The Healthy Kids Check — is it evidence-based?

The Healthy Kids Check (HKC), introduced by the Australian Government into the Enhanced Primary Care Program in July 2008, continues the trend of illness prevention and improved coordination of care through services that attract Medicare Benefits Schedule rebates. It targets every 4-year-old child in Australia for a basic health check before commencing school, to “promote early detection of lifestyle risk factors, delayed development and illness, and introduce guidance for healthy lifestyles and early intervention strategies”.1

Medical practitioners and practice nurses can administer the HKC, with a Medicare rebate for the service being contingent on completing the vaccinations for 4-year-olds.2 Six areas of health must be examined as part of the HKC (Box 1), some of which contain a number of components. Additional examinations may be completed at the discretion of the practitioner.

We aimed to determine whether the mandatory assessments within the HKC are supported by evidence-based clinical guidelines or systematic reviews.

We performed a search of databases and websites (Box 2) for clinical practice guidelines and systematic reviews published between January 2000 and October 2008. Search terms included “child health”, “prevention”, “screening”, and health topics reflecting the mandatory components of the HKC.

Guidelines and systematic reviews were included if they were published in English, considered children of preschool age, and were relevant to practitioners in primary care. The topic “immunisation” and guidelines adapted from other primary guideline sources were excluded.

For each component of the HKC, guidelines were extracted if they addressed the presumed rationale for screening or the test or tool required to implement the examination in the primary care setting. Guideline recommendations are often graded to reflect the best available evidence, but the method used for this is not consistent between guideline developers. For the purposes of this review, statements were considered to be “evidence-based” if they incorporated evidence equivalent to National Health and Medical Research Council (NHMRC) level III-3 or above, and “consensus-based” if below this level.3

A total of 29 guidelines and five systematic reviews that contained statements relevant to the mandatory components of the HKC were retrieved.4-37 Guideline recommendations were tabulated according to whether they supported or opposed each HKC assessment (Box 3). Many guidelines identified gaps in the evidence and were unable to make a recommendation either for or against a particular screening examination. One guideline10 has since been withdrawn, at the end of 2009.

The mandatory assessment components of the HKC, although in line with health promotion and disease prevention primary care agendas, do not have a strong evidence base.

Stand-alone measures of height and weight do not confer health benefits for preschool children in screening programs,4,5 but are useful when translated into measures of body mass index (BMI) (weight [kg] divided by height squared [m2]). Guidelines consistently indicate that calculating BMI is a practical estimate of childhood overweight and obesity and should be documented on appropriate BMI percentile charts.5-13 The United States Centers for Disease Control and Prevention BMI-for-age percentile charts, which identify children at risk of overweight at a BMI above the 85th percentile (obesity, above 95th percentile), should be used until local BMI growth charts become available.12 The lack of effective treatment measures means that screening programs for childhood overweight and obesity remain controversial.4,5

Guidelines are contradictory in their recommendations for each component of vision screening. There is no direct evidence that screening for visual impairment, compared with no screening, leads to improved visual acuity.14,15 Despite this, preschool screening programs are strongly supported in the US,16-18 based on indirect evidence that screening tests are effective at detecting and allowing treatment for strabismus, amblyopia and refractive error.14,15 However, their application in primary care has not been established,15 and there is insufficient evidence to determine if screening and subsequent treatment reduce the prevalence of amblyopia in older children.19 Screening for eye infections or injury may only be appropriate in some Indigenous communities in Australia,38 and programs should be tailored accordingly.

How to assess a child’s hearing as part of the HKC is unclear, as hearing test options have not been adequately trialled for use in primary care.20 One guideline advocates inspection of the eardrums and direct questioning of the parent about problems with hearing or speech development.21 A review of the whispered voice test found it to be reasonably sensitive (80%–96%) and specific (90%–98%) in children, but the testing procedure requires standardisation in the primary care setting.22 In the US and United Kingdom, audiometry is the preferred screening method.20,21,23 Pneumatic otoscopy successfully identifies otitis media with effusion, but screening programs for non-Indigenous children are not supported by guidelines.4,24,25

There is currently insufficient evidence to recommend for or against oral health screening in preschool children.4 However, the rising prevalence of dental caries in young school-aged children is a major public health concern.39 Evidence-based guidelines do not currently support general practitioners implementing caries risk assessments26,27 (clinical evaluation of the teeth and gums for plaque, gingivitis and decayed or missing teeth), and there is debate as to whether they should be trained to do so,28 or if this should be confined to dental practice.26 There is also insufficient evidence that referring children to the dentist and dietary counselling by GPs improves oral health.26 However, guidelines are consistent in recommending assessment of a child’s exposure to fluoride in drinking water29 or toothpaste, with good evidence for the benefits of brushing teeth twice daily with fluoride toothpaste.26,29,30

The evidence indicates that screening for problems with toileting at 4 years of age is inappropriate and should be removed from the HKC. Guidelines do not recommend assessment of enuresis until a child is at least 5 years old.31-33 A fifth of normal 5-year-olds still experience nocturnal enuresis.40 Screening for constipation and encopresis is not addressed in guidelines, except in association with enuresis.

Identifying children at risk of anaphylaxis and their subsequent management is an important step towards preventing food anaphylactic reactions in schools. This recommendation is derived from a consensus-based guideline,34 and recent Victorian legislation enforces it.41 Re-evaluating patients with suspected food allergy is also supported by guidelines to avoid unnecessary dietary restrictions, as many nutritionally important food allergies are outgrown.35,36 The assessment of other allergies is not addressed by guidelines, other than an evidence-based recommendation that referral to an allergist–immunologist may improve outcomes for children with allergic rhinitis and eczema.37

By filling a gap between maternal and child health nurse screening and examinations of selected children by school nursing services, the HKC has the potential to play a key role in childhood developmental surveillance, whereby professionals work with parents to detect specific problems over the course of time. However, despite the limitations of the search methods we used, the evidence behind the HKC is not compelling and its components are ill defined and lack rationale. The HKC could be refined to better reflect the available evidence. For example, guidelines that discussed fluoride exposure for oral health were based on high levels of evidence, and information on a child’s exposure to fluoride should be sought. On the other hand, screening for chronic otitis media and questioning about toilet habits are not supported by evidence and should be removed from the HKC.

Guidelines are also inconsistent in their recommendations. Most of the components of the HKC are not supported by evidence-based guidelines relevant to primary care, though a number of consensus-based guidelines are supportive. Some components of the eyesight check, hearing tests and the use of caries risk-assessment tools have not been validated in the general practice setting.15,22,27

This review attempted to identify guidelines that support the assessment tasks of the HKC. It did not include a formal review of the quality of those guidelines because the subject matter covered by the HKC is so diverse. Guideline quality may also account for inconsistency between recommendations, and further research could incorporate such a review.

Appraisal of guidelines that endorse the non-mandatory components of the HKC and that identify other useful preventive health measures is required. The uptake and utilisation of the HKC, and its perceived usefulness by health care providers and parents, could inform the program as a whole. Longer-term evaluation should ascertain how well parents comply with follow-up recommendations and the program’s impact on health outcomes.