Rationale for Periodic Reporting on the Use of Selected Clinical Preventive Services to Improve the Health of Infants, Children, and Adolescents — United States

Lorraine F. Yeung, MD1

Stuart K. Shapira, MD, PhD2

Ralph J. Coates, PhD3

Frederic E. Shaw, MD, JD4

Cynthia A. Moore, MD, PhD1

Coleen A. Boyle, PhD2

Stephen B. Thacker, MD5*

1Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, CDC

2Office of the Director, National Center on Birth Defects and Developmental Disabilities, CDC

3Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology, and Laboratory Services, CDC

4Office of Health System Collaboration, Office of the Associate Director for Policy, CDC

5Office of the Director, Office of Surveillance, Epidemiology, and Laboratory Services, CDC

*Deceased

Corresponding author: Lorraine F. Yeung, Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, CDC. Telephone: 404-498-3824; E-mail: lyeung@cdc.gov.

Summary

This supplement is the second of a series of periodic reports from a CDC initiative to monitor and report on the use of a set of selected clinical preventive services in the U.S. population in the context of recent national initiatives to improve access to and use of such services. Increasing the use of these services can result in substantial reductions in the burden of illness, death, and disability and lower treatment costs. This supplement focuses on services to improve the health of U.S. infants, children, and adolescents. The majority of clinical preventive services for infants, children, and adolescents are provided by the health-care sector. Public health agencies play important roles in increasing the use of these services by identifying and implementing policies that are effective in increasing use of the services and by collaborating with stakeholders to conduct programs to improve use. Recent health-reform initiatives, including efforts to increase the accessibility and affordability of preventive services, fund community prevention programs, and improve the use of health information technologies, offer opportunities to improve use of preventive services. This supplement, which follows a previous report on adult services, provides baseline information on the use of a set of selected clinical preventive services to improve the health of infants, children, and adolescents before implementation of these recent initiatives and discusses opportunities to increase the use of such services. This information can help public health practitioners, in collaboration with other stakeholders that have key roles in improving infant, child, and adolescent health (e.g., parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations), understand the potential benefits of the recommended services, address the problem of underuse, and identify opportunities to apply effective strategies to improve use and foster accountability among stakeholders.

Introduction

Children have distinct health-care needs that are different than those of adults. They undergo rapid and constant physical, physiological, and developmental changes from infancy through adolescence. Their unique health needs in various life stages of development present different opportunities for health-care providers to offer clinical preventive services that can improve the health of infants, children, and adolescents and promote healthy lifestyles to increase the opportunity for all children to achieve their full potential.

During infancy, newborn bloodspot and hearing screenings and continuous developmental screening are vital for early detection of many chronic conditions, including some genetic disorders. Injury prevention and vaccination, two clinical preventive services that also occur during infancy and continue through adolescence, are important to protect against acute conditions that could lead to injury, illness, disability, and death.

During early and middle childhood, major chronic disease risk factors begin to emerge. Identification of these risk factors, including those associated with adult conditions (e.g., hypertension and hyperlipidemia), can help minimize progression of diseases that might persist into adulthood and can protect children from adverse health outcomes later in life. Provision of clinical preventive services such as vision screening, lead screening, blood pressure screening, lipid screening, obesity screening, and oral health services, are crucial during this period.

During adolescence, provision of clinical reproductive health services, screening for risky behaviors (e.g., tobacco, alcohol, and drug use), identification of potential negative consequences of risky behaviors (e.g., sexually transmitted infections and unintended pregnancy), and provision of interventions to mitigate such outcomes are essential services that improve the health of adolescents. Instilling healthy behaviors in adolescents provides benefits as they enter adulthood and sets the course for a healthy next generation as they themselves become parents.

Early screening and prevention of diseases and disorders during critical stages of development are the fundamentals of clinical preventive services in infants, children, and adolescents. Because child health care relies on active participation by parents, guardians, or other adults, in addition to health-care providers and public health practitioners, the provision of clinical preventive services to children requires a coordinated effort. Because of the years of potential healthy life lost with inaction, intervening with clinical preventive services in childhood can yield substantial long-term benefits (1). Optimizing the use of available and effective clinical preventive services in childhood and adolescence is a public health priority (2–5), and it lays the groundwork for a healthy trajectory into adulthood (6,7).

Clinical Preventive Services

Preventive services delivered by health-care providers in clinical settings encompass multiple goals: preventing the onset or progression of various physical, physiological, and mental health problems through screening, use of preventive medications, and vaccinations and providing information for making good health decisions (8). Interest in preventive services for children and adolescents resulted in formal practice guidelines for infants, children, and adolescents in the 1980s, such as those found in the Guide to Clinical Preventive Services (8). Additional formal practice guidelines for adolescents, known as the Guidelines for Adolescent Preventive Services (GAPS) by the American Medical Association (AMA), were published in the 1990s (9,10), as well as the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, which was first introduced in 1994 and supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau, and the American Academy of Pediatrics (AAP) (11). Various professional organizations (e.g., AAP and the American Academy of Family Physicians [AAFP]) develop condition-specific guidelines and recommendations as needed using an evidence-based process (12–14). Additionally, the U.S. Preventive Services Task Force (USPSTF) (15), the Advisory Committee on Immunization Practices (ACIP) (16), the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (DACHDNC) (17), and other committees (18) make recommendations for clinical preventive services applicable to infants, children, and adolescents.

Certain clinical preventive services guidelines for infants, children, and adolescents are consistent among advisory groups because they are often collaboratively prepared or jointly recommended, such as the collective approval of child and adolescent immunization schedules by ACIP, AAP, AAFP, and the American College of Obstetricians and Gynecologists (19). However, other clinical preventive services guidelines for infants, children, and adolescents differ between professional societies or advisory groups. For example, differences exist in screening recommendations between those of USPSTF and Bright Futures, particularly for school-aged children and adolescents, for depression, dyslipidemia, hearing problems, hypertension, testicular cancer, and vision problems (20). Additional differences exist in recommendations for screening and counseling for high-risk behaviors (e.g., tobacco, alcohol, and drug use) and for addressing sexual activity and sexually transmitted infections (21). These differences typically occur because professional society guidelines often are developed to inform the needs of current clinical practice and might include expert opinion rather than relying solely on evidence-based review.

Even when there are specific guidelines and recommendations from advisory groups and professional societies, substantial opportunities remain to improve uptake and use of the clinical preventive service. For example, although the level of vaccine coverage among children aged 4–6 years is generally high (≥90% [22)]), this level is below the Healthy People 2020 target of ≥95%, and coverage for some vaccines remain relatively low. For example, vaccination coverage for tetanus, diphtheria, acellular pertussis vaccine and the meningococcal conjugate vaccine in 2011 among adolescents aged 13–17 years was 78.2% and 70.5%, respectively (23). The challenge is even greater for other health indicators where screening and intervention could substantially improve child and adolescent health. For example, 18.1% of U.S. high school students in 2011 were current cigarette smokers (i.e., smoked cigarettes on at least 1 day during the 30 days before the survey) and, among these, 49.9% had tried to quit during the preceding 12 months (24); however, this percentage is well below the Healthy People 2020 tobacco use objective of 64% for the proportion of adolescent smokers in grades 9–12 with a past year quit attempt (25). Similarly, 42% of children aged 2–11 years have dental caries in their primary teeth, and 59% of adolescents aged 12–19 years have dental caries in their permanent teeth. However, the percentage of children using dental care is suboptimal (e.g., <50% of children aged 2–5 years visited a dentist during the preceding year) (26).

Provision of clinical preventive services for adolescents presents additional challenges not typically encountered for younger children. Potential adolescent health problems include the use of tobacco, alcohol, and drugs; unintended injuries, violence, and suicide; sexually transmitted infections; and unintended pregnancy. Although many adolescent health problems and approximately 75% of the causes of adolescent mortality (i.e., motor vehicle accidents, homicide, and suicide) are potentially preventable (27), many preventive services recommendations lack sufficient evidence of effectiveness (28). Successes in achieving targeted reductions in these risky behaviors or outcomes in the United States have been mixed (29,30). Success at screening and counseling for high-risk behaviors is hindered by the fact that these are typically sensitive health-compromising behaviors that require discussion in a confidential environment (31–34), and some states include limitations on the types of care and/or counseling that can be provided to children and adolescents (35). Despite the dissemination of guidelines, frequency of service delivery is relatively low for adolescent clinical preventive services with good evidence of effectiveness (28), which occurs in both private practice and community-based settings and in managed care organizations (36–39). Barriers to guideline implementation include physician knowledge and attitudes (40,41) and constraints on the amount of time health-care providers have available for comprehensive preventive health screening and counseling (33,42). Despite these barriers, provision of effective training, tools, and resources can increase preventive screening and counseling of adolescents across multiple risky health behaviors (43,44).

A recent study evaluated the evidence of effectiveness of clinical preventive services in relation to the clinically preventable burden (CPB), defined as quality-adjusted life years (QALYs), that could be gained if the services were delivered at recommended intervals to four million persons in the United States from birth, and cost effectiveness (CE), defined as the incremental net cost per QALY gained in typical practice by offering the clinical preventive service to the same target population of four million persons when compared with not offering the clinical preventive service (45,46). The study included a scoring system for making distinctions among clinical preventive services without overstating the precision of the CPB and CE estimates. Services were sorted in descending order by the CPB base-case estimates and in ascending order by the base-case incremental cost effectiveness ratios (ICERs). Services were then divided into quintiles so that services with the highest CBP were assigned a CPB score of five and those with the lowest ICERs were assigned a CE score of five. Scores for CPB and CE were added such that the total possible score was between two and 10. The majority of the 25 clinical preventive services evaluated in this manner were not applicable to infants, children, and adolescents. However, among the four applicable services, a high score of 10 was achieved for vaccinating children, a score of six (CPB and CE scores of two and four, respectively) was achieved for screening women aged <25 years for chlamydia and screening children aged <5 years for visual impairments, and a score of four (CPB and CE scores of one and three, respectively) was achieved for injury prevention counseling for parents of children aged <5 years (45). A follow-up study evaluated whether clinical preventive services saved money. For childhood vaccination, 1,233 life years were saved per 10,000 persons per year of intervention with a substantial annual net medical cost savings of $2.67 million (2006 dollars) for 10,000 persons receiving the intervention. For both chlamydia and childhood vision screening, even though the life years saved per 10,000 persons per year of intervention was zero, and increasing use to 90% was not predicted to produce a net medical savings, these clinical preventive services were determined to be cost effective (CE range, defined as dollar per QALY saved, discounted: >$0–<$14,000) for each (1,45). Although there are extremely favorable effects of childhood vaccination and high cost effectiveness for chlamydia and childhood vision screenings, the lack of published data on the effectiveness and value of many clinical preventive services for children and adolescents indicates the need for more research in this area.

Role of Public Health in Clinical Preventive Services

Because of their focus on population health, public health agencies had and will continue to have important roles in increasing use of recommended clinical preventive services (47–52). Two long-standing roles for public health are developing policies and practices to improve individual and community health and ensuring provision of health care when it is not otherwise available (49–51). For example, federally supported panels make policy recommendations for a range of clinical preventive services including newborn screening (17); hearing screening (53); lead screening (54); prevention and control of caries using fluoride (55); vaccinations of children and adults (56, 57); and counseling, screening, and prevention of human immunodeficiency virus (HIV) and sexually transmitted infections (58,59). In addition, public health agencies improve access to clinical preventive services to the broader population by providing services directly; funding the delivery of services through nonprofit community public health clinics, school-based health centers, community organizations, or private practices; and providing selected services in nontraditional settings (60–62). For example, there are approximately 2,000 school-based health centers in the United States (63), each of which is a partnership between the school and a community-health organization. The HRSA Health Center Program provides funding to approximately 20% of these health centers (63). Other sources of funding include state government, private foundations, sponsored organizations, and school districts. Services typically provided at these health centers include primary medical care, mental/behavioral health care, dental/oral health care, health education and promotion, substance abuse counseling, case management, and nutrition education; however, the specific services provided at each center vary based on community needs and resources (63).

Another important role of public health is identifying community preventive services (e.g., policies, laws, programs and initiatives, education programs, and health system interventions) that are effective in increasing use of clinical preventive services (48,51). To support this function, in 1996, the U.S. Department of Health and Human Services established the Community Preventive Services Task Force (CPSTF) to examine the effectiveness of a range of community preventive services. CPSTF conducts systematic literature reviews to evaluate evidence and uses explicit criteria and procedures to make recommendations (48). Among the community preventive services reviewed and recommended by CPSTF are policy and health system interventions that facilitate the delivery of clinical preventive services through reduction of patients' out-of-pocket costs, reducing barriers to access, and using patient tracking systems to identify eligible patients and provide decision support. For example, CPSTF recommends reducing client out-of-pocket costs for vaccination; increasing vaccination rates through home visits; establishing vaccination programs in schools, organized child care centers, and the special supplemental nutrition program for women, infants and children settings; providing client or family incentive rewards for vaccination; and establishing client reminder and recall systems. In addition, CPSTF recommends ongoing surveillance to monitor, evaluate, and report on performance in the use of clinical preventive services, which is an effective and important means of increasing service delivery by clinicians and health plans (48). CPSTF also reviews and makes recommendations about policy changes, public health education programs, school-based policies and programs, and changes in the physical and social environment to promote use of clinical preventive services and healthy behaviors (e.g., tobacco avoidance, physical activity programs in schools, behavioral interventions to reduce screen time to improve weight-related outcomes, and use of child safety seats and safety belts) (64).

Public health agencies also collaborate with other stakeholders to implement effective community interventions to increase use of clinical preventive services among infants, children, and adolescents. Population health is affected not only by services provided by the health-care system and public health agencies but also by the activities of private and voluntary organizations, employers, health plans, and other stakeholders (49–52). Each stakeholder can implement interventions to increase use of clinical preventive services. CDC has played a leading role in collaborating with stakeholders at the national level and in supporting state and local public health agencies to develop community coalitions to engage in prevention and control programs, including, but not limited to, increasing implementation of interventions recommended by CPSTF (58,65–67). For example, CDC and its parent department, the U.S. Department of Health and Human Services, convened work groups of fluoride experts to develop recommendations for using fluoride to prevent and control caries (55,68). In addition, CDC convened an expert work group to review and update the recommendations for school-based dental sealant programs (69). CDC staff also served as members of panels sponsored by the American Dental Association Council on Scientific Affairs and collaborated with CPSTF to develop an evidence review for the prevention and control of dental caries in children (70).

Finally, to help other stakeholders plan effective collaborations, public health has a role in monitoring, evaluating, and reporting on progress among communities and stakeholders in increasing use of recommended clinical preventive services (52,71). Examples of such surveillance include CDC-funded Early Hearing Detection and Intervention programs, which help ensure that infants are screened for hearing loss and receive recommended follow-up through active tracking, surveillance, and coordination with clinical service providers and families (72). To promote accountability among stakeholders responsible for population health, public health authorities will need to develop additional performance-measurement systems that track specific, effective actions by stakeholders (e.g., use of parent/patient tracking and reminder systems for clinical preventive services) as well as benchmark measures of key health outcomes (e.g., the proportion of children with genetic disorders or sensory problems identified during the newborn period) and systems to track use of resources and costs (52,71).

Opportunities Offered by Recent Changes to the U.S. Health-Care System

Ongoing changes in the U.S. health-care system offer opportunities to improve the use of clinical preventive services among infants, children, and adolescents. The Patient Protection and Affordable Care Act of 2010 (as amended by the Health Care and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (73–77). The goal of the law is to have the states expand Medicaid to cover persons with incomes up to 138% of the federal poverty level (FPL) (ACA § 2001). State Medicaid programs are required to cover children aged 0–6 years with family incomes up to 133% of FPL and children aged 6–18 years with family incomes up to 100% of FPL. The Children's Health Insurance Program (CHIP) offers health insurance coverage for some children depending on the income eligibility levels set by each state. ACA extends authorization for CHIP through 2019 and CHIP funding through 2015. The law also provides up to a 23 percentage point increase in the federal medical assistance percentage (FMAP) used to determine federal support to states for their CHIP program from October 2015 through September 2019 (ACA § 2101). Starting in 2014, the law also extends Medicaid coverage to children aged <26 years who were in foster care when they became 18 years old (ACA § 2004). Finally, the law requires that states maintain current income eligibility levels for children in Medicaid and CHIP through September 30, 2019 (ACA § 2001).

The U.S. Supreme Court determined in National Federation of Independent Business v. Sebelius that the states are not required to expand their Medicaid programs. But the law incentivizes Medicaid expansion in the states by covering nearly all the costs for the newly Medicaid eligible. Approximately half of states plan to expand their Medicaid programs, resulting in an estimated 12 million new Medicaid enrollees by 2019 (78,79). States that have not yet chosen to expand their Medicaid programs can do so at any time and still benefit from substantial federal funding.

As of September 23, 2010, Section 1001 of the ACA requires that new (or "nongrandfathered") group or individual private health plans provide coverage for four categories of clinical preventive services, with no cost-sharing for 1) services graded A (strongly recommended) or B (recommended) by USPSTF; 2) vaccinations recommended by ACIP; 3) services adopted for infants, children, and adolescents under the Bright Futures guidelines supported by HRSA and AAP and those developed by the DACHDNC; and 4) women's preventive services as provided in comprehensive guidelines supported by HRSA (ACA § 1001). Under regulations adopted by the U.S. Department of Health and Human Services, states that expand their Medicaid programs must offer these four types of services to enrollees in expanded Medicaid (80). Also, the law provides a one percentage point increase in FMAP for states that cover with no cost-sharing for all Medicaid beneficiaries all of the recommended preventive services graded A or B by USPSTF and vaccinations recommended by ACIP (ACA § 4106). Several provisions in ACA also promote clinical recommended preventive services in persons who receive benefits from Medicare (81).

The Health Insurance Marketplace (or Health Insurance Exchange) began providing access to private health insurance for small employers and to persons and families interested in exploring their options for coverage, with policies taking effect as early as January 2014.† Federal tax credits are available on a sliding scale to assist eligible persons living at 100%–400% of FPL who purchase health insurance through the Marketplace (ACA § 1401). All qualified plans in the Marketplace are required to offer a package of essential health benefits, which must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care (ACA § 1302). On the basis of a state-selected benchmark plan, each state determines the specific evidence-based clinical services that will be included in their essential health benefit package given these required categories.

ACA also expands consumer protections by guaranteeing the issuance of insurance, ending denials of coverage for preexisting conditions, prohibiting rescission (dropping coverage) and lifetime coverage limits, and ensuring emergency care can be sought at an out-of-network hospital without prior approval of a person's health plan (ACA § 1001). This protection has important implications for children with chronic conditions, including many of those identified through one-time and periodic clinical preventive services (e.g., newborn, sensory, and developmental screening). The law expands access to primary care providers by making substantial investments in the primary care workforce through recruitment and retention programs, including loan repayment (ACA § 5204), and training for primary care professions (ACA § 5301). The law encourages coordinated care for infants, children, and adolescents through the Medicaid Pediatric Accountable Care Organization Demonstration Project (ACA § 2706). In addition, the law provides for prevention outside of the clinical setting, for example, by creating and providing funding for the Prevention and Public Health Fund, with the goals of enabling communities to prevent the leading causes of death, strengthening state and local disease detection and response, and producing information for action (ACA § 4002).

ACA also includes the National Prevention Strategy, a comprehensive plan created by the National Prevention Council in consultation with the public and an advisory group of nonfederal experts. The National Prevention Strategy aims to improve public health by helping to create healthy and safe communities, expand clinical and community-based preventive services, empower persons to make healthy choices, and eliminate health disparities (ACA § 4001). The National Prevention Strategy has identified seven priority areas with evidence-based recommendations. These priorities include recommendations to improve infant, child, and adolescent health: providing effective sexual health education, especially for adolescents and enhancing early detection of HIV, viral hepatitis, and other sexually transmitted infections and improving linkage to care (priority: reproductive and sexual health); expanding use of tobacco cessation services (priority: tobacco-free living); supporting policies and programs that promote breastfeeding (priority: healthy eating); creating environments that empower young persons not to drink or use other drugs, and identifying alcohol and other drug abuse disorders early and providing brief intervention, referral, and treatment (priority: preventing drug abuse and excessive alcohol use); promoting and strengthening school and early learning policies and programs that increase physical activity (priority: active living); implementing and strengthening policies and programs to enhance transportation safety (priority: injury- and violence-free living); and promoting positive early childhood development, including positive parenting and violence-free homes (priority: mental and emotional well-being) (82).

About This Surveillance Supplement

This surveillance supplement is the second of a series of periodic reports from CDC to monitor and report on progress made in increasing the use of clinical preventive services to improve population health. This supplement focuses on the use of selected services to improve the health of U.S. infants, children, and adolescents. The audience for the report is the broad range of stakeholders who shape the health of the U.S. infant, child, and adolescent population, including public health practitioners, parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations. Before selecting a limited set of clinical preventive services to include in this report, CDC considered a wide range of services linked to the prevention or control of a specific condition or disorder. For example, CDC considered the set of clinical preventive services for infants, children, and adolescents that were identified by ACA and that have been evaluated and recommended by various Federal advisory or guideline development committees (73). Also reviewed were clinical preventive services in the Bright Futures/AAP Periodicity Schedule (11) and clinical preventive services relevant to infants, children, and adolescents in areas of public health identified by CDC as priorities, including newborn and developmental screening, vaccinations, motor-vehicle injuries, obesity/nutrition/physical activity, teen pregnancy, and tobacco use (83).

To select indicators important to the public, stakeholders, and policy makers, CDC identified a set of clinical preventive services that 1) are important in helping to decrease childhood illness, injury, or disability across the developmental spectrum from infancy to late adolescence; 2) are underused but have the potential for substantial increases in use over the next few years with focused effort; 3) have important effects on infant, child, and adolescent health, as measured by potential healthy life years gained (1,45); 4) are priorities of CDC public health programs and the coalitions of stakeholders; and 5) have routinely collected nationally representative surveillance data available for measurement. Also considered was whether the same or similar indicators were used by other national efforts to monitor and promote progress in use of clinical preventive services, including Healthy People 2020, the National Quality Forum, and the National Committee for Quality Assurance (84–86).

Using these criteria, CDC initiated an iterative process to develop the final list of indicators. A work group that included leaders from multiple CDC programs was formed to develop a proposal; the proposal was then reviewed in more detail by experts from a broader set of CDC programs. A revised proposal was developed and approved by CDC.

Clinical Preventive Services Indicators

The indicators included in this supplement address the clinical preventive services that not only are important in various life stages of development in infants, children, and adolescents, but also have surveillance data available for measurement: prenatal period (breastfeeding counseling); infancy (hearing screening and follow-up and developmental screening); early and middle childhood (lead screening, vision screening, hypertension screening, and provision of dental care and preventive dental services); and adolescence (human papillomavirus vaccination, tobacco use screening and cessation assistance, chlamydia screening, and provision of reproductive health services) (Table). Several of the indicators are for services recommended by USPSTF, ACIP, DACHDNC, and Bright Futures, but others also are included. The indicators measure use of clinical preventive services that have been demonstrated to be underused and that, if increased over the next few years, could substantially improve the health of U.S. infants, children, and adolescents. Improvement in the use of the services described in this surveillance supplement is also a focus of public health and community programs as well as national health-care quality improvement efforts.

Services for pregnant women were initially included for consideration in this supplement, but because of the large number of clinical preventive services recommended for infants, children, and adolescents combined, and recognizing that the set of stakeholders and surveillance systems for child and adolescent services differ somewhat from those for pregnant women's services, CDC decided to limit the scope of this supplement to infant, child, and adolescent services and only included one service for pregnant women that is most relevant for the infant and child time frame (i.e., breastfeeding counseling).

For multiple reasons, certain important services for infants, children, and adolescents were not included. For example:

• DACHDNC has a Recommended Universal [newborn] Screening Panel of 31 conditions, including 29 conditions identified from laboratory analysis of the newborn blood spot, hearing loss identified from select audiologic screening technologies, and critical congenital heart disorders identified from pulse oximetry screening (87). Only newborn hearing screening is included in this report because it is the one component of newborn screening that has a national surveillance and tracking system for monitoring implementation.
• USPSTF does not have recommendations for childhood injury prevention except for the determinations that evidence is insufficient to assess 1) the incremental benefit, beyond the efficacy of legislation and community-based interventions, of counseling in the primary care setting, in improving rates of proper use of motor vehicle occupant restraints children and adolescents and 2) the balance of benefits and harms of primary care interventions to prevent child maltreatment among children without signs or symptoms of maltreatment (15).
• Screening for obesity and alcohol are recommended by USPSTF (15), but surveillance data were not available for adequate indicators.
• Screening for depression in adolescents was not included because surveillance systems do not have information on the ability of clinician practices to provide effective supportive care for depression. USPSTF recommends depression screening in children and adolescents only when staff-assisted depression care supports are available to assure accurate diagnosis, effective treatment, and follow-up (15).
• Screening for dyslipidemia in children aged ≥9 years and for those at high risk was not included because no surveillance data were available.

Additionally, universal influenza vaccination and vaccination for other diseases in infants, children, and adolescents have been recommended by ACIP and have a complimentary surveillance system, but are extensively covered in other periodic CDC publications (23,88–91). Finally, HIV screening in adolescents was addressed in the adult supplement (92).

Use of This Report

Several uses for the type of information provided in this supplement were outlined in the 2011 Institute of Medicine report on the role of measurement in action and accountability in public health (52). The reports in this supplement provide the public and stakeholders responsible for infant, child, and adolescent health (e.g., public health practitioners, parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) with easily understood and transparent information about the use of selected clinical preventive services that can improve the health of infants, children, and adolescents. Stakeholders can use this information to increase use of these services and promote responsibility and accountability among partners for implementing effective strategies to increase use. In addition, publication of this information on a diverse set of selected services for infants, children, and adolescents will increase awareness and offer the opportunity for stakeholders to reduce the burden of illness and disability by coordinating efforts when appropriate to increase use of these preventive services for all U.S. infants, children, and adolescents.

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