2.4 Age-Specific Screening Schedules

The FNP-BC secondary classifications use eight age groups: infant, preschool, school-age, adolescent, young adult, adult, older adult, and frail elderly. Screening calendars change at those seams. You are not expected to memorize every Bright Futures checkbox. You are expected to pick the right package for the age, name the authority (USPSTF versus Bright Futures versus ACIP versus obstetric guidelines), and avoid two errors: starting adult cancer screens too early, and treating a frail 88-year-old as if she were a 55-year-old with a 30-year horizon. If an interval is not published by a named guideline, teach the decision rule and the uncertainty — do not invent a memorable number.

Newborn and infant

Before discharge and in the first weeks, confirm that the nursery actually completed the screens — a “normal stay” is not proof.

• Newborn metabolic and endocrine blood spot (state panel: PKU, congenital hypothyroidism, hemoglobinopathies, and others that vary by state). Review the result; do not assume the card left the hospital.
• Newborn hearing screen; refer fails promptly.
• Critical congenital heart disease (CCHD) pulse-oximetry screen.
• Bilirubin risk assessment with transcutaneous or serum measurement before discharge and early follow-up for jaundice.
• Developmental dysplasia of the hip: Ortolani and Barlow in the newborn period; later limited abduction and Galeazzi. Image when risk factors persist (breech, family history, unstable exam) according to AAP imaging guidance — do not invent a universal ultrasound week for every infant.
• Growth at every visit: weight, length, head circumference, plotted on WHO charts from birth to 2 years.

Through infancy, perform developmental surveillance every visit and standardized developmental screening at Bright Futures intervals (commonly 9, 18, and 30 months). Add autism-specific screening with M-CHAT-R/F at 18 and 24 months. Assess anemia risk and obtain hemoglobin around 12 months in typical well-child pathways. Lead is targeted by risk (housing built before 1978, sibling with lead poisoning, immigrant or refugee background). Many Medicaid programs still require 12- and 24-month blood lead levels — follow the coverage rule in front of you. USPSTF has an I statement for screening asymptomatic children for elevated lead; do not call lead a USPSTF Grade A universal test. Vision and hearing begin with history and observation; formal vision charts come later. Oral health: first dental home by 12 months and fluoride varnish in the medical home when indicated. Immunizations follow ACIP; reconstruct catch-up conceptually and leave the full tables for the immunization chapter. Vitamin D for exclusively or partially breastfed infants and iron guidance belong with nutrition and anticipatory guidance, but the assessment step is asking how the infant is fed.

Preschool and school-age

Preschool (about 3–5 years) adds routine blood pressure from age 3, age-appropriate vision charts, hearing when feasible, dental surveillance, growth, school-readiness development, and ongoing lead risk. School-age visits track BMI trajectory, vision and hearing, dental health, sleep, bullying and safety, and lipids. AAP/NHLBI: universal lipid screening once at 9–11 years and again at 17–21, with earlier targeted testing if a parent had early CVD, familial hypercholesterolemia is known, or the child has diabetes, hypertension, BMI at or above the 95th percentile, or smokes. USPSTF: I statement for routine childhood lipid screening. If the item cites USPSTF, do not claim a Grade A universal child lipid test.

Adolescent and young adult

HEADSS (Home, Education/employment, Eating, Activities, Drugs, Sexuality, Suicide/depression/Safety) is the adolescent assessment frame. Build confidential time into the visit before you skip the history because a parent is in the room.

• Depression screening (USPSTF ages 12–18, Grade B; continue into young adulthood).
• Anxiety screening (USPSTF ages 8–18, Grade B).
• STI and HIV based on sexual history. HIV at least once in the 15–65 band; more often with risk.
• Cervical screening starts at 21, not at first intercourse, not at HPV-vaccine completion, and not at 18 “because she is at college.”
• Lipids once at 17–21 on the AAP/NHLBI calendar.
• Firearms, substances, and intimate-partner safety questions belong here even when the “reason for visit” is a sports form.

Young adults (roughly 18–39) inherit adult USPSTF A/B items that start at 18 — blood pressure, depression, alcohol, HIV, HCV once between 18 and 79 — while average-risk breast and colorectal screens have not yet begun. Cervical screening starts at 21. High-risk patients (BRCA pathway, longstanding ulcerative colitis, heavy tobacco starting in adolescence) leave the average-risk calendar early; that is individual-risk reasoning from Section 2.1, not a license to start mammography on every 28-year-old.

Adult

Apply Section 2.1 as a calendar, not a trivia list.

Do not invent a required PSA start age. USPSTF: men 55–69 Grade C (selectively offer after shared decision); 70 and older Grade D. If the stem does not give that frame, do not auto-order PSA. Do not invent annual “wellness labs” (CBC, CMP, TSH) as USPSTF screens — those are diagnostic or case-finding tools unless a specific recommendation applies.

Older adult and frail elderly

Chronologic age 65 and older is not frailty. Frailty is decreased reserve — weight loss, exhaustion, slowness, weakness, low activity — and it changes the net-benefit horizon. Assessment-stage additions:

• Falls. Ask about falls in the past year, gait, and assistive devices; watch the patient rise from a chair.
• Cognition. Screen when the patient, family, or function raises concern. Many AWV workflows include a structured cognitive screen even without a complaint.
• Hearing and vision. Under-recognized drivers of falls, isolation, and “cognitive” complaints.
• Osteoporosis in women 65 and older if not already done. A fracture history in a man may still justify testing even though USPSTF lacks a universal male Grade B start age.
• Deprescribing opportunity. The comprehensive or AWV medication list is the assessment moment to flag anticholinergics, stacked antihypertensives, sliding-scale-only insulin in a frail eater, and NSAIDs in CKD. You are not writing the taper in this chapter — you are noticing the risk.
• Stop rules. Do not reflexively continue colorectal screening after 85, LDCT after limited life expectancy or loss of surgical candidacy, mammography as if the 40–74 Grade B still applies unchanged after 75 (I statement), or cervical screening after adequate history and hysterectomy for benign disease.

Pregnancy as family-NP scope

Family NPs assess pregnancy in primary care. Confirm pregnancy, date by LMP and the ultrasound pathway, and open a different screening calendar the same day: HIV, syphilis, hepatitis B, blood type and Rh, CBC, urine, rubella immunity, and other obstetric-panel items per current obstetric guidelines; offer aneuploidy-screening options rather than a single invented test; identify SDOH and intimate-partner violence; review teratogens and immunization status (inactivated influenza when indicated, Tdap timing, and what must wait). Detailed obstetric protocols belong in the pregnancy chapter. The assessment skill is this: a positive home pregnancy test is not a wellness add-on.

One calendar, many authorities

Vignette. A 14-year-old is in for a sports physical with a parent in the room. The FNP who only listens to the heart and signs the form has not done an age-specific assessment. Confidential HEADSS time, a depression screen, a sexual and substance history, firearm storage, and a decision not to perform a Pap are the Domain I moves. Contrast that with an 88-year-old who wants to “catch up on everything.” She had a normal colonoscopy at 78 and a mammogram at 76. The correct assessment is frailty, falls, cognition, hearing, vision, bone health, and the medication list — not a restart of midlife cancer screening because someone handed her a checklist.