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Hearing

Hearing Screenings

Hearing screening is mandated in public schools in Montana in grades K, 1, and either 9th or 10th grades. The Hearing Conservation Program, through the Montana Office of Public Instruction oversees the hearing screenings in schools, but it is up to the individual public school districts to take on the primary responsibility for conducting the screenings.

Screening of school-age children is the responsibility of the public school. The hearing screening is intended to identify those individuals in need of referral for evaluation and identification. The initial hearing screening is often the responsibility of the school nurse.

  • The Montana office of public instruction has laid out guidelines for the educational hearing conservation program. They state that the purpose of the hearing conservation program are as follows:
  • To identify children with educationally significant hearing losses through hearing screening, on-site audiology procedures, and comprehensive hearing evaluations;
  • To assist schools and parents in determining appropriate educational placement and intervention;
  • To serve as a consultant to school personnel, parents, and students regarding potential educational effects of an identified student's hearing impairment and the function of hearing aids and assistive listening devices;
  • To provide consultative services regarding hearing aids, cochlear implants, assistive listening devices, and, where appropriate, classroom acoustics; • To provide education, as needed, regarding the prevention of hearing loss; and
  • To provide follow-up support to children, families and schools.

Results of hearing screening program have shown that five to ten percent of the school age population do not pass audiometric tests. The majority of these children are in need of medical treatment. Such treatment may result in restoration of hearing and prevention of permanent hearing impairment. Approximately two percent will show permanent hearing impairment and will require special educational services. Communication is an integral part of human behavior. Seldom does one consider the implications of not being able to hear. The most serious effect of a hearing loss is the interference with and breakdown of communication between persons. In a child, some of the consequences may be: (a) Interference with normal speech and language development. (b) Development of abnormal social growth and behavior. (c) Interference with education and human potential. (d) Development of adjustment problems in the child and his/her family. (e) Isolationism in a hearing world.

A child’s behavior in the classroom may indicate the possibility of a hearing loss. The child may be inattentive, may ask for frequent repetitions, or his/her achievement may be low. The observation of such behavior will assist in identifying children in need of help and indicate the need to assess hearing levels.

ANATOMY AND PHYSIOLOGY OF THE EAR

The ear receives sound waves which are processed and transmitted to the hearing center in the brain for interpretation. The ear is divided into three parts: outer, middle, and inner. The outer ear consists of the auricle or pinna and external auditory canal. The auricle, or visible part of the ear, directs and concentrates the sound waves along the external ear canal to the tympanic membrane. The ear canal contains hairs and wax producing glands which serve to protect the eardrum from dirt, insects, or foreign matter. The tympanic membrane is a thin diaphragm which completely closes the end of the ear canal and separates the outer ear from the middle ear. The middle ear is a tiny, air-filled cavity between the eardrum and the bony wall of the inner ear and contains the three smallest bones, called ossicles. The first bone in the ossicular chain is the hammer (maleous) which is attached to the ear drum. The anvil (incus) fits between the hammer and the third bone, known as the stirrup (stapes). The footplate of the stapes is set in the window of the inner ear. A passage between the middle ear and the back of the nose (eustachian tube) serves as a means for equalizing air pressure and ventilating the middle ear cavity. The inner ear contains the sensory organ for balance (including the semicircular canals) as well as the organ for hearing known as the cochlea. The cochlea resembles a snail shell in appearance and is filled with fluid. Sound vibrations from the eardrum are transmitted through the ossicular chain to the oval window to the fluid in the cochlea. The sound sets in motion thousands of hair-like sensory cells in the cochlea called the Organ of Corti. These sensory cells transform fluid movements into electrical impulses and, by a series of complicated processes, transmit them to the auditory nerve to the brain, where they are perceived as sound.

“The school nurse must know and understand the anatomy and physiology of the ear if she/he is to understand the results of hearing tests. Interpretation of the findings of the hearing tests are often based on the structure and functioning of the ear and its many parts. It is easier for the teacher to understand the problem of a child with a hearing loss if the nurse will first explain the functioning of the ear, and then explain how the child’s problem relates to the functioning of the ear.” -National Association for School Nurses, Hearing Screening Guidelines

HEARING DISORDERS

“The two most common types of hearing loss found in school age children are sensorineural (permanent) losses, and conductive (not permanent) hearing loss. Sensorineural loss can result from inner ear defects; auditory nerve damage, or damage to the auditory center in the temporal lobe of the brain. Known causes of sensorineural losses include viral (especially measles and mumps) and bacterial infections; prolonged exposure to loud noises such as rock bands, gunfire, motorcycles, and power motors; ototoxicity; congenital abnormality; and head trauma. Treatment for these losses includes auditory training with amplification devices (hearing aids); and special habilitation, including speech reading (lipreading) and speech therapy.

Conductive hearing loss, which is the most common loss in children, results from a problem in the external ear canal, tympanic membrane, or middle ear cavity, interfering with the transmission of sound. Causes include: impacted earwax, foreign objects (beans, erasers, cotton, etc.) in the ear canal, otitis media, congenital abnormalities, and ruptured or scarred eardrums secondary to trauma or infection. Conductive losses can be mild or more severe, and are considered significant when they interfere with a child’s ability to communicate effectively. Many cases of conductive loss respond to medical or surgical treatment. However, these losses may fluctuate over time so that a pupil who is referred to a physician for follow-up may not be experiencing the loss at the time of medical evaluation. This is another strong argument for the necessity of rescreening before referring a pupil.”

Though the conduction of hearing screening and rescreening is the responsibility of the school, the hearing conservation program provides significant help to the school nurse in the following ways:

The Hearing Conservation Program provides training and technical assistance, comprehensive hearing evaluations, and follow-up technical assistance and support to schools and families in the event the child has a confirmed hearing loss. The audiologist under contract with the Hearing Conservation Program is available to the schools in the area for assistance in training screening personnel, interpreting screening results for referral, providing hearing evaluation following screening, participating in child find screenings, providing inservice training for teachers, counseling parents regarding hearing loss, participating in evaluation and individualized education program (IEP) team meetings, when appropriate, and the various other functions as time will allow.

Hearing Conservation Program 

Initial Screening

Initial Screening Screening personnel should perform a listening check of equipment prior to screening to assure that equipment is working and that the ambient noise will not preclude valid results. The room in each building that is the most quiet should be used for hearing screening with constant attention to changing noise levels throughout the day. The mandatory grades to be screened annually may be limited to grades Kindergarten (K), 1, and 9 or 10.

Pure tone air conduction screening for the school-age child must be conducted in each ear at the frequencies of:

1000 Hz, at 20 dB
2000 Hz  at 20 dB
4000 Hz, at 25 dB

Students who have a history of fluctuating hearing should be screened at the initial screening or by the area audiologist at a follow-up screening. Students with a known sensorineural hearing loss should not be screened at the initial screening, but should be monitored by the area audiologist during a school visit. The frequency of the monitoring will be determined by the area audiologist.

If a child fails the initial screening, he/she should be screened again in a quieter area on the same day if possible. Implementation of this procedure will help to reduce the number of over-referrals due to ambient noise levels.

Follow-Up Screening

Follow-up screening should not be done for one to three weeks after the initial screening except where distance is a factor and then it may be done on the same day as the initial screening. Follow-up screening should be accomplished by personnel with a thorough knowledge of screening procedures and the screening process (audiologist, audiology aide, nurse, speech-language pathologist or someone approved by the HCP audiologists, etc.). Additional screening procedures may be used when determined necessary by the audiologists or specifically trained audiology aide to determine the need for referral. These procedures may include otoscopy, tympanometry, acoustic reflex screening, otoacoustic emissions screening, and/or air conduction thresholds. Preventing over-referral or under-referral is the priority of a good screening program.

Tympanometry screening, utilizing noninvasive probe tips, is encouraged but not mandatory and may be performed by trained personnel for grades kindergarten and first, following careful visual inspection of the ear canal.

Screening of Preschool-Age Children

Preschool child find screenings are those organized by the public schools for the purpose of identifying preschool children, birth through five, who are not enrolled or provided services by the public school that may have a disability. The area 3 audiologist is expected to participate in this child find activity by conducting the hearing screening. Preschool hearing screening must be done by the area audiologist. This is generally accomplished with the assistance of another person. Children suspected of having a hearing impairment are referred for a hearing evaluation to determine the presence of a hearing impairment. Otoacoustic emissions and/or air conduction audiometry are an essential part of this screening and should be done whenever possible. The audiologist may include other screening methods as well, such as: otoscopy, tympanometry, and/or pure tone conduction audiometry (utilizing the same pass/fail criterion as for school-age testing). The methods used are typically dependent on the child's developmental age and other relevant factors as determined by the audiologist. Preschool-age children who did not participate in the preschool child find screening, but are referred later for hearing screening, may be referred to the audiologists for screening at the audiology clinic or the audiologist may elect to screen the child at the school, if feasible.

Management/Referral Following Screening/Rescreening

After the area audiologist has conducted and/or interpreted the results of a school follow-up screening or preschool screening, management decisions may include, but are not limited to the following as determined by the audiologist:

  • Recheck in one year (such as for borderline middle ear problems);
  • Periodic or annual monitoring (such as for chronic fluctuating hearing loss, child with ventilating tubes, or mild loss which is not educationally significant);
  • Follow-up screening after an upper respiratory infection or middle ear condition has had time to resolve; and
  • Referrals may include, but are not limited to: comprehensive audiological evaluation in the Hearing Conservation Program area audiology center, medical referral, or medical referral with follow-up screening or audiological evaluation.

Medical evaluations are performed by physicians and are essential for proper diagnosis and treatment of children suspected of having ear or vestibular disease. Medical services are not provided by the Hearing Conservation Program. If a child is referred by the audiologist for a medical evaluation or the audiologist recommends that a medical evaluation be conducted, it is the parent's decision whether the medical evaluation will be done. The parent is responsible for the cost of the medical evaluation. The role of the audiologist is one of referral and monitoring.

For any medical referral or referral for audiological evaluation, the family of the child will be notified by mail. The audiologist may also contact the family by phone or in person.

Audiological Evaluation

The purpose of a comprehensive hearing evaluation is to determine the degree and nature of hearing difficulty and to provide educationally relevant recommendations. The audiologic evaluation shall be performed by a fully or provisionally licensed audiologist. Written parent permission is required prior to conducting the evaluation. The HCP audiologist is expected to provide a timely and relevant report of the evaluation to the school, parent and/or referral source.

Effects of Hearing Loss Threshold Degree of Loss Effects

  • 15 to 30 db Mild (hard of hearing) Difficulty hearing faint or distant speech; may require hearing aid; needs preferential seating in classroom.
  • 30 to 50 db Moderate (hard of hearing) Difficulty hearing distant speech; requires amplification; preferential seating, auditory training, and probably speech therapy.
  • 50 to 70 db Moderate to severe Difficulty with conservation, unless loud; great difficulty in group/classroom discussion; requires hearing aid; may require special class for hard of hearing.
  • 70 to 90 db Severe (deaf) May hear loud voice close to ear; may hear some vowels, recognize some sounds in environment; needs special education for the deaf, with specific training in speech language.
  • Over 90 db Profound (deaf) May hear some loud sounds; does not rely on hearing for communication; requires special education for the deaf.

DIFFICULT TO TEST OR UNTESTABLE PUPILS
Pupils found to be difficult to test or untestable by pure tone audiometry because of inability to respond or understand instructions should have:

(a) An ear examination, using an otoscope, by the school physician, school nurse practitioner, or school audiologist.

(b) Teacher input regarding child’s performance in classroom.

(c) Gross testing procedures such as alerting (eye movement, head turn, facial expression) to noise maker, finger-snap, hand-clap, crinkling paper, voice, etc., when presented at varying loudness and distance from the ear and outside the child’s visual field and awareness.

(d) Parent input regarding child’s auditory awareness and responsiveness to voice, music, and sound in the home environment.

Preparation of the Pupil

The procedure for testing should be described and demonstrated briefly to the entire class or entire group. A suggested method of carrying this out is to present exaggerated tones from the audiometer and ask the children to respond by raising their hands when they hear the tone. Practice with a group will simplify the testing on individual children. Should a child be confused, it would be wise to demonstrate with one or two tones before starting to test. Another helpful suggestion is to have one or two children in the testing room while another is being tested. This will enable them to follow the example of the child being tested. The following instructions should be provided to each class to be tested: “You are going to have your hearing tested. You will hear sounds from the earphones. Some will be high-sounding and some will be low-sounding. Some will sound like whistles and some will sound like hums. When you hear the sound, no matter how soft or little it is, you are to raise your hand. Keep your hand up as long as you hear the sound, and put it down as soon as the sound goes away. When you hear a sound again, raise your hand again. Remember, no matter how soft the sound is, if you think you hear it, raise your hand.
 

Screening Forms

Primary School Screening Form: Vision-Hearing-BMI

Secondary School Screening Form: Vision-Hearing-BMI

References

http://www.chadphila.org/files/CHADassets/downloads/Hearing-Screening-Protocol.pdf

http://opi.mt.gov/pdf/speced/HearConservGuide.pdf



 

Dental

Dental Screening in Schools

Dental screening for school children in Montana is not mandated, though many districts choose to have their students participate in oral health screenings.

There is information on the DPHHS website concerning school dental screenings and how to conduct them and can be found at dphhs.mt.gov/publichealth/oralhealth/OHSchool-based.    

Scoliosis

Montana has no mandate concerning scoliosis screening. In fact, routine screening for scoliosis is a bit controversial and many states do not require this screening. Scoliosis is an appreciable lateral deviation of the normally straight vertical line of the spine or one or more lateral rotary curvatures of the spine. (see diagram below)

One can find studies that both support and discourage school screenings. Some studies show that screenings can catch students with idiopathic scoliosis and, if referred in a timely manner for further treatment, might prevent them from worsening   Other studies seem to indicate that routine screening in schools is not effective as the number of students screened is far too large to justify the few who might benefit from it, and there could be a danger of over-referral.

It is estimated that approximately 4% of school-age children will have a curvature of varying degrees. The effect of scoliosis depends upon its severity, how early it is detected, and how promptly it is treated. Rate of treatment is 2 per 1,000 children in the target age group. Early identification and management of scoliosis is the purpose of  a screening program.

Your school district may have a policy about screening students for scoliosis and if so, at what age they will be screened.  If your school district does have a policy requiring scoliosis screening, the following will be helpful in implementing the screening.

Preparation of Students for Screening

  1. Explanation of the screening procedure.
  2. Boys and girls should be screened separately.
  3. Boys should strip to the waist.
  4. Girls should wear a bra, bathing suit top, or halter under a blouse or sweater.
  5. Boys and girls should remove shoes.

Initial Screening

  1. A marked line should be placed on the floor. With toes on the line, each student will be viewed in both the erect standing and forward bend positions. The screener may wish to stand, or be seated, several feet from the line.
  2. With the student standing erect, feet together and arms hanging relaxed at sides, the screener scans the back for obvious abnormalities:
            a. Are the shoulders level?
            b. Are the hips level?
            c. Is one shoulder blade higher, or more prominent than the other?
            d. Are there unequal distances between the arms and the body?
            e. Does the spine appear curved?

(This data is not recorded, but is used as a guide).

3. The student now assumes the forward bend position, bending at the waist to 90°, with fingertips of the hands together.
    The screener observes for signs of a possible scoliosis:
             a. Rib hump on either side of the upper back – rib hump
             b. Rotational hump on either side of the lower back – lumbar rotation

4. The student should be viewed from both the front and the back standing and forward bend positions (see diagram ).

5. The screener observes for:
             a. Excessive prominence of thoracic spine; possible Kyphosis.
             b. Excessive sway back; possible Lordosis.
             c. Other orthopedic conditions.
             d. Prominence of sacrum or buttocks.

Second Screening (Rescreening)

All students who have positive findings shall be further screened by a more experienced screener prior to referral. It is important that an excess referral rate does not occur. In order to avoid the possibility of unnecessary referral, all students with positive findings in any part of the screening should be rescreened at a separate session.

Referral and Case Management

Following the re-screening program, those students with positive findings should be referred for a physician evaluation. A positive rib hump in the forward bend position is the major criteria for scoliosis referral (see Diagram ). The other observations made by the screener are merely supportive of the rib hump finding. In most cases, it will be helpful to speak with those students to allay their fears and encourage their cooperation. It will also be helpful to call each parent to describe the screening procedure and encourage physician evaluation.

Sample Parent Information Letters

Sample Scoliosis Screening Program: Parent Information Letter #1
Sample Scoliosis Screening Program: Parent Information Letter #2

Additional Resources

Scolionmeter for use with smart phone
http://www.scoliosis.org/store/scolioscreen.php 

Video to show kids before doing a scoliosis screening
https://www.youtube.com/watch?v=NRqiyqz7TXU 

 

BMI

The state of Montana has no state policy regarding BMI screening in public schools, though the administrative rule 37.111.825 - recommends that students be evaluated by registered professional nurses or other appropriately qualified health professionals on a periodic basis in order to identify those health problems which have the potential for interfering with learning, including: a) assessment of student’s health and developmental status, b )vision screening c) hearing screening d) scoliosis screening e)chemical and alcohol abuse f) nutritional screening and g) dental screening.  

CDC statistics on obesity and eating disorders 

  • Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years
  • The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.
  • In 2012, more than one third of children and adolescents were overweight or obese.
  • Overweight is defined as having excess body weight for a particular height from fat, muscle, bone, water, or a combination of these factors.
  • Obesity is defined as having excess body fat.
  • Overweight and obesity are the result of “caloric imbalance”—too few calories expended for the amount of calories consumed—and are affected by various genetic, behavioral, and environmental factors.

Immediate health effects

  • Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. In a population-based sample of 5- to 17-year-olds, 70% of obese youth had at least one risk factor for cardiovascular disease.
  • Obese adolescents are more likely to have prediabetes, a condition in which blood glucose levels indicate a high risk for development of diabetes.
  • Children and adolescents who are obese are at greater risk for bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem.

Long-term health effects

  • Children and adolescents who are obese are likely to be obese as adults and are therefore more at risk for adult health problems such as heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis.  One study showed that children who became obese as early as age 2 were more likely to be obese as adults.
  • Overweight and obesity are associated with increased risk for many types of cancer, including cancer of the breast, colon, endometrium, esophagus, kidney, pancreas, gall bladder, thyroid, ovary, cervix, and prostate, as well as multiple myeloma and Hodgkin’s lymphoma.

Prevention

  • Healthy lifestyle habits, including healthy eating and physical activity, can lower the risk of becoming obese and developing related diseases.
  • The dietary and physical activity behaviors of children and adolescents are influenced by many sectors of society, including families, communities, schools, child care settings, medical care providers, faith-based institutions, government agencies, the media, and the food and beverage industries and entertainment industries.
  • Schools play a particularly critical role by establishing a safe and supportive environment with policies and practices that support healthy behaviors. Schools also provide opportunities for students to learn about and practice healthy eating and physical activity behaviors.

Growth screening enables school health professionals to:

  • Monitor growth and development patterns of students.
  • Identify students who may be at nutritional risk or who may have a common nutritional problem
  • Notify parents/guardians of screening results with a recommendation to share findings with the student’s health care provider for further evaluation and intervention, if necessary.

Promoting Healthy Lifestyles

School health professionals may also take the lead in promoting healthy lifestyle behaviors by being a valued health resource to the school and the community. Nutrition is recognized as a critical factor in the promotion of health and the prevention of disease. Moderate malnutrition can have lasting effects on children’s cognitive development and school performance. When children are hungry or undernourished, they have difficulty resisting infection and therefore are more likely than other children to become sick, to miss school, and to fall behind in class. They are irritable and have difficulty concentrating; and they have low energy levels. Unhealthy eating patterns may result in under-nutrition, iron deficiency anemia, and overweight and obesity.

Eating disorders are increasingly prevalent. According to the CDC, a recent poll taken by high school aged children showed almost 15% of girls and 4% of boys scored at or above the threshold of 20 on the EAT-26, which indicated a possible eating disorder.

Disordered eating behaviors are closely associated with poor school achievement, lack of communication and caring within families, and “health-compromising behaviors” like drug abuse.

SCREENING PROCEDURE

Equipment 

  • Properly calibrated scale (balance beam, dial or digital)
    • Note: To maintain accuracy, scales should be periodically validated. Recalibrate as needed.
  • Device to measure height (stadiometer preferred)
    • A ruler or right angle (will help to assure accuracy)
  • Two gender-appropriate growth charts
    (Stature-for-Age Percentiles and Body Mass Index-for-Age Percentiles or Tool for determining BMI: CDC BMI Table for viewing or printing, found at: http://www.cdc.gov/nccdphp/dnpa/bmi/00binaries/bmi-tables.pdf)
  • BMI wheel (available from medical/school health catalogs.) / BMI calculator (available from medical/school health catalogs.)
  • Grades to be screened: Montana has no mandated grades to be screened

Procedure

Note: Students should be weighed and measured in a setting that provides privacy. Confidentiality is always important and care should be taken that findings are not accessible to other students or shared with staff. Students react in a variety of ways to being weighed and measured at school. Girls are most often concerned about being overweight regardless of their actual size. Boys worry about being short and too thin. During screening, neutral comments like “Kids bodies come in different sizes and shapes” are encouraged. Screeners should be prepared to be objective, calm and open to students’ concerns. Some students may need to meet with the school nurse at a later time to discuss their concerns.

Weight

  1. Students should be wearing light clothing (without shoes and jackets or coats). Have the student empty his/her pockets. (If the student must be weighed wearing a special device, such as a prosthesis, then this is noted when weight is recorded).
  2. Place the scale in the “zero” position before the child steps on the scale.
  3. Position the student with both feet in the center of the platform with his/her back to the scale.
  4. Read the measurement to the nearest ¼ pound and immediately document student’s weight in lb. or kg. (Reminder: 2.2 pounds is equal to 1 kilogram)
  5. The graphing of this measurement is neither necessary nor required because weight alone is not used to classify children and adolescents as under or over weight.
  6. Ask the student if he/she would like to know the weight; if you suspect an eating disorder, use caution in reporting the weight as this can trigger a compensatory event.

Stature (height)
The vertical distance is measured by placing a firm, flat surface against the vertex or crown of the head, while the student stands against a measuring device attached to a wall or flat surface. For the most accurate measurement, a wall-mounted unit (stadiometer) should be used. One way of improvising a flat surface for measuring length is to attach a paper or metal tape or yardstick to the wall, position student adjacent to the tape, and place a three dimensional object, such as a thick book or box, on top of the head. The side of the object must rest firmly against the wall to form a right angle

  1. Student should be measured without shoes, hat, and bulky clothing such as a coat or sweater. Undo or adjust hairstyles and remove hair accessories that interfere with measurement. The student should stand erect, with shoulders level, hands at sides, knees or thighs together and his/her weight evenly distributed on both feet. The student’s feet should be flat on the floor or foot piece, with both heels comfortable together and touching the base of the vertical board.
  2. When possible, all four contact points (i.e., the head, back, buttocks, and heels) should touch the vertical surface while maintaining a natural stance . Some students will not be able to maintain a natural stance if all four contact points are touching the vertical surface. For these students, at a minimum, two contact points – the head and buttocks, or the buttocks and heels – should always touch the vertical surface.
  3. Position the student’s head by placing a hand on the chin to move the head
  4. Lower the headpiece until it firmly touches the crown of the head and is at a right angle with the measurement surface. Check contact points to ensure that the lower body stays in the proper position and heels remain flat. Some students may stand up on their toes, but verbal reminders are usually sufficient to get them in proper position.
  5. Immediately document the student’s stature or length in inches or centimeters to the nearest ¼-inch or 1 mm .

 

 

 

What to Know

Definition of Stature: Natural height in an upright position. The terms stature and height are used interchangeably throughout this manual and in the CDC resource materials.

AVERAGE GROWTH VELOCITY “Normal” growth covers a wide range. Most healthy children have stable, steady growth rates, staying within one or two growth channels on the NCHS growth charts. Growth channels are smoothed percentile curves depicting the growth percentiles of 3, 5, 10, 25, 50, 75, 90, 95 and 97. Incremental growth velocity provides an additional measure of “normal” growth. If the student is assessed as growing normally, then no further intervention is indicated.

The general growth pattern over a period of time is more important than a single measurement plotted at any one time. For many people, overweight begins in childhood and tracks into adulthood. Once a person becomes overweight, weight reduction and weight maintenance are extremely difficult to achieve, so prevention is by far the most effective solution to the problem. (CDC, 2000)

BMI is a weight-for-stature index that can be used to determine whether the student is within a normal growth pattern, overweight, at risk of becoming overweight or underweight. BMI is the standard obesity assessment in adults, and its use in children provides a consistent screening measure across age groups. BMI provides a reasonable index of adiposity since the measurement is reliable, non-intrusive, and it has been validated against measures of body density. “The new BMI growth charts will allow school health care providers to detect, at early ages, the students who are showing signs of being at risk for overweight/obesity or under-nutrition. Not only is BMI predictive of body fat, but it can also be used throughout the age range to compare individuals to their peers and to characterize underweight or risk of underweight (though no expert guidelines exist for the classification of underweight based on BMI).” (CDC, 2000 and 2004)

NOTE: BMI should be considered a screening tool and not a definitive measure of overweight and obesity as the indicator does have limitations. For example, athletes, dancers and other physically active students may have a high BMI due to their increased muscle mass, which weighs more than fat mass.

Procedure: 1) Determine the student’s BMI (choose one):

a. Use the CDC Table for viewing or printing, found at http://www.cdc.gov/nccdphp/dnpa/bmi/00binaries/bmi-tables.pdf.

Rounding Rule: Whenever a child’s specific height or weight measurement is not listed in the table, round to the closest number. If the height or weight measurement is at the midpoint or equal distance between two units, round down to the previous unit. (Ex. 26¼ lbs.= 26; 26¾ lbs.= 26½; 60¾ lbs.= 61; 34¾ in.= 34½) Note: Upper weight limit for table is 250 pounds and the BMI limit is 35.0. A different tool is needed for weights in excess of 250 lbs.

b. Use a BMI wheel.

c. Use a BMI calculator.

d. Use a computer application* * There are several computer applications available that calculate and graph BMI and some that can track a student’s growth. The Baylor College of Medicine’s website provides a program that calculates BMI and graphs BMI percentiles for children.

The CDC’s NutStat program, part of its Epi Info program, is public domain and can be obtained from the Internet free of charge (Only operates from a Windows platform). CDC’s program will not only calculate BMI and graph percentiles, but can also store and analyze data for tracking growth from year to year and generate reports.

There are other commercial programs available, or one may be developed by a school Information Technology Department.

NOTE: To expedite the screening process, the screener may elect to calculate the BMI and BMI percentile at a later time, preferably within 30 days.

PARENT/GUARDIAN NOTIFICATION AND REFERRAL CRITERIA:

Parent/Guardian Notification

Weight Less Than 5th Percentile: Students with a BMI-for-Age below the 5th percentile (or a BMI below 18.5 if age 18 and older) are identified as at risk for undernutrition.  Consider whether the student has grown along the similar growth pattern, as their short stature or weight for stature may be their “normal” pattern. For example, Asian children may fall below the 5th percentile for stature for age, but they will continue to grow along this pattern as their “normal.”

If an eating disorder is suspected, communicate directly with parent/guardian.

Additional considerations:

Recommend that the student’s nutritional status be evaluated by the primary care provider.  

Provide educational materials with the Parent/Guardian Notification

Provide a list of community-based food supplementation programs in the area if undernutrition may be related to an inadequate food supply:  Local food pantries; WIC Program.  County Cooperative Extension Agencies  Local programs offering education to low-income families about stretching food dollars while maximizing nutrient value.

Stature-for-Age below 5th percentile or Student has dropped by more than 2 channels on the growth chart Uncommon, may be at risk for long term undernutrition Check parents’ stature Consider genetic basis Usually seen in neurologic disorders with microcephaly May be related to prenatal factor or genetic disorder  

At age 18 and beyond, a BMI of <18.5 should be used to identify possible undernutrition.

PARENT/GUARDIAN NOTIFICATION AND REFERRAL CRITERIA I

Weight Equal To or Greater Than percentile Overweight

Overweight  Send Parent/Guardian Notification home in a timely manner

Communicate directly with parent/guardian if needed.

Additional considerations: Recommend that the student be evaluated by his/her primary care provider to assess:  Blood pressure  Total cholesterol  Family history  Exogenous causes of overweight & obesity (e.g., Prader-Willi Syndrome)  Type II diabetes in children Encourage healthy eating behaviors and regular physical activity.  Provide age-appropriate educational materials on nutrition, physical activity and weight management with the Parent/Guardian Notification.

Refer student to a school-based healthy lifestyle program, if offered. Please note:  For students with a BMI > 95 percentile, support implementation of a treatment plan if recommended by the primarycare physician  For students with a BMI between the 85th and 95th percentiles, encourage/monitor a weight maintenance plan if implemented by the primarycare physician.

SPECIAL HEALTH CARE NEEDS Many students with special health care needs are not similar to the population that was the basis for the NCHS Growth Charts. There are both nutritional and non-nutritional bases for their different growth pattern. Specialized growth charts are available for certain conditions - Down Syndrome, Prader-Willi Syndrome, Turner Syndrome, Achondroplasia, Williams Syndrome, Cornelia deLange Syndrome, Rubinstein-Taybi Syndrome, and Marfan Syndrome. Some clinicians may elect to use them, for example, to illustrate to families how a specific condition can alter a student’s growth potential. Special charts have also been developed to assess growth of children who have conditions with no genetic or chromosomal basis for an altered growth pattern, such as cerebral palsy. These charts are not recommended by the CDC. The current CDC recommendation is to use the CDC growth charts in all cases.

Teen pregnancy is a concern for school nurses. Adolescence is a time of rapid physical growth and the additional energy and nutrient demands of pregnancy place adolescents at nutritional risk. The school nurse can play a significant role in caring for pregnant teens.

FOLLOW UP AND CASE MANAGEMENT A. Eating Disorders or Undernutrition Eating disorders are complex disorders involving two sets of issues and behaviors: those directly relating to food and weight and those involving the relationships with oneself and with others. It is estimated that more than one million Americans, mostly adolescents, are affected with eating disorders - mainly anorexia nervosa or bulimia nervosa. The desire for thinness is evident in girls as young as 5 years. Abramovitz and Birch (2000) studied this group and found 7% had already dieted and up to 65% considered dieting. By middle childhood, reports of dieting are more prevalent among school age girls with about 30% of third graders and 60% of sixth graders reporting that they have dieted (Gustafson-Larson and Terry, 1992).

Disordered eating behaviors are closely associated with poor school achievement, lack of communication and caring within families, and "health-compromising behaviors" like drug abuse. Although considered to be mental disorders, eating disorders are remarkable for their nutrition-related problems. In anorexia nervosa, nutrition-related problems include refusal to maintain a minimally healthy body weight (e.g., 85% of that expected), dramatic weight loss, fear of gaining weight even though underweight, preoccupation with food, and abnormal food consumption patterns. Anorexia nervosa is 10 times more common in females, especially just after onset of puberty, peaking at ages 12-13.

Bulimia nervosa is an eating disorder with food addiction as the primary coping mechanism. In bulimia nervosa, problems include recurrent episodes of binge eating, a sense of lack of control over eating, and compensatory behavior after binge eating to prevent weight gain (e.g., self-induced vomiting, abuse of laxatives or diuretics, fasting). Body weight is often normal or slightly above normal. For a person with either diagnosis to recover fully, issues concerning food-intake patterns, food- and weight-related behaviors, body image, and weight regulation must be resolved.

The registered dietitian is the logical member of the treatment team to address these issues with people recovering from anorexia nervosa and bulimia nervosa. Keep in mind that a diagnosis of an eating disorder can be made only by a physician or an appropriate health care provider. Students identified to be at risk for undernutrition, failure-to-thrive or suspected eating disorders should be referred to a primary care provider for in-depth medical assessment. These nutrition-related conditions must be addressed cautiously and expediently. Aside from psychological disturbances, eating disorders can lead to serious electrolyte imbalances and dehydration. Long-term effects include osteoporosis and Cushing's disease. Death can occur in extreme cases. Because of the serious nature of these potential conditions, it is imperative that school health personnel communicate observations and concerns directly (letter, phone call or face-to-face) to the parent/guardian. Effective treatment for eating disorders involves medical and psychological treatment, nutritional counseling, and family and school support.

http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/39/Overweight-and-Obesity-in-Youth-in-Schools-The-Role-of-the-School-Nurse-Revised-June-2013

http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/39/Overweight-and-Obesity-in-Youth-in-Schools-The-Role-of-the-School-Nurse-Revised-June-2013

http://www.cdc.gov/pcd/issues/2008/Oct/07_0164.htm

http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/39/Overweight-and-Obesity-in-Youth-in-Schools-The-Role-of-the-School-Nurse-Revised-June-2013

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