diverse in age (range: 0-18 years), race/ethnicity (white: 37%; Hispanic: 26.4%; Asian: 15.0%; black: 11.8%; other: 8.4%; not stated by parent: 1.6%), and household annual income (range: $10 524-$175 282). Overall incidence of positive TST results was 1.0% at the 10-mm cutoff and 0.5% at the 15-mm cutoff. Positive predictive value of selected individual risk factors at the 10-mm cutoff were: child born outside the United States, 10.4%; history of receiving bacille Calmette-Guerin vaccine, 5.5%; and child having lived outside the United States, 5.3%. Using multivariate analysis, we selected a subset of risk factors that were independently and significantly associated with a positive TST result greater than or equal to 10 mm: history of receiving bacille Calmette-Guerin vaccine (odds ratio [OR]: 2.31; 95% confidence interval [CI]: 1.70-3.13); household member with history of positive TST result or TB disease (OR: 1.53; 95% CI: 1.14-2.04); child born outside the United States (OR: 8.63; 95% CI: 6.16-12.09); child having lived outside the United States (OR: 2.06; 95% CI: 1.49-2.85); and race/ ethnicity reported by parent as Asian (OR: 2.28; 95% CI: 1.59-3.27) or Hispanic (OR: 1.57; 95% CI: 1.09-2.26). Several factors were not statistically significant predictors of a positive TST result: age, sex, household annual income, household member infected with human immunodeficiency virus or who had stayed in a homeless shelter, and being an adopted or foster child. Overall sensitivity of the 9 main items on the questionnaire was 80.9%; when a subset of 4 of these questions plus the race/ethnicity questions were used, sensitivity of responses was 83.5%. Parents failed to recognize positive TST results at a rate of 9.9% (for the 10-mm cutoff) and 5.9% (at the 15-mm cutoff). Conclusion. A 5-question risk assessment questionnaire completed by parents can be used to accurately identify risk factors associated with TB infection in children. In our population, some risk factors suggested by the American Academy of Pediatrics could not be validated. Parents cannot be relied on to read TST results accurately. Screening for TB can be enabled by using a standardized, validated questionnaire to identify children who should be given tuberculin skin testing. Pediatrics 2001;107(4). URL: http://www.pediatrics.org/ cgi/content/full/107/4/e54; ethnic groups, mass screening, physicians' practice patterns, tuberculin test, tuberculosis, children, tuberculin screening, Mantoux test, targeted tuberculin testing.

ABBREVIATIONS. SIDS, sudden infant death syndrome; ECG, electrocardiogram. The good news is that the incidence of sudden infant death syndrome (SIDS) is steadily decreasing. Preliminary available US data reveal a [...]

Deafness from childhood is relatively common, with 1.3 per 1000 children affected,[1] but until recently the causes have been obscure. It is clear that mutations in many different genes can [...]

Universal screening of newborn infants for hearing loss will inaccurately label many children as impaired, increase the use of unnecessary diagnostic testing, and increase parental anxiety, despite clear evidence that it is cost-effective. Newborn screening for hearing loss is inexact, and as many as 90% of children labeled as impaired will in fact have normal hearing. As the prevalence of newborn hearing loss is low, attempts to use parental education and mass-media outreach should precede efforts to increase newborn testing., ABBREVIATIONS. NIH, National Institutes of Health; HRR, highrisk-register; ICN, intensive care nursery. Across the nation pediatricians are being importuned, and indeed propelled, to implement universal newborn hearing screening, despite a [...]

Children living in areas at low risk for lead exposure may still need to be tested. Researchers measured the amount of lead in blood samples from 738 children, 282 of whom lived in a high-risk area for lead exposure. Twelve percent of those in high-risk areas had elevated blood lead levels, compared to 3.5% of those in low-risk areas. State guidelines consisting of questions about exposure were effective in identifying children with elevated blood lead levels, even in the low-risk areas. These questions solicited information about when the child's home was built, whether it had been renovated, and other potential sources of lead., Objective. Beginning in 1995, Illinois law permitted targeted--as opposed to universal--blood lead screening in low-risk areas, which were defined by ZIP code characteristics. State guidelines recommended specific lead risk assessment questions to use when targeting screening. This study was designed to evaluate the sensitivity and specificity of Illinois lead risk assessment questions. Design. Parents bringing their 9- or 10- or 12-month and 24-month-old children for health supervision visits at 13 pediatric practices and parents of children (aged 6 through 25 months and who needed a blood lead test) receiving care at 5 local health departments completed a lead risk assessment questionnaire concerning their child. Children had venous or capillary blood lead testing. Venous confirmation results of children with a capillary level [is greater than or equal to] l0 [micro]g/dL were used in analyses. Children. There were 460 children with both blood and questionnaire data recruited at the pediatric practices (58% of eligible) and 285 children (51% of eligible) recruited at local health departments. Of the 745 children studied, 738 provided a ZIP code that allowed their residence to be categorized as in a low-risk (n = 456) or high-risk (n = 282) area. Results. Sixteen children (3.5%) living in low-risk areas versus 34 children (12.1%) living in high-risk areas had a venous blood lead level (BLL) [is greater than or equal to] 10 [micro]g/dL; 1.8% and 5.3%, respectively, had a venous BLL [is greater than or equal to] 15 [micro]g/dL. For children living in low-risk areas, Illinois mandated risk assessment questions (concerning ever resided in home built before 1960, exposure to renovation, and exposure to adult with a job or hobby involving lead) had a combined sensitivity of .75 for levels [is greater than or equal to] 10 [micro]g/dL and .88 for levels [is greater than or equal to] 15 [micro]g/dL; specificity was .39 and .39, respectively. The sensitivity of these questions was similar among children from high-risk areas; specificity decreased to .27 and .28, for BLLs [is greater than or equal to] 10 [micro]g/dL and [is greater than or equal to] 15 [micro]g/dL, respectively. The combination of items requiring respondents to list house age (built before 1950 considered high risk) and indicate exposure to renovation had a sensitivity among children from low-risk areas of .62 for BLLs [is greater than or equal to] 10 [micro]g/dL with specificity of .57; sensitivity and specificity among high-risk area children were .82 and .36, respectively. For this strategy, similar sensitivities and specificities for low and high-risk areas were found for BLLs [is greater than or equal to] 15 [micro]g/dL. Conclusions. The Illinois lead risk assessment questions identified most children with an elevated BLL. Using these questions, the majority of Illinois children in low-risk areas will continue to need a blood lead test. This first example of a statewide screening strategy using ZIP code risk designation and risk assessment questions will need further refinement to limit numbers of children tested. In the interim, this strategy is a logical next step after universal screening. Pediatrics 1999;103:100-106; blood lead level, blood lead screening., ABBREVIATIONS. IDPH, Illinois Department of Public Health; CDC, Centers for Disease Control and Prevention; LHD, local health departments; IDPHL, Illinois Department of Public Health Laboratory; BLL, blood lead level; WIC, [...]