complete physical examination is included as part of every Bright Futures visit. The examination must be comprehensive and also focus on specific assessments that are appropriate for the child’s or adolescent’s age, developmental phase, and needs. This portion of the visit builds on the history gathered earlier. The physical examination also provides opportunities to identify silent or subtle illnesses or conditions and time for the health care professional to educate children and their parents about the body and its growth and development. The chapters in this section of the book focus on topics that emerge during the examination. Assessing Growth and Nutrition; Sexual Maturity Stages; In-toeing and Out-toeing; and Spine, Hip, and Knee discuss critical aspects of healthy development that must be assessed with regularity. Blood Pressure and Early Childhood Caries examine issues of vital public health importance and provide updated guidelines. Sports Participation provides useful guidance for health care professionals at a time when increased physical activity among children and adolescents is a priority.



Assessing Growth and Nutrition Blood Pressure

Susanne Tanski, MD, MPH, and Lynn C. Garfunkel, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Marc Lande, MD, and William Varade, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Early Childhood Caries

Burt Edelstein, DDS, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Fluoride Varnish Application Tips Intoeing and Outtoeing Sexual Maturity Stages Spine, Hip, and Knee Sports Participation

Suzanne Boulter, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Donna Phillips, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Marcia Herman-Giddens, PA, DrPH, and Paul B. Kaplowitz, MD . . . . . . . . . . . . . . . . . . . . . . 79

Stuart Weinstein, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Eric Small, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93




Accurate and reliable physical measures are used to monitor the growth of an individual, detect growth abnormalities, monitor nutritional status, and track the effects of medical or nutritional intervention. As such, they are essential components of the physical examination. This chapter reviews measurement of length, height,

weight, and head circumference and calculation of body mass index (BMI).

Why Is It Important to Assess Growth and Nutrition During the Physical Examination?
Growth measurements correlate directly to nutritional status and can indicate whether a child’s health and well-being are at risk.1 Deviations from normal growth patterns may be familial patterns but may indicate medical problems.2 For example, abnormal linear growth or poor weight gain could indicate a variety of medical problems, including malnutrition, chronic illness, psychosocial deprivation, hormonal disorders, or syndromes with dwarfism.3 Similarly, growth trajectories that deviate above the norm (increased weight for height [or increased BMI]) can also indicate medical problems with adverse consequences. Monitoring growth and deviations from normal patterns can help detect and allow intervention for many medical conditions and abnormalities.2 Calculating and tracking BMI provides vital information about weight status and risk of overweight and obesity. Body mass index is a clinically useful weight-for-height index that reflects excess body fat as well as nutritional status.4,5 Obesity in childhood is associated with immediate and long-term adverse health and psychosocial outcomes, leading to health problems in as many as 50% of US children.2 Obesity in children has been associated with

increased blood pressure, total cholesterol, low-density lipoprotein cholesterol, and triglycerides and low levels of high-density lipoprotein cholesterol.5 The American Academy of Pediatrics and American Academy of Family Physicians endorse universal screening of BMI and use of BMI growth curves for plotting BMI percentiles to identify obese and overweight children. Measuring head circumference, especially within the first 3 years, may identify neurologic abnormalities as well as malnutrition.5,6 Identification of abnormal growth patterns can lead to early diagnosis of treatable conditions, such as hydrocephalous, or identification of disorders associated with slowed head growth, such as Rett syndrome.7

How Should You Take These Measurements?
General Considerations The measurement process has 2 steps—measure and record. Accurate weighing and measuring have 3 critical components—technique, equipment, and trained measurers. You must use the appropriate techniques for each measurement. Your choice of whether to use English or metric units for measurements and plotting can depend on a variety of circumstances. If the available equipment is accurately calibrated and the measurers follow standard procedures, 51


then you can record data in either English or metric units. The use of metric measures is encouraged when weighing infants, children, and adolescents in a clinical setting. To convert from kilograms to pounds, multiply the kilogram amount by 2.2 (eg, 50 kg x 2.2 = 110 lb). Consistent procedures must be used. If measures are in error, then the foundation of the growth assessment is also in error. It is important to record the date, age, and actual measurements so the data can be used by others or at a later time. Measure Stature (Length or Height)

••Align the measuring bar perpendicular to the wall

••If a scale with a measuring bar is not available, place

and parallel to the floor (on a stadiometer or other measuring rod) with the top of the head.

••Plot height measurements on a standardized growth
chart for age and gender, or one appropriate for the child. Measure Weight Infancy and Early Childhood

a flat object such as a clipboard on the child’s head in a horizontal position and read the height at the point at which the object touches a measuring tape on the back of the scale or a flat wall surface.

••Until they can stand securely (age 2 years), measure

Infancy and Early Childhood (0–2 years)

••Align the infant’s head snugly against the top bar of the ••Straighten the infant’s body, hips, and knees. ••Hold the infant’s feet in a vertical position (long axis of ••If an examining table is used, mark the spots at the
foot perpendicular to long axis of leg). Bring the foot board snugly against the bottom of the foot. Some authorities suggest measuring twice and taking an average. frame and ask an assistant to secure it there. Parents can help restrain infants for length measurements, as it is a painless procedure.

infants lying down in a supine position on a measuring frame or an examining table.

••Weigh younger infants nude or in a clean diaper on a ••Position the infant in the center of the scale tray. ••It is desirable for 2 people to be involved when

calibrated beam or electronic scale. Weigh older infants in a clean, disposable diaper.

••Plot length measurements on a standard growth chart
for age and gender, or one appropriate for the child (eg, low birth weight infant, infant with trisomy 21, infant with Turner syndrome). Child (2 years and older)

top of the child’s head and bottom of feet and then measure between the marks. (Note that this is not ideal as it is difficult to get an accurate length using this technique.)

••Weigh the infant to the nearest 0.01 kg or 1/2 oz. ••Record the weight as soon as it is completed. ••Then reposition the infant and repeat the weight

weighing an infant. One measurer weighs the infant and protects him or her from harm (such as falling) and reads the weight as it is obtained. The other measurer immediately notes the measurement in the infant’s chart.

measurement. Note the second measurement in writing. Compare the weights. They should agree within 0.1 kg or 1/4 lb. If the difference exceeds this, reweigh the infant a third time. Record the average of the 2 closest weights.

If an infant is too active or too distressed for an accurate weight measurement, try the following options:

••Have the child remove his or her shoes. ••Have the child stand up with the bottom of the heels

••Postpone the measurement until later in the visit when the infant may be more comfortable with the setting. ••If you have an electronic scale, use this alternative
measurement technique: Have the parent stand on the scale and reset the scale to zero. Then have the parent hold the infant and read the infant’s weight.

on floor and back of foot touching the wall, knees straight, scapula and occiput also on the wall, looking straight ahead with head held level.



••A child older than 36 months who can stand without ••Have the child or adolescent wear only lightweight undergarments or a gown. ••Have the child or adolescent stand on the center of the platform of the scale. ••Record the weight of the individual to the nearest 0.01 ••Reposition the individual and repeat the weight measure. ••Compare the measures. They should agree within 0.1
kg or 1/2 oz. (If the scale is not digital, record to the nearest half-kilo or pound). Record the weight on the chart. assistance should be weighed standing on a scale using a calibrated beam balance or electronic scale.


to calculate both the BMI and age- and sex-adjusted BMI percentile ( Calculator.aspx). See the Resources section for further details. Measure Head Circumference Obtain an accurate head circumference, or occipital frontal circumference, by using a flexible non-stretchable measuring tape. Head circumference is generally measured on infants and children until the age of 3 years. Measure head circumference over the largest circumference of the head, namely the most prominent part on the back of the head (occiput) and just above the eyebrows (supraorbital ridges).


••Place a tape measure around an infant’s head just ••Pull the tape snugly to compress the hair and ••Reposition the tape and remeasure the head

kg or 1/4 lb. (If the scale is not digital, compare to the nearest half-kilo or pound.) If the difference between the measures exceeds the tolerance limit, reposition the child and measure a third time. Record the average of the 2 measures in closest agreement.

above the eyebrows and around the most prominent portion of the back of the head, the occipital prominence. underlying soft tissues. Read the measurement to the nearest 0.1 cm or 1/8 inch and record on the chart. circumference. The measures should agree within 0.2 cm or 1/4 inch. If the difference between the measures exceeds the tolerance limit, the infant should be repositioned and remeasured a third time. The average of the 2 measures in closest agreement is recorded.

In the standardized scale for children, all weights between the 5th and 85th percentiles are considered normal. As important as the fact that a child’s weight falls between these percentiles on a growth chart is that over time the weight follows one of the percentile curves. In other words, a child who is at the 80th percentile the first time he or she is weighed and at the 40th percentile a month later is cause for concern. A child is defined as having a failure to thrive syndrome (a medical diagnosis) if height or weight drops below the third percentile on a standardized growth chart. Calculate BMI

••Plot measurements on a standardized growth chart for age and gender. ••Head circumference should correlate with the child’s
length (eg, if length is in the 40th percentile, head circumference should also be 40th percentile).

••Choose English or metric calculation for BMI.
`• English: (Weight (lb) / [Stature (in) x Stature (in)]) x

What Should You Do With an Abnormal Result?

••Plot the child’s or adolescent’s BMI on a growth chart
for age and sex to determine BMI percentile. In the United States, BMI growth charts are available for ages 2 to 20. Alternatively, the Centers for Disease Control and Prevention (CDC) has a Web-based tool

`• Metric: Weight (kg) / [Stature (m) x Stature (m)]

••Children who fall off their height curves (decline in ••First, be sure that the measurements are accurate,
make sense, and are appropriately plotted.

stature/length percentiles or present with extreme short stature) may need to undergo evaluations for underlying medical problems.


neurologic and pulmonary disorders. Pubertal delays may be genetic/familial or be due to an underlying medical condition `• Reveal asymmetries `• Abnormalities in muscle tone. ••Assess for signs and symptoms of increased intracranial 54 PERFORMING PREVENTIVE SERVICES . endocrinopathies. ••Conduct neurologic and developmental assessments that may the pattern of head growth. pubertal delay. (These are average heights for male and female population. ••Note the presence or absence of congenital abnormalities involving other organ systems. ••Observe for the presence or absence of dysmorphic features. strength. boney dysplasias. father is 5'9" (69"): (5'9" + 5'4") +/. ••A number of medical conditions can present with percentile or presentation with extreme underweight may warrant further investigation. family or environmental difficulties. `• These children all need to be followed closely and ••Those with short stature may need to be assessed for Weight/BMI evaluated or referred to an appropriate specialist. renal disease. he or she may have constitutional delay. including malabsorption. or syndromes. ••Measure the head sizes of first-degree relatives.5")/2 = mean parental height. and chronic infections. and reflexes ••Drop in weight percentiles by more than one large ••First be sure measurements are correct and were plotted correctly. `• Mean parental height calculation: Add parental heights and subtract 5 inches for a girl (from Dad’s height) or add 5 inches (to Mom’s height) for a boy. A girl’s mean parental height would be 5'4" and a boy’s would be 5'9 ". cardiac disorders. Example: mother is 5'4" (64"). ••Accurately measure the head circumference and assess ••Inspect and palpate the skull. posture. If previous measurements are available.ASSESSING GROWTH AND NUTRITION ••Calculate mean parental height and plot. `• If the child is short.) ••Review the “Weight Maintenance and Weight Loss” Head Circumference Consider the following actions for a child with an abnormal head size: and “Metabolic Syndrome” chapters in this volume for issues with overweight/obesity. ••Compare the head circumference with other growth parameters. assess the onset of the abnormal head size. weight loss or fall off weight growth curves. and then divide that entire number by 2. the child may have familial short stature. Workup and potential referral should proceed as suggested by history and physical examination. `• If the parents entered puberty late and the child is short and prepubertal at a time when most children are in puberty. food or feeding abnormalities. but mean parental height falls in the same percentile. `• Generalized psychomotor retardation `• Motor delays `• Speech or language and cognitive impairments `• Autistic features pressure.

severe* Overweight* Abnormal loss of weight and underweight (use BMI code if known. and BMI measurements in the child’s growth charts. check to see if they are consistent with those from previous visits (ie. if supine length is measured. recurrent) Macrocephaly Megalencephaly Microcephaly Obesity (constitutional. If not. birth to 36 mos Boys. the measurement you obtain must match the graph you use (eg. US Preventive Task Force. 2 to 20 yrs Girls. Share the information with the family (ie. birth to 36 mos Boys.4 Dwarfism Gigantism (cerebral. 2 to 20 yrs Girls.00 For children between ages 2 and 3. familial.4 742. obstructive. use the 0–3 years length-for-age graph. V85. internal. * Obesity codes are not reimbursed in all jurisdictions. 2 to 20 yrs Girls. birth to 36 mos Girls.41 783. pituitary) Hydrocephalus (acquired.0 742. simple)* Obesity.0) Loss of weight Underweight Failure to thrive. the child is on roughly the same percentile lines as before).00 783. external. including an annual edition of Coding for Pediatrics. The CDC growth charts are presented as ICD-9-CM Codes 259. 2 to 20 yrs Boys 2 to 5 yrs Girls 2 to 5 yrs Charts Weight-for-length Weight-for-age Length-for-age Head circumference-for-age Weight-for-length Weight-for-age Length-for-age Head circumference-for-age BMI-for-age Weight-for-age Stature-for-age BMI-for-age Weight-for-age Stature-for-age Weight-for-stature (optional) Weight-for-stature (optional) 783.43 783.0 331.2 756.4 253. After graphing a set of measurements. The American Academy of Pediatrics publishes a complete line of coding publications. hypophyseal. Screening for overweight in children and adolescents: where is the evidence? A commentary by the Childhood Obesity Working Group of the US Preventive Services Task Force. graphing. nutritional.aap.01 278. A straight edge.116(1):235–238 55 .01 278. birth to 36 mos Girls. birth to 36 mos Girls. and plotted them on the appropriate growth chart. 2005.21 783. For more information on these excellent resources. It is essential to select the appropriate chart for the age and sex of the child or adolescent. 2 to 20 yrs Boys. or both. right angle triangle or commercially available plotting aid is recommended to locate the intersecting point of the axis values. calculated age correctly.1 278. birth to 36 mos Girls. birth to 36 mos Boys.3 278. When you have made accurate measurements. not the 2–20 stature [standing height]-for-age graph). exogenous. weight. noncommunicating.What Results Should You Document? Plot height.22 783. Resources Articles Childhood Obesity Working Group. morbid* Obesity. visit the American Academy of Pediatrics Online Bookstore at www. birth to 36 mos Boys. Practitioners may select additional diagnoses.3 779. use the information in the clinical assessment process. check the measurements. 2 to 20 yrs Boys. translate the measurements into a form that is useful to them). poor weight gain Short stature Feeding problem Newborn feeding problem PHYSICAL EXAMINATION Sex and Age Boys. Pediatrics.

cdc. 4th ed.B. Anthropometric Standardization Reference Manual. References 1. 3rd ed. 2006.aspx National Center for Health Statistics: Clinical Growth Charts: http://www. Pediatrics.102(3):e29 5. eds. http://www. DeAngelis CD.ASSESSING GROWTH AND NUTRITION Centers for Disease Control and Prevention.htm Scales or Tools Centers for Disease Control and Prevention: BMI Percent Calculator for Child and Teen: http://apps. Obesity evaluation and treatment: expert committee recommendations. Atlanta. Barness LA. Sulkes SB. Goran MI.cdc. National Center for Health Statistics Web Site. 1968. Philadelphia. Weighing and Measuring Children: A Training Manual for Supervisory Personnel. Pietrobelli A. Nellhaus G.cdc. 1998:1 7. Atlanta.41:106–114 56 PERFORMING PREVENTIVE SERVICES . Grummer-Strawn LM. Chapter 5: Pediatric history and physical examination.27:473–476 3. IL: Human Kinetics Books. Pediatr Rev. In: Nelson WE. GA: Centers for Disease Control and Prevention. Kliegman RM. Dietz dnpabmi/Calculator. Beker L. and Welfare. Goulding A. and US Department of Health. Head circumference from birth to eighteen years: practical composite international and interracial graphs. Purugganan OH. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. 2006:33 2. Barlow SE. GA: Centers for Disease Control and Prevention. Section 1: Introduction to Pediatrics. Oski’s Pediatrics: Principles and Practice. Martorell R. Feigin RD. 2007 Third National Health and Nutrition Examination (NHANES III) Anthropometric Procedures Video. Champaign. PA: W. Behrman RE. 1980 4. 1998. Nelson Essentials of Pediatrics.75:978–985 Pillitteri A.27:196–198 6. PA: Lippincott Williams and Wilkins. In brief: principles of growth assessment. In brief: abnormalities in head size. 1976 Lohman nchs/products/elec_prods/subject/video. Dietz WH. In: McMillan JA. Public Health Service. Am J Clin Nutr. 1988 Mei Z. Saunders Co. eds. 5th ed. Identification and Quantification of Sources of Error in Weighing and Measuring Children. Philadelphia. Education. Pediatrics. Pediatr Rev. Jones MD. Roche AF. Centers for Disease Control and Prevention and Health Service Administration. 2008. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. 2006.nccd. Section II: Growth and development. PA: Lippincott Williams and Wilkins. 2002.

Ambulatory BP monitoring is often needed to make this diagnosis. Primary hypertension is detectable in children and adolescents. The long-term health risks of hypertension can be substantial. Obesity and hypertension are linked. Evaluation. Left ventricular hypertrophy. Target-organ damage is commonly associated with hypertension in children and adolescents. it is a common problem. ••White-coat hypertension is BP at ≥95th percentile ••Hypertension is defined as systolic BP and/or diastolic `• Stage 1: BP ≥95th percentile but <5 mm Hg above the 99th percentile (<99th percentile + 5 mm Hg) `• Stage 2: BP is >5 mm Hg above the 99th percentile (>99th percentile + 5 mm Hg) See the Resources section of this chapter for National Heart. MD WILLIAM vARADE. Moreover. is present in up to 36% of hypertensive children. 57 . A large national database shows that the prevalence of high blood pressure (BP) in children and adolescents is increasing. Children and adolescents with hypertension are frequently overweight. ≥90th percentile but <95th percentile for age. These increases are even larger than would be expected from the increase in obesity prevalence. sex. with hypertension present in approximately 30% of overweight children.PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK MARC LANDE. hypertension is becoming a significant health issue. normal outside of the office setting. the most prominent finding. Lung. in the office. even if 120/80 is less than the 90th percentile. Given the marked increase in childhood obesity. MD BLOOD PRESSURE The following guidelines are adapted directly from the “Fourth Report on the Diagnosis. How Is Hypertension Defined in Children and Adolescents? PHYSICAL EXAMINATION ••Prehypertension is systolic BP and/or diastolic BP Blood pressure falls into several categories. The prevalence of children who are overweight is increasing. In addition.” 1 Why Is It Important to Assess Blood Pressure During the Physical Examination? High blood pressure is a growing health concern for children and adolescents. Adolescents with BP ≥120/80 should be considered prehypertensive. and height. and Treatment of High Blood Pressure in Children and Adolescents. and Blood Institute blood pressure tables for children and adolescents. elevated BP in childhood correlates with the presence of hypertension in adulthood. sex. Hypertensive children are further categorized into 2 stages. BP ≥95th percentile for age. and height on 3 or more occasions.

use the next largest cuff. despite a trial of lifestyle modification. ••Position the child.B LO O D P R E S S U R E When and How Should You Measure Blood Pressure? When to Measure ••Take the measurement. Consider early referral to a practitioner with expertise in pediatric hypertension for all children and adolescents with Stage 2 hypertension. Consider referral to a practitioner with expertise in pediatric hypertension. `• Determine the diastolic BP by the disappearance of Korotkoff sounds (K5). In this situation. `• Child should be sitting quietly for 5 minutes prior to taking BP `• Back supported with feet on floor ••Use the appropriate cuff size. `• History of prematurity. have diabetes. repeat the BP with less pressure on the stethoscope head. may need antihypertensive medications. `• Cuff bladder length should cover 80% to 100% of the arm circumference. and Treatment of High Blood Pressure in Children and Adolescents. `• If a cuff is too small. even if it appears too large. `• Right arm supported with cubital fossa at heart level `• Inflatable bladder width should be at least 40% of the arm circumference at the midpoint between the olecranon and acromion. Evaluation. then record muffling of the Korotkoff sounds (K4) as the diastolic BP. 58 PERFORMING PREVENTIVE SERVICES . ••Children older than 3 years should have their BP How to Measure `• If Korotkoff sounds still go to 0. kidney disease. it may allow softer Korotkoff sounds to be heard. or Stage 1 hypertension should have the appropriate evaluation for secondary hypertension and target-organ damage as recommended in the “Fourth Report on the Diagnosis. What Should You Do With an Abnormal Result? Children and adolescents with persistent prehypertension (>6 months in duration) who are overweight. use the right arm. `• Consider using the bell of the stethoscope.”1 Children and adolescents with persistent Stage 1 hypertension. care in the `• Congenital heart disease `• Renal or urologic disease `• Family history of congenital renal disease `• Solid-organ or bone marrow transplant `• History of malignancy `• Treatment with drugs known to raise BP `• Any systemic illness associated with hypertension `• Elevated intracranial pressure routinely measured. `• If possible. `• In some children. proximal and medial to the cubital fossa. Korotkoff sounds can be heard all the way to 0. `• Determine the systolic BP by the onset of Korotkoff sounds (K1). below the bottom edge of the cuff. low birth weight. This will make the measurement consistent with national norms and will prevent confusion with the effects of potential coarctation. ••Children younger than 3 years should have their BP measured under the following circumstances: neonatal intensive care unit `• Place stethoscope over brachial artery pulse.

Cutler JA. The fourth report on the–2113 Web Sites American Heart Association: http://www. and treatment of high blood pressure in children and adolescents. For more information on these excellent resources. PHYSICAL EXAMINATION Resources Tools National Heart.0 Elevation of blood pressure. Wildman RP.jhtml?identifier=4609 International Pediatric Hypertension Association: http:// www. benign Hypertension. 2004.aap. He J. evaluation. Article Muntner P. Pediatrics. Trends in blood pressure among children and adolescents. JAMA. americanheart. 2004.2 401.nhlbi. and Blood Institute Blood Pressure Tables for Children and Adolescents: http://www.What Results Should You Document? Document routine blood pressures in the medical record with other vital tbl. malignant The American Academy of Pediatrics publishes a complete line of coding publications including an annual edition of Coding for Pediatrics.114:555–576 59 . Record prehypertension and stage of hypertension in the problem HEARTORG/ High Blood Pressure in Children: http://www.1 401. no diagnosis of hypertension Hypertension.heart. visit the American Academy of Pediatrics online bookstore at ICD-9-CM Codes 796.htm Reference 1 National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Whelton PK.




PHYSICAL EXAMINATION Reproduced from: National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. evaluation. The fourth report on the diagnosis. and treatment of high blood pressure in children and adolescents. 2004.114:555–576 63 .


Certain groups are at high risk of developing ECC. and a screening tool for assessing caries risk is included in this chapter. the highest rates of dental pain. dietary. These determinants interact at multiple levels and result in inequitable distribution of ECC by income and race.3 ••Children with special health care needs for whom diet and oral hygiene are problematic ••Children of mothers/caregivers with a high caries experience ••Children who do not yet have cavities but have ••Children with high-frequency sugar consumption.1 Early childhood caries has strong social.1 Caries prevalence in children is 5 times that of asthma. experience the highest rates of tooth decay. In children whose teeth have erupted. DDS. and environmental determinants.2 The percentage of children with ECC increased 15% over the past decade. like those targeted by Head Start. Some children need early referral to a dentist before tooth eruption.4 Why Is It Important to Assess for ECC During the Physical Examination? Early childhood caries is highly prevalent and becoming more so. MPH EARLY CHILDHOOD CARIES Bright Futures recommends that all children establish a dental home by 12 months. missing. ••Poor and low-income children ages 3 to 5 years. and the fewest dental visits despite enjoying the highest rates of dental coverage because of Medicaid and SCHIP. the “Knee-to-Knee Oral Exam” represents the basic physical examination required to assess for dental caries. Children at high risk of ECC include •• By income Poor children younger than 5 years are 5 times more likely to have cavities than are children from families living at 3 times the poverty level.3 decayed teeth than higher-income children. PHYSICAL EXAMINATION What Is Early Childhood Caries? The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as one or more decayed.5 times more . the most unmet dental care needs. ••Native American and Asian-Pacific Islander children 3 By race experience the highest rates of ECC. biological. or filled teeth in children younger than 6 years. Currently 28% of US children ages 2 to 5 have visible cavities.PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK BURT EDELSTEIN. and 73% of these children are in need of treatment. ••Hispanic children experience higher rates of ECC (36%) than do black (30%) or white (23%) children. ••Children in families of low socioeconomic status 65 including those who sleep with a bottle or continuously breastfeed throughout the night earlier signs of caries activity including heavy plaque accumulation along the gum line or “white spot” demineralizations ••Poor and low-income children have 3. cultural.

and age-appropriate engagement of children in their own oral hygiene. These issues include oral and dental development. The ECC process becomes established at an early age. Early childhood caries also has varied and serious consequences for growth and development. oral soft tissues. or in your lap as you sit knee-to-knee with the parent. in a carrying seat. Once established. The first signs of ECC occur on the front surfaces of these teeth. They include heavy soft plaque accumulation on the maxillary incisors. particularly for ••2 x 2 gauze ••A source of good direct overhead light ••Gloves ••Tongue depressor ••Dental mirror (optional) ••Fluoride varnish (optional) Position Yourself Correctly Visualize the infant or toddler’s mouth from above by positioning yourself behind the child’s head with the child lying on the examining table. Young children are more likely to have a first dental visit for pain relief than for preventive care or anticipatory guidance. sleeping. oro-facial injury prevention. American Academy of Pediatrics and AAPD policies support establishing an early dental home. often results in disturbances of eating. use of fluorides. The caries process is typically established before age 2. and may disturb growth. Conduct the Examination ••Pull down on the lower lip and examine the mucosa. including juice. These policies recommend that children have a dental home at the time of the first tooth or first birthday. 66 PERFORMING PREVENTIVE SERVICES . Any visible difference between the integrity. Children with ECC are therefore more susceptible to long-term dental problems. or sheen of the lower and upper teeth may indicate early signs of ECC. which are typically acquired by infants from their mothers by direct salivary transmission children at risk of ECC or with signs or symptoms of other oral problems. ••Lift the upper lip to examine mucosa and the maxillary anterior teeth. with consequences for future dental health. particularly along the gum line. and behavior. Early childhood caries is preventable. digit sucking and occlusion. Pain and infection resulting from the rapid progression of ECC into the dental pulp distracts from play and learning. well before most children obtain their first dental visit. Have Your Supplies and Equipment Ready ••Delay in acquisition of Streptococcus mutans and other ••Reduced frequency and duration of sugar consumption.and risk-appropriate use of fluorides and exposure to fluoridated water Unmet needs for dental care among all US children are 3 times greater than unmet needs for medical care. How Should You Perform an Early Childhood Caries Examination (“Knee to Knee Oral Examination”)? Early signs of ECC are subtle but significant. The ECC process typically begins well before most children obtain their first dental visit but long after they have begun medical care visits. color. home care. For those children at high risk as noted previously. the intensity of an individual’s caries process tends to be stable over the lifetime. Note that the front surface of the lower front teeth are almost never affected by caries in young children. It can be stopped through a combination of cariogenic bacteria. Infant oral health care provides an opportunity to examine children and counsel families on a range of issues in addition to ECC. and “white spot” lesions that indicate early enamel decalcification. feeding behaviors. the referral should be made as early as 6 months of age and no later than 6 months after the first tooth erupts or 12 months of age (whichever comes first). in the bottle or sippy cup when used ad libitum as pacifiers ••Age. including in bottle and sippy cup use ••Exclusion of sugar-laden liquids.E A R LY C H I L D H O O D C A R I E S Children should be referred to a dentist so that a dental home can be established by 1 year of age.

with particular attention to the front and back surfaces of the maxillary incisors. Recommend appropriate topical fluoride toothpaste use: AAPD5 recommends that parents use an age-appropriate toothbrush twice daily to apply a “smear” of fluoridated toothpaste for children younger than 2 years who are at caries risk and a non-fluoride toothpaste for children not at risk. Table 1. Primary ••Press gently on the teeth to assess that all are firmly •• teeth should be uniform in these aspects. form. ••Examine the dentition for numbers.00 mg 0. For children with a primary water supply that contains suboptimal fluoride. 67 . A disposable or sterilized dental mirror is recommended for use. gauze. Fluoride supplementation recommendations by AAPD for children at risk for caries. tongue. particularly on obviously decayed teeth. and integrity. ••Apply fluoride varnish: After drying the teeth with the Comparison of a smear (left) with a pea-sized (right) amount of toothpaste.25 mg 0. `• Assess systemic fluoride: For children whose water supply is not fluoridated and at caries risk. assess the child’s primary water supply for fluoride content by submitting a water sample to a state or private laboratory. palate. For children ages 2 through 5. trauma. scrape with a tongue blade along the gum line to see if this plaque is present on these upper teeth before wiping them dry. Any discoloration is cause for concern. or caries. Gently •• ••Check for color and translucency (shininess). Examine for bite. Examine the posterior teeth for color. Any dark fissure in young children is of concern. form. Look for normal occlusion. in place and that the child does not react to upward pressure. press down on—or in front of (in the mucolabial fold)—the lower teeth to open the child’s mouth. and ••Lean forward while tipping the child’s head back to ••Grasp the child’s chin gently and guide the mouth With gentle pressure. Figure 1.6 ppm F 0 0 0. look closely at the back surface of the maxillary incisors as this is another common place for first cavities to appear.3–0. Alternatively place the tongue blade between the child’s molars and turn 90 degrees. All of the upper teeth should drape closely over all of the lower teeth.50 mg 1.3 ppm F 0 0. and oropharynx. ••Counsel and prescribe appropriate topical and systemic fluoride. Look closely at the dry teeth along the gum line for crescent shaped or linear white opacities (white spots). prescribe a fluoride supplement according to Table 1.50 mg <0.••Look for soft whitish plaque accumulation. disturbances that may relate to development. color. a “pea sized” amount of toothpaste is appropriate (Figure 1).6 ppm F 0 0 0 0 PHYSICAL EXAMINATION ••Examine the buccal mucosa.25 mg 0. Any disturbance from this pattern is cause for concern. use the brush supplied with the fluoride varnish to apply a thin layer of the material to all surfaces of the teeth. closed along the midline until the teeth touch. Dietary Fluoride Supplementation Schedule Age Birth–6 months 6 months–3 years 3–6 years 6 years up to at least 16 years <0.

refer children for further evaluation by a dentist comfortable with young A R LY C H I L D H O O D C A R I E S ••Plaque accumulation ••White opacities ••Discoloration of primary teeth ••Differences in tooth surface appearance ••Any disturbance from normal occlusion What Should You Do With the Results? For any findings of concern. or evidence of oral trauma. malocclusion. ••Use the AAPD Caries Risk Assessment Form to document risk. with oral or dental symptoms. Summary: Causes of Concern ICD-9-CM Codes 521. visit the American Academy of Pediatrics Online Bookstore at www. abnormal development. For other children. counsel parents to establish a dental home at the time of the first tooth or first birthday. Ensure referral of all children older than age 1 for routine dental care. including any specific recommendations to parents facilitating the referral. ••Document fluoride varnish application as applicable. Resources Photographs Normal Primary Dentition ••Make an urgent dental referral for any young child ••Make an urgent dental referral for a child with any ••Make an immediate dental referral for any young child with dental discoloration. including stimulated or unstimulated pain. including an annual edition of Coding for Pediatrics. For more information on these excellent resources. 68 PERFORMING PREVENTIVE SERVICES . illuminated teeth. and occlusion. Document referral to the dentist. Note linear “white spot” decalcification along the gum line on these dried. soft tissue lesion. developmental irregularity. particularly if the child awakens at night with apparent dental pain. Normal primary dentition shows normal mucosa and white. intraoral or extraoral swelling that you suspect is of dental origin. opalescent teeth with spacing. Subtle Manifestations of ECC—Early Signs ••Document that an intraoral examination was What Results Should You Document? performed and report findings that may indicate hard and soft tissue pathologies.0 Dental caries The American Academy of Pediatrics publishes a complete line of coding publications. This is the first clinical manifestation of tooth damage and typically progresses rapidly. Prioritize those children whose parents report a history of problems with tooth decay in themselves or their other children.

org/oralhealth/linkstraining.cfm PHYSICAL EXAMINATION Association of Clinicians for the Underserved: ••Pocket cards Web-based Self-education and Resource Materials Protecting All Children’s Teeth (PACT): A Pediatric Oral Health Training Program: http://aap.cfm The purpose of this free training is to provide a concise overview of how to perform an oral examination and conduct an oral health risk assessment and triage for infants and young children. and more comfortable sharing the responsibility of oral health with dental colleagues. 22-month-old child with extensive dental home.cfm ••Tools and resources: oralhealth 18-month-old with extreme ECC and abscessed incisor. and adolescent health about the important role that oral health plays in the overall health of patients. 69 . but to become more knowledgeable about child oral health. and others interested in 12-month-old with extreme ECC. Crossbite Note that the posterior upper teeth are inside the lower teeth and the upper and lower midlines do not coincide.Overt Manifestations of ECC Tools American Academy of Pediatric Dentistry: http://www. more competent in providing oral health guidance and preventive care.cfm ••Training and videos: http://aap. ••Policy statements: http://aap. pediatricians in ••Reference manual guidelines on infant oral health care.aap. aapd. Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals: http://aap. child. age 1 dental visit. Note that the lower incisors remain intact. cfm Protecting All Children’s Teeth (PACT): A Pediatric Oral Health Training Program aims to educate pediatricians. ECC. fluoride therapy ••Caries Risk Assessment Tool American Academy of Pediatrics: http://www. clinicians. The goal of this curriculum is not to train pediatricians to become

E A R LY C H I L D H O O D C A R I E S Opening the Mouth: http://ccnmtl. including professionals. Smith V.aapd. National Center for Health Statistics. Available at http://www.pdf 70 PERFORMING PREVENTIVE SERVICES . Centers for Disease Control and Prevention. Trends in oral health status: United States. 2000 3.60:221–229 5. National Institute of Dental and Craniofacial Research. MD: US Department of Health and Human FluorideTherapy. Third National Health and Nutrition Examination Survey (NHANES III).org/ The Children’s Dental Health Project is a national nonprofit organization with the vision of achieving equity in children’s oral health. Tan projects/otm/index. policymakers. http://www. US Department of Health and Human Services.cdc. Oral Health in America: A Report of the Surgeon General—Executive Summary. Edelstein BL.cdhp. 2000. 1999-2002.columbia. National Institutes of Health.11(248) 2. and parents.html This online training program was developed for maternal and child health educators and policymakers to better understand early childhood oral health and to facilitate oral health supervision into pediatric well-child supervision. Pediatr Dent 2009-10. Lewis BG. J Pub Health Dent. References 1. Guideline on Fluoride Therapy. 2007. et al. American Academy of Pediatric Dentistry. The project designs and advances research-driven policies and innovative solutions by engaging a broad base of partners committed to children and oral health. Children’s Dental Health Project: http://www. Access to dental care for Head Start enrollees. Thornton-Evans G. Rockville. communities. US Department of Health and Human Services. Dye BA. Barker LK.htm 4. Vital Health Stat. 1988–1994 and 1999–2004. 31(6 Reference Manual) nchs/nhanes.

have a medical assistant. or ••Have the parent/guardian pull the child back up into a other parent/guardian hold the light source (your sitting position. MD FLUORIDE VARNISH APPLICATION TIPS Fluoride varnish is not a substitute for fluoridated water. older sibling. it will go away in 2 to 3 days due to brushing and eating. 71 (facing the parent/guardian) with legs wrapped around parent/guardian’s waist. The teeth ••Wipe the teeth with 2 x 2 gauze. or on an examination table. otoscope light will work fine) directed toward the mouth. ••Have the parent/guardian drop the patient’s head back Instructions after onto your lap and have them hold the child’s hands. Pediatricians should consider applying fluoride varnish for patients at risk PHYSICAL EXAMINATION for caries during well-child visits between 6 months and until the patient is able to access a dental home. instructions that can be shared with parents ••Quickly brush the varnish on all tooth surfaces. ••If possible. No brushing until the following morning. or sealants. multiple languages).PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK SUZANNE BOULTER. Varnish applications are most effective if done 4 times per year. toothpaste. consider brushing most of the Depending on the brand of fluoride varnish. after the first primary tooth erupts for high-risk children. so there is very low risk of toxicity from swallowing.cfm (in are available dries almost instantly on contact with it will help set up the varnish. be a slight temporary discoloration of the teeth. but it can decrease tooth decay rates by as much as 38%. time if applying to more that 12 teeth. neck lamp or head light lamp. or sitting on caregiver’s lap . How to Apply Flouride varnish Supplies needed Gloves Wipes Light source Varnish packets ••Position the patient on the lap of the parent/guardian Technique ••Sit with your knees touching knees of parent/guardian. THAT’S IT! ••Have supplies ready to go and gloves on. ••Open the varnish packet. do 1 quadrant at a will return to their natural color. other options include a well-positioned goose ••Give the child something cold to drink. there may material on the non-dominant glove to retrieve quickly. Varnish After varnish at: aap.

) 72 PERFORMING PREVENTIVE SERVICES . aap. States With Medicaid Funding for Physician Oral Health Screening and Fluoride varnish (see aap. (See Figure 1.) Reimbursement for oral health risk assessment and fluoride varnish application vary from state to state. D 1206. The most common codes that Medicaid will reimburse are health for future updates) Billing Current Dental Terminology (CDT) codes are included as part of the standard procedural code set (along with CPT) under L U O R I D E VA R N I S H A P P L I C AT I O N T I P S Figure 1. (see Oral Health Reimbursement Table available at: http://www.pdf. and D-0145.

25 mL 0. 0. 0.4 mL VarnishAmerica Medical Product Laboratores 800/523-0191 Topex DuroShield a Direct sales 0. if you have a child that doesn’t have a full set of primary teeth.dentsply.25 mL Darby. Omnii/3M ESPE 800/445-3386 Yes Patterson 800/552-1260 Multiple Unit Doses in Dose 1 Tube 0.Resources Suppliers of fluoride varnish Fluoride Name AllSolutions Manufacturer Colophonium Supply Company Resina Dentsply Professional 800/989-8826 www.25. others Same as above 0. the amount not used is wasted. Omni claimed that some people are allergic to colophonium and this offers an alternative.4 mL 0.5 mL in each unit dose container. and the practitioner would use a dispensing guide to use the desired amount (eg. 0.4 mL Sultan Healthcare 800/238-6739 Yes + xylitol Patterson or Darby 5% NaF White Varnish from 3M ESPE is available without the colophonium resin. It also has a total of 0. 0.4 mL 0.) 0.1% difluorosilane 5% NaF Fluo-Protector Ivoclar North America Vivadent 800/327-4688 Polyurathane base No Patterson 0.40 mL Sullivan-Schein.4. 0. Since it is a unit dose intended for one person.25 mL Fluoride 5% NaF Cavity Shield Patterson.5 mL). or 0. The listing of brand names does not imply endorsement.4 mL brushes separate 5% NaF PHYSICAL EXAMINATION White Varnisha 3M ESPE 800/445-3386 Medicom 800/361-2862 Colgate Oral Pharmaceuticals No 5% NaF Durafluor Yes Patterson 800/552-1260 5% NaF Duraphat Yes Colgate Oral No Pharmaceuticals 10-mL tube 5% NaF (Purchase brushes separately from Henry Schein: 800/372-4346.25 mL 10-mL tube. Dental Supply Companies Darby Patterson Dental City 800/645-2310 800/328-5536 800/292-7910 73 Sullivan Schein 800/372-4326 .25 mL 04 mL 0.


which is the degrees that the foot points in (a negative foot progression angle) or points out (a positive foot progression angle) relative to a straight line. While Bright Futures does not have specific recommendations regarding orthopedic assessments during early childhood. To discover where the toeing in or toeing out is coming from you must assess the hip range of motion. Lie the child down on the lap and do the same examination with the hips extended. To do this.PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK DONNA PHILLIPS. Estimate the degree of rotation and record it quickly on the examination paper to prevent confusion when 75 How Should You Perform These Examinations? The evaluation of the child needs to begin with a history. place one hand on the pelvis and rotate the hip internally and externally until you feel the pelvis move. Estimate the degree of internal and external rotation. internally and externally rotate the hips. MD INTOEING AND OUTTOEING Given the prevalence of rotational findings of the lower extremities in early childhood. It is also imperative that a long hallway is used to observe the child run or walk and observe their gait. knowledge of the etiology and the natural history is reassuring to the parents. and outtoeing. appropriate studies and referrals can be made. Examine each hip individually. it is useful to observe the undressed child playing in the examination room. If normal. it is important to understand when additional studies and referral are necessary. Ideally. Hip Rotation Evaluation With young or fearful children. turn the child prone to assess the rotation with the hips extended. Evaluation for each of these includes observing the child walking or running. Including the following questions: ••What do parents see that they are concerned about? ••When did they first notice the problem? ••Has it changed over time? Is it better? Is it worse? Is it just different? ••What is the family history? Did anyone else have the problem as a child or persisting into adulthood? ••What is the child’s birth history? ••Have they reached the appropriate developmental milestones? ••What is the child’s diet? . Estimate the foot progression angle. Our task is to distinguish normal from abnormal. Intoeing and Outtoeing Toeing in or out may come from the hip. and examine the feet. including intoeing. examine them on their parent’s lap. tibia or foot. PHYSICAL EXAMINATION Why Is It Important to Assess Orthopedic Issues During the Physical Examination? Many children who toe in or toe out are normal. With the child’s hips flexed to a right angle. the editors determined that these conditions are sufficiently important and common to include in this handbook. If the condition is thought to be abnormal. It can be of great concern to parents. an appearance of knock knees and bow legs can be normal. While taking the history. Similarly. The specific examinations for different conditions are as follows. assess the tibial torsion. if the child is not apprehensive.

As a result. If you explain the natural history to the parents. and now the internal tibial torsion is “uncovered” and they intoe. It can be done at the same time as the hip rotation evaluation. By the time the children are age 3. especially as time goes on and they see that the bowing is disappearing and the intoeing in is appearing as predicted. for feet that turn outward as a result of twisting of the tibia outward. I do the examination on the parent’s lap. As the hips loosen up. Over time. With the child prone. The typical physiologic genu valgum corrects spontaneously and the knees should be straight by about age 6 years. giving an appearance of bow legs. the ankle joint is facing inward (internal tibial torsion) or outward (external tibial torsion). however. The children will be less fearful in this position. For a strong demonstration to the parents about the etiology. The child can still be placed in this in-utero position to demonstrate to the parents. there is no in-utero position with the knees and feet straight ahead. or metatarsus varus. the tibial torsion and the femoral anteversion also correct. Confirm this by putting the patellae facing anteriorly and the bowing should be much less evident. although it is slow. giving it a bean shape. they will be reassured. Show the parents the position of the leg between the knee and the ankle. If they have a combination of internal rotation of the hip (the typical child will sit in the “W” position easily) combined with external tibial torsion the knock knee appearance will be more pronounced. Assess how flexible it is by tickling the child or observing their spontaneous movements. they walk with their knees turned outward and their feet straight ahead. Point the knee toward you and gently dorsiflex the foot to neutral.” Family history and examining the parents can be useful in predicting how much the child will correct the intoeing by the time they reach adulthood. Therefore. Similarly. they walk with their knees forward. Feet Observe the feet separately from the tibia. their knee flexes and looks like it is jutting out laterally. or children who are not fearful. that all children do not fully correct these rotational “deformities. the degree of twisting of the tibia and the amount of twisting is assessed with the patient in a sitting or supine position. I reserve this examination for older children. Remember that the child can also be packed in utero with the feet turned outward in the same direction as the knee and will be born with external tibial torsion. Tibial Torsion Tibial torsion is most accurately evaluated with the patient prone on the examination table. Most noticeable is when one leg has external tibial torsion and one has internal tibial torsion. However. This is the “thigh-foot-angle” and represents the amount of tibial torsion. flex the knee 90 degrees and imagine a line down the thigh and a line down the axis of the foot. This is not a true varus. Usually this will be with the hips externally rotated so the knees are facing outward. and it is easier to demonstrate to the parents why the child toes in. With younger children. usually by the age of 2 years. This is metatarsus adductus. place the child in their in-utero position. stretch it and see if it is passively correctable. The tibia has to be twisted for the child to fit in the uterus. For feet that turn inward as a result of twisting between the knee and the ankle (internal tibial torsion) this would be a negative thigh-foot-angle and is measured in degrees. and the feet tucked in toward the midline.INTOEING AND OUT TOEING documenting the examination in the medical record. If the child does not straighten it out spontaneously. Do one hip at a time and record the degree of internal and external rotation as you do the exam. This is one of the reasons toddlers look so cute running up and down your hallway in their diaper—every time they take a step. Beware. Putting It All Together Natural history: Many children when they start to walk have physiologic bow legs (genu varum). Show the parents that while the knee is facing you. the thigh-foot-angle would be a positive number. From the bottom of the foot you will be able to see clearly if there is a “hooking” inward of the forefoot. giving a “windswept” appearance. they will typically have a true knock knee (genu valgum). They have soft tissue external rotation contractures of their hips from the in-utero positioning combined with internal tibial torsion. 76 PERFORMING PREVENTIVE SERVICES .

including an annual edition of Coding for Pediatrics. These children have external rotation contractures of their hips. and bowlegs are of concern in toddlers. I describe it to parents as “hips like a baby. however. Surgery may be indicated in these children. knock knees. visit the American Academy of Pediatrics Online Bookstore at www. Most intoeing and outtoeing is normal.”). so simple examination and observation are indicated. their feet will also be straight ahead. or residual internal tibial torsion. Keep a close eye on the child to be sure the condition is correcting and changing the way you expect. Adolescent children with genu varum should be referred to a pediatric orthopedist for diagnosis and treatment for possible adolescent Blounts. If it is rigid or severe. The adolescent who outoes needs to be evaluated for a slipped capital femoral epiphysis.Young babies who have external tibial torsion from their in-utero position. There is no predictable way to change the natural history. Often simple stretching is sufficient to fully correct the foot deformity. If the examination is also consistent with normal intoeing and outtoeing. determine if the history is consistent with a normal condition (“My child was so bow legged when he first started walking.41 736. Most intoeing and outtoeing. They should be referred to a pediatric orthopedist. 754. but now combined with external tibial torsion.” As the hips loosen up and they walk with their knees straight ahead. ICD-9-CM Codes 736. then the intoeing may be very noticeable.89 736. will predictably outtoe when they start to walk. PHYSICAL EXAMINATION 77 .60 Tibial torsion (internal and external) Genu valgum Genu varum Metatarsus varus (adductus) Unspecified/other congenital anomaly of LE The American Academy of Pediatrics publishes a complete line of coding publications. It is usually detected at birth or shortly after birth. as typically seen with calcaneovalgus feet. What Do You Do With an Abnormal Result? First. If this is combined with internal tibial torsion that has persisted.aap.53 755. The children who have metatarsus adductus may spontaneously correct without treatment. For more information on these excellent resources. Do not overlook this diagnosis as the presenting complaints may be outtoeing and a limp. and now he toes in. There are some children who reach early adolescence and they are unable to get their feet straight ahead due to femoral anteversion. specific treatment may be needed. There are exceptions to this. reassure the family. legs like an adult. older children may continue to intoe due to excessive internal rotation of their hips.


DrPH PAUL B. Several studies suggest that earlier onset of puberty may be associated with being overweight in girls. Early puberty may be a marker for environmental exposure to estrogen-like chemicals. or both.PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK MARCIA HERMAN-GIDDENS. known as endocrine disrupters. PA. anticipatory guidance for children and parents is even more important than it was in the past Racial and ethnic differences in ages of achieving pubertal milestones vary. but studies are ongoing. Many early-maturing children do well. gymnastics. These children may be late maturers because of constitutional delayed puberty. that may affect the reproductive axis. but occasionally boys or girls with precocious puberty have intracranial abnormalities or adrenal or gonadal conditions that require intervention. Several papers report an increased incidence of psychopathology in young adults who started puberty at an early age. approximately half of African-American girls and 15% of white girls will have some evidence of breast development. pubic hair growth. and late onset may be associated with abnormal thinness or a very high sustained level of physical activity. Identification of sexual maturity also is important in order to offer appropriate anticipatory guidance and to recognize problems related to pubertal abnormalities that need referral. Recent studies suggest that the age of onset of puberty is close to 1 year earlier in US girls than 30 years ago. Results from the Pediatric Research in Office Settings study of puberty published in 1997 indicate that by the age of 8 to 9. Evidence as to whether a similar trend is occuring in boys is inconclusive at this time. Most cases of precocious puberty are idiopathic. for which there is often a positive family history. Children with delayed puberty may have conditions that require intervention. or anorexia nervosa. isolated gonadotropin deficiency. KAPLOWITZ. or decreased body fat due to exercise (particularly swimming. but others show an increase in behavioral problems. MD SEXUAL MATURITY STAGES Sexual maturity staging is a standard assessment for normal growth and development. Given the younger age of appearance of signs of puberty. The age of pubertal onset may be declining. Other conditions that may need assessment or intervention include acquired gonadal failure. PHYSICAL EXAMINATION Why Is It Important to Assess Sexual Maturity Stages During the Physical Examination? Children with early puberty may have problems coping with the physical and hormonal changes of puberty. The issue of whether or not early puberty is associated with more frequent emotional problems is complex. With regard to boys. Early and rapidly progressive precocious puberty can sometimes result in adult short stature. Girls may have difficulty coping with early menses and boys may experience excessive libido. data on the relationship between overweight and earlier pubertal development are conflicting. 79 . This suggests that early-maturing children need close monitoring of their physical and mental health. gonadal dysgenesis due to Turner syndrome. and studies are conflicting. and ballet dancing). Currently no clear evidence exists that environmental chemicals are the major cause of earlier puberty in girls.

2001:155.911–919. During the fourth grade (age 9). slightly pigmented downy hair. Pediatrics.4 14.07 14.70 10.00 16.5 11. but the area over which it is present is smaller than in most adults. mainly at the base of the penis. 1988–1994. This rating system has been widely used for decades in studies worldwide. It has not yet spread to the medial thighs or along the linea alba (in males).24 13. The stages are commonly referred to as the Tanner stages.70 13. about 21% of African-American boys and 4% of white boys have at least Stage 2 pubic hair. 80 PERFORMING PREVENTIVE SERVICES .8 13. et al. Estimates from the National Health and Nutrition Examination Survey III.4 13.1 14. Boys: Median Age of Transition to Tanner Stages by Race/Ethnicity Stage Pubic Hair 2 3 4 5 Genital Development 2 3 4 5 10. and more curled.9 10.80 11.39 11. It is spread sparsely over the pubis. Secondary sexual characteristics in boys. Koch G.5 15.70 10.57 11. This hair has not yet developed the characteristics of pubic hair.30 White AfricanAmerican MexicanAmerican Reliable data for American boys are not available for testicular growth. It may spread to the medial surface of the thighs. straight or only slightly curled.57 11.38 11.29 15.5 15.S E X U A L M AT U R I T Y S TA G E S Girls: Median Age of Transition to Tanner Stages by Race/Ethnicity Stage Pubic Hair 2 3 4 5 Breast Development 2 3 4 5 10.1 12.5 13. There is no conventionally accepted scale for axillary hair development.43 10.7 11.43 13.33 9. Pubic Hair: Male and Female Pubic Hair Stage 1 Prepubertal.7 15.79 12. Source: Sun SS.90 14.9 9.8 White AfricanAmerican MexicanAmerican Source: Herman-Giddens ME.2 12. Pubic Hair Stage 2 There is sparse growth of long.19 16.47 9. coarser. Wang L.48 10. 2002:110.6 13. Pubic Hair Stage 5 The hair is adult in quality and quantity and has the classical triangular distribution in females.4 12. Arch Pediatr Adolesc Med.7 15.8 13.4 12.75 13.1 15. The vellus over the pubis is similar to that on the abdomen.5 13. Cameron W. What Are the Stages of Sexual Maturity? The system of sexual maturity rating most commonly used is based on the work of Marshall and Tanner.92 9.7 12 12. Schubert CM.3 13. Pubic Hair Stage 4 The hair is adult in type. Pubic Hair Stage 3 The hair is considerably darker. National estimates of the timing of sexual maturation and racial differences among US children.

Genital Stage 4 The penis enlarges further in length and breadth and the glans becomes more prominent. Breast Stage 3 The breast and areola further enlarge. Genital Stage 2 Only the testes and scrotum have begun to enlarge from the early childhood size. How Should You Perform Sexual Maturity Staging? Pubic Hair Staging ••Ensure adequate lighting. The papilla and areola project to form a secondary mound above the rest of the breast. Breast Stage 2 The “breast bud” stage. testes. where the first pubic hair may initially be only along the labia. The penis is still prepubertal in appearance. PHYSICAL EXAMINATION ••Familiarity with the pictures in standard texts (such Breast Staging colored hair in the genital area with pubic hair if it is similar to the hair found on other parts of the trunk or thighs. Penis. The texture of the scrotal skin is beginning to become thinner and the skin appears redder due to increased vascularization. ••The Tanner method. Breast tissue is firmer and discoid in shape. Some females never progress to Stage 5. There is further darkening of the scrotal skin. Genital Stage 5 The penis. Breast Stage 5 The mature adult stage. Genitals: Males Genital Stage 1 Prepubertal. testes. in some children. it is likely adipose tissue. lightwith the pants and underwear completely removed or lowered to the knees. `• If further assessment is needed • Examine breast with patient in supine position. It can be difficult to distinguish between Stages 2 and 3. as some children may be in between stages. and scrotum are about the same size and proportions as in early childhood. A bud of glandular tissue is palpable below the nipple. and elevates from the rest of the breast. with progressive exposure to estrogens. It is important to take into account whether the penis is uncircumsized when assessing penile growth. mainly in length with some increase in breadth. the areola widens. needs to be supplemented by palpation for overweight girls. as the uncircumsized penis may appear larger than it really is. Only the nipple is elevated. There is no change of contour between the nipple and areola and the rest of the breast. presenting a rounded contour. slightly darkens. Genital Stage 3 There is further growth of the testes and scrotum. the areola becomes thicker and darker 81 . and scrotum are adult in size and shape. The diameter of breast tissue is still smaller than in a mature breast. • In girls. Breast Stage 4 The breast continues to grow. If the consistency under the areola is similar to peripheral tissue. This is especially true in girls. the appearance does not match the pictures.Breasts: Females Breast Stage 1 There is no development. The secondary mound disappears. as those shown in this chapter) is helpful but. and examine the genital area ••In assessing pubic hair do not confuse fine. The testes and scrotum are larger. which involves staging of breast development by inspection alone and comparing it with standard pictures found in many texts. The penis is also beginning to grow.

As included in Yen SSC. 1978. Pathophysiology and Clinical Management. 2nd ed. De Haas JH. Growth Diagrams 1965. De Haas JH. 2 3 1 2 4 3 4 5 5 Girls stages of pubic hair growth. Philadelphia. 1971. Jaffe RB. 1971. 2nd ed. 82 PERFORMING PREVENTIVE SERVICES . Growth Diagrams 1965. Verbrugge HP. PA: WB Saunders. Growth Diagrams 1965. Jaffe RB. 2nd ed. The Netherlands: WoltersNoordhoff. Verbrugge HP.S E X U A L M AT U R I T Y S TA G E S 1 2 3 4 5 Boys stages of genital and pubic hair development. Groningen. Wafelbakker F. Source: Reprinted of Elsevier from van Wieringen JC. As included in Yen SSC. Reproductive Endocrinology: Physiology. Verbrugge HP. Groningen. Wafelbakker F. Pathophysiology and Clinical Management. eds. PA: WB Saunders. 1978. eds. Philadelphia. The Netherlands: Wolters-Noordhoff. Girls stages of breast development 1 Source: Reprinted of Elsevier from van Wieringen JC. Reproductive Endocrinology: Physiology. Groningen. 1978. PA: WB Saunders. Reproductive Endocrinology: Physiology. 1971. Philadelphia. De Haas JH. The Netherlands: WoltersNoordhoff. eds. Wafelbakker F. As included in Yen SSC. Source: Reprinted of Elsevier from van Wieringen JC. Pathophysiology and Clinical Management. Jaffe RB.

and estradiol are of no value if there is no breast development. calipers. known as an orchidometer. The risk of pathology is low. ••Labs are of limited use in typical cases in `• Prepubertal boys nearly always have a testicular length of 2. Ultrasound is the most accurate measurement method. do not increase penile length. The beads correspond to testicular volumes of 1 mL through 25 mL. index. which there is early appearance of pubic hair. such as chordee. Breast Development Isolated breast development with normal growth starting before age 3 is most likely due to premature thelarche. the earliest and most reliable sign of pubertal ••Where further assessment is needed descended and that the urethral opening is at the tip of the glans (ie. and eventually reaches the adult size of 5. However.5 cm or less or volume of 4 mL or less. 83 `• To measure penile length accurately. and bone age should be considered in higher-risk cases. • Adrenal androgens. as it reflects increased secretion of the pituitary gonadotropins. hypospadias. a benign normal variant due to an early increase in adrenal androgen secretion. follicle stimulating hormone (FSH). or anomalous genital development. `• In normal prepubertal boys. and middle finger and lining up a small ruler along the long axis of the testis. It occurs more often in girls but is not infrequent in boys. 17-hydroxyprogesterone. As puberty progresses. `• Testicular size can be assessed by comparing testes with beads of varying size developed by Prader. and extensive hormone testing and x-ray evaluation are generally not needed. Other methods of measurement include rulers. girls whose breast enlargement progresses rapidly (eg. the diagnosis is likely premature adrenarche. `• Increasing penile length occurs later than initial growth of the testes. Luteinizing hormone (LH). another benign normal variant. early breast development is most often found in normal girls who start to mature at the early end of the normal range. Dehydroepiandorsterone sulfate (DHEA-S). Pathology is not common but is more likely in those children showing clear acceleration of linear growth.0 cm or 25 mL. In girls ages 7 to 8. These girls can be monitored by the primary care physician if there is no progression or referred to a specialist if there is rapid growth or significant increase in breast diameter over time. that the boy does not have hypospadius). Breast development starting between the ages of 3 and 7 should generally be referred if it has persisted for at least 6 months. development is enlargement of the testes. testosterone. unless there is rapid progression of pubic hair and/or growth acceleration. the increase in testicular size usually precedes the increase in penis size. the penile length is usually between 5 to 7 cm. use either a ruler or a marked tongue blade pressed at the base of the penis while applying firm stretch to the penis itself. penile abnormalities. .Male Genital Measurements ••The examiner should verify that the testes are What Should You Do With an Abnormal Result? Precocious Puberty General Observations Any child with signs of early puberty should have growth carefully plotted. If the only abnormal finding is appearance of pubic hair (often accompanied by axillary hair and odor). already at Tanner 3 when first seen or rapidly increases to Tanner 3) are at higher risk of pathology. `• The physical examination record should note for undescended testicles. which cause pubic hair development. PHYSICAL EXAMINATION `• Another widely used method is to measure the greatest diameter by positioning the testis between the thumb. A stretched length of 8 cm or greater indicates increased testosterone effect. ••In boys. and ultrasound.

Bourdony CJ. Delayed Puberty Girls who have not started having breast enlargement by age 13 and boys who have not started having penile and testicular enlargement by age 14 are. and bone age A child with delayed puberty and significant slowing of growth may need to be evaluated for growth hormone and possibly other pituitary hormone deficiencies. it may be helpful in these cases to see the child every 6 months rather than yearly. premature thelarche ••Useful labs if there is both testicular and penile growth: LH. and bone age The American Academy of Pediatrics publishes a complete line of coding publications. 1999. premature adrenarche. Boys with pubic hair only most likely have premature adrenarche. 2005 Herman-Giddens ME. ICD-9-CM Codes 259. compared with about 2% of girls starting puberty between the ages of 6 and 8. delayed and need to be evaluated and appropriately managed. Oberfield SE. 84 PERFORMING PREVENTIVE SERVICES . though with less urgency. estradiol. Drug and Therapeutics and Executive Committee of the Lawson Wilkins Pediatric Endocrine Society. American Academy of Pediatrics. such as visual abnormalities. FSH (will be elevated in gonadal failure). 1995 ••Useful labs: LH. For more information on these excellent resources. American Academy of Pediatrics. pulmonary). estradiol (in girls). including an annual edition of Coding for Pediatrics. they should also be referred. 17-hydroxyprogesterone. and bone age ••Useful labs if there is increased penile growth but prepubertal testes: testosterone. cardiac. Assessment of Sexual Maturity Stages in Boys. The risk is much higher if there are new neurologic findings. Genital Development Boys who have an increase in testicular and penile size before age 9 need to be referred for evaluation. Be certain to send full evaluation testing on growth chart to referral DHEA-S.S E X U A L M AT U R I T Y S TA G E S ••Useful labs for high-risk cases: LH. and results. IL: Pediatric Research in Office Settings. IL: Pediatric Research in Office Settings. Boys with a significant increase in penis size but not testicular enlargement may have congenital adrenal hyperplasia or a virilizing adrenal or testicular tumor.104:936–941 Books Herman-Giddens ME. gastrointestinal. Document lab tests and x-rays ordered. What Results Should You Document? Record Tanner staging in the chart at all routine health supervision visits. renal. by definition. a hypothalamic hamartoma [nonmalignant] or a glioma or astrocytoma). testosterone (in boys). For patients showing signs of early or delayed pubertal maturation. If the child is referred to a specialist for further evaluation. and bone age Nearly 20% of girls who start puberty before age 6 have abnormal brain magnetic resonance imaging findings (eg.0 259. Bourdony CJ. severe and frequent headaches. Assessment of Sexual Maturity Stages in Girls. as well as other chronic diseases (eg. be certain to give a copy of the results of any hormone testing or x-rays done as well as the growth chart to the parents to take to the appointment. FSH. visit the American Academy of Pediatrics Online Bookstore at www.1 Delayed puberty Precocious puberty. testosterone. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. before deciding if a referral to an endocrinologist is needed. FSH. or new onset of seizures. Pediatrics. Resources Evidenced-based Guidelines Kaplowitz PB.aap. as well as the follow-up plan. Elk Grove Village. Elk Grove Village.

Mendola P. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings Network. Pediatr Rev. Variations in the pattern of pubertal changes in girls. Marcus M. diagnosis.31:189– 195 Rosen DS. 1988–1994. Brauner R. Adan L.30:205–212 Marshall WA. 2002. New York. Secular trends in height among children during 2 decades: the Bogalusa Heart Study. Slora EJ. 1997. Rubin CH. Pediatrics.51:37–62 Kaplowitz. Pediatr Rev. Arch Pediatr Adolesc Med. 2001. Wasserman RC.109:61–67 Freedman DS. Khan LK. Pediatrics. Serdula MK. 1988–1994. and treatment. Kieszak SM. Arch Dis Child. Delayed puberty. 2004 Articles General Chalumeau M. Trivin C. Early puberty in Girls: The Essential Guide to Coping With This Common Problem. Arch Dis Child. Troiano RP. Arch Pediatr Adolesc Med. Earlier onset of puberty in girls: relation to increased body mass index and race. Adv Pediatr. 2002. Stature and pubertal stage assessment in American boys: the 1988–1994 Third National Health and Nutrition Examination Survey. Testicular size: assessment and clinical importance. Buck GM. Foster C. PB. Koch G. NY: Ballantine Books. Hormone Res. Herman-Giddens NE. 2001.44:291–303 Prader A.22:309–315 PHYSICAL EXAMINATION 85 . Variations in the pattern of pubertal changes in boys. Central precocious puberty in girls: an evidence-based diagnosis tree to predict central nervous system abnormalities. Breart G. Triangle.Kaplowitz PB. definitions. Delayed puberty. Wang L. Secondary sexual characteristics in boys: estimates from the national health and nutrition examination survey III.154:155–161 Gafni RI. Pediatrics. 2000. Slora EJ.155:1022 1028 Kaplowitz PB. 2004. Wasserman RC. Berenson GS. Chemaitilly W. Pedlow SE. 1966. 1970. Pediatrics.45:13–23 Marshall WA. 1969.99:505–512 Herman-Giddens ME. Tanner JM. 2010. J Adolesc Health. Precocious puberty: update on secular trends. Tanner JM. Ethnic differences in the presence of secondary sex characteristics and menarche among US girls: the Third National Health and Nutrition Examination Survey. Bryant J. Assessment of thelarche by the inspection method of Tanner is less accurate than palpation. Chow C. 2001. et al. Srinivasan SR.108:347–353 Karpati AM. 2002. 2005:64(suppl 1):205–206 Herman-Giddens ME.110:752– 757 Pubertal Abnormalities Kaplowitz P.7:240–243 Wu T. Baron J.


and knee. or disruption of the skin in the midline raises concern for underlying spina bifida. Some of these conditions will require further evaluation and treatment by a specialist in general or pediatric orthopedic surgery. hip. Perform a Spine Examination Observe. Specifically. A spine examination begins with inspection of the skin overlying the spine. deep tendon reflexes. HIP. and knee. the scapula. and gag reflex. ••Examine the extremities. Examination findings are often the key to appropriate referral. ••Observe gait and other movements. ••Take a careful history of developmental milestones. Hip. a number of pathologic hip conditions will present with knee symptoms. is specifically described in Bright Futures. This chapter reviews and illustrates several of the skills and findings from the orthopedic examination of the spine. and the iliac crests with the patient in a 2-leg 87 light touch sensation in the major dermatomes and peripheral nerve distributions. and knee during childhood. A number of pathologic conditions can arise or present in the spine. Specific incidences of each vary with age. `• Unilateral refusal to bear weight in the very young child or significant exacerbation of pain with weight bearing in the verbal child can be worrisome and requires further evaluation. PHYSICAL EXAMINATION Why Is It Important to Assess Spine. at a minimum. Assess. Perform an Overview Examination of the Musculoskeletal System ••Test muscle strength in the major flexion and extension groups for each joint. such as developmental hip dysplasia. How Should You Perform This Examination? The examination will vary with the age of the patient and the suspected anatomy involved.THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES STUART WEINSTEIN. it is critical to evaluate the spine. `• Asymmetry should raise suspicion for underlying pathology. ••Assess neurologic function. MD SPINE. AND KNEE Although this manual is not intended to replace books that review physical examination techniques. Visually and manually note the symmetry in the height of the shoulders. `• Observation of gait for screening is primarily concerned with symmetry and secondarily with difficulty in basic movements. This examination includes the following components: . abdominal reflexes. and Knee During the Physical Examination? An accurate examination is key to appropriate referral. including. Dimples. hip. at minimum. When evaluating any presenting complaint anywhere in the lower extremities or back. hip. screening for specific diseases of high incidence. hair tufts.

Palpate. `• With hands together and arms dangling down. Although more sensitive radiographic measures of lower limb length discrepancy and truncal imbalance for screening exist. Rotate at hip. however.S P I N E . flexion contracture. extension. `• The patient stands with feet shoulder width apart. abduction. When feet are brought toward and past each other. 90 degrees. facing you. careful observation should reveal any severe asymmetries. the hips are in internal rotation. Swelling or erythema around a hip is highly unusual. is common with long-standing intraarticular hip pathology. which usually prevents it from laying flat against the bed. these should be vertically well-aligned. The patient then straightens up again. Preventive Services Task Force no longer recommend screening for scoliosis. ••The American Academy of Pediatrics and the US Conduct a provocative test. H I P. the difference in height relative to the lower side or the angle subtended between the horizontal and a line tangential to the rotated section of the trunk should be measured and recorded. Hip internal rotation levers the foot away from body midline and hip external rotation levers the foot toward body midline. ••Internal/external rotation: Assess with the hip flexed to examination table. ••Flexion/extension: With the child lying supine on an Assess `• The patient repeats the bending a second time with ••Watch for the truncal rotations that consistently result from scoliosis and other spine deformities. Lack of full extension. If the scapula or ribs on one side appear rotated upward when the patient is bent forward. best clinical information about the hip joint is gleaned from observing gait and supine resting preferred position as well as examining range of motion (flexion. Typical signs of an intra-articular source of pain and effusion are that the patient with a painful effusion resists or refuses to bear weight. the patient slowly bends forward at the hips and lower spine until the hands are near or have touched the floor. bring both hips up to maximal flexion and then release one at a time to extend back to the examination table. It will not generally be noticeable unless the contralateral hip is fully flexed. Assess rotation with the hip extended with the child lying prone on the examination table and the knees flexed to 90 degrees. Observe. or perpendicular to the body. the hips are in external rotation. but these initial basics can be included for children and adolescents of most ages. Although the hip joint capsule may be palpated just lateral to the palpable femoral pulses. symmetric. 88 PERFORMING PREVENTIVE SERVICES . Palpate. adduction. The hip is slightly flexed and externally rotated. ••The scapulae and posterior rib contours should be back facing you. when a concern is present regarding spinal curvature. A N D K N E E stance. the forward bend test is as follows. A scoliometer can also be used and the angle of rotation measured and recorded. slowly. When the feet are brought away from midline. This permits measurement of both the degree of flexion in the flexed hip and the potential presence of a lack of full extension in the extended hip. A single spinous process should be palpable in the midline at all levels from the lower cervical through the lumbar spine. Perform a Hip Examination Hip examinations will vary significantly with age. Both the maximal arc of motion and the presence of pain at the extremes of that arc should be noted. In the coronal plane. and internal and external rotation) and strength.

This may indicate that the bowing is not physiologic. With the child supine on the examination table. Normal adult alignment of 7 degrees of valgus between the tibia and the femur is reached by early school age. With the infant supine on a firm surface and sufficiently calm. Apply posterior (downward) pressure. The infant’s knees are nested in the examiners first web space. grasping knee between thumb and fingers. smooth resistance without yield or clunk. this test is subluxes or dislocates from the acetabulum. performed in infants 0 to 3 months of age. Developmental dysplasia of the hip (DDH) may have no obvious sign other than limited hip abduction unilaterally and/or bilateral waddling gait. observe the overall alignment of the lower limbs. Hip abduction raises the joint reactive forces across the painful hip. Adduction is measured similarly in hip extension but with the knees brought toward and past midline. is characteristic of 3. Hold hips as in Barlow. Abduct hips with the thumbs and simultaneously apply medial and anterior pressure with the long fingers. or the patient leaning over the painful hip for balance. With the child standing in a 2-leg stance. A positive test will reduce the femoral heads into the acetabulum during abduction. Watch the child walk and look for a lateral thrust of the knee. or an opening up of the knee into a more varus position. the patella should be roughly vertically aligned between them. Compare side to side. Measure abduction by recording the angle subtended between the midline axis and the femur at the extremes of abduction. and is avoided. flex the both hips to 90 degrees (thighs will be perpendicular to the trunk if the knees are also at 90-degree flexion).••Abduction/adduction: This maneuver is especially important in toddlers. PHYSICAL EXAMINATION Perform a Knee Examination Observe. When the ankles are centered under the anterior-superior iliac spines. The normal degree of coronal plane angulation across the knee will vary with age. or knock-kneed alignment. Maximal valgus. Hold the infant’s thighs with thumbs medially and fingers laterally. but place the tip of (second or third digit) finger(s) over the infant’s greater trochanters. Infants are born with physiologic varus or bow-legged alignment of their lower extremities. ••Ortolani test: Also for DDH screening. A negative test should yield firm. Single-leg stance on the normal hip with normal abductor strength will maintain a level 5-year-olds. This corrects to neutral alignment by 18 to 24 months of age. Conduct a provocative test ••Trendelenburg sign: Intra-articular hip pathology ••Barlow provocative test: This maneuver is intended to frequently induces weakness in hip abduction. screen an infant (0–3 months of age) for DDH. the knees are brought maximally away from midline both at full hip extension and at 90 degrees’ hip flexion. A positive Barlow test will yield a clunk sensation as the femoral head 89 . A positive Trendelenburg sign is defined as the contralateral pelvis dropping below level. Weakness will be evident when the patient stands on the ipsilateral lower limb.

If there is internal tibial torsion. the child should be supine on the examination table with the knees and hips extended and adducted until the limbs touch. If the child is bow legged. If the ankles approximate first. if a specialist with experience in this technique is available in your medical care system). to full flexion. is suggestive of (lateral or medial) meniscal pathology. the child can be examined in the parent’s lap: Child and parent will be facing examiner with child seated in lap. examine wrists for metaphyseal flaring. at the joint line (laterally or medially). To evaluate Q-angle: With the child lying supine. the angle between a line connecting the anterior superior iliac spine and the center of the patella and a line from the center of the patella to the tibial tubercle (the insertion of the patella tendon). Infantile Blount’s disease. If the child is apprehensive. Differentiate effusion from generalized swelling by the presence of a fluid wave or by shifting of the area of maximal swelling with variously applied manual pressure over bulging areas of the joint capsule. consider rickets (obtain a dietary history. or tibia vara. phosphorus. If bowing (or valgus) is no longer present. calcium. Tenderness of the knee just proximal to the tibial plateau. This is a radiographic diagnosis and requires consultation from a pediatric orthopedist. maintain a low threshold. measure the distance between the medial malleoli of the ankles (intermalleolar distance). This is a quantitative measure of clinical valgus. where the tibia and femur are parallel. must be considered in children who walk early and have an increasing or persistent varus deformity at 2 1/2 years.S P I N E . Scales or Tools No specific grades or tools exist for these examinations. Increases in this angle may be associated with patellofemoral instability. the distance between the medial femoral condyles (intercondylar distance) is the quantification of genu varum. the condition is likely physiologic. Symmetry is more important than meeting a set expected range of motion. feet will cross. and obtain radiographs. H I P. but with the knee flexed 30 degrees. where the heel touches the ipsilateral buttocks. A N D K N E E Palpate. Assess. 90 PERFORMING PREVENTIVE SERVICES . Prominence or tenderness of the tibial tubercle suggests a diagnosis of Osgood-Schlatter disease. Refer the infant for plain films (generally after 4 months of age) of the hips or for ultrasonography (usually done in the first 2–4 months. Hips and knees are flexed 90 degrees with knees facing examiner. especially with lateral thrust on weight bearing. To evaluate genu varum (bow legs) or genu valgum (knock knees). examine ribs for beading. alkaline phosphatase. Consider skeletal dysplasia in any child with genu varum or valgus deformities who has poor linear growth. and it is getting worse over time. Knee motion ranges from full extension. and 25 OH vitamin D). What Should You Do With an Abnormal Result? For hip abnormalities in an infant. Make the referral to the orthopedic surgeon who cares for children’s orthopedic problems in your referral system. This specialist may be a general orthopedic surgeon or a pediatric orthopedic surgeon. This angle is normally 12 degrees with the apex toward the midline. If the knees touch first.

31 754. 686–694. thigh. It is a non-billable code unless a diagnosis is attached.aap. and knee.6 What Results Should You Document? Findings for each of these examination maneuvers can be documented in a typical clinical note by simple description of both normal and abnormal findings. Be certain to perform and document an examination of the knee and hip for any patient with complaints near either joint. as well as knee. since hip pathology often presents with knee pain. Provides information on various orthopedic screening examinations for children. 9th ed.0 754.0 588. 745–778 Morrissey R.30 fractures.43 754.5 754. including an annual edition of Coding for Pediatrics. 91 . Philadelphia. Genu valgum may represent a variety of pathologic conditions. Scoliosis (and kyphoscoliosis) idiopathic Resolving infantile idiopathic scoliosis Progressive infantile idiopathic scoliosis Genu valgum Genu varum Active rickets Renal osteodystrophy Congenital dislocation of hip unilateral Congenital dislocation of hip bilateral Congenital subluxation of hip unilateral Congenital subluxation of hip bilateral Congenital dislocation of one hip with subluxation of other hip Congenital bowing of tibia and fibula Congenital bowing of unspecified long bones of leg Congenital varus deformities of feet Congenital metatarsus varus Congenital valgus deformities of feet PHYSICAL EXAMINATION 737. and Weinstein SL (eds) Lovell and Winters Pediatric Orthopaedics: 6th ed.fpnotebook. Web Sites The Family Practice Notebook: http://www.30 737. Lippincott. It is often a unilateral disorder in obese children with complaints of knee pain.53 754.31 737. Williams and Wilkins. Provides information on screening examinations and techniques for the spine. Bates’ Guide to Physical Examination & History Taking.3 for screening for developmental dysplasia of the hip. Wheeless’s Textbook of Pediatric Orthopaedics: http://www. or asymmetric genu valgum to an orthopedic surgeon or pediatric orthopedist for evaluation. It is especially important to examine and document hip findings. For more information on these excellent resources.42 2002:507–557.Adolescent children may develop Blount’s disease. referral to an orthopedic or pediatric orthopedic surgeon is recommended. com/Ortho/Exam. Use radiographs to rule out tumors.32 736. and skeletal dysplasias. The American Academy of Pediatrics publishes a complete line of coding publications. Resources Books Bickley LS. Philadelphia. PA 2006.35 754. Use laboratory studies to rule out renal osteodystrophy and rickets.32 754. PA: Lippincott Williams and Wilkins.44 754. wheelessonline. ICD-9-CM Codes 1130 The only coding specific to these musculoskeletal screening examinations is V82. visit the American Academy of Pediatrics Online Bookstore at www.41 736. especially poor linear growth. progressive. Refer severe. and leg findings. hip.33 754. with any knee complaint in children.


PHYSICAL EXAMINATION How Should You Perform a Sports Physical Examination? The history is the most important aspect of the evaluation process. The most common causes of sudden cardiac arrest in children and adolescents are hypertrophic cardiomyopathy (HCM). or feel more fatigued than expected during exercise? ••Has a doctor ever told you that you have any heart problems? ••Has a doctor ever ordered a test for your heart? ••Has any family member or relative died of heart ••Does anyone in your family have a heart condition. but a full history and physical also are warranted. total anomalous pulmonary venous return. tightness. with the 3 key systems being the cardiac. or pressure in your chest during exercise? ••Does your heart ever race or skip beats during exercise? ••Do you get lightheaded. If an athlete answers yes to any of the following questions. arrhythmias.” Now the American Academy of Pediatrics suggests that adolescents in need of a yearly physical examination to participate in sports receive a complete health supervision checkup.PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK ERIC SMALL. the most important cardiac history questions include ••Has anyone in your family had unexplained fainting or 93 . These statements can guide your history interview. health care practitioners performed a specific “sports physical. and neurologic systems. or long QT syndrome? Based on the latest Preparticipation Physical Evaluation. Perform a Cardiac History and Examination A cardiac history and examination are important because 12 to 36 sudden cardiac deaths occur annually in youth younger than 18 years. pain. feel more short of breath. and long QT syndrome. This chapter will discuss some of the particular aspects that may need to be addressed in children and adolescents who are interested in participating in sports. Many of these issues also may be reviewed in adolescents and children who do not participate in organized sports. drowning? problems or had an unexpected or unexplained sudden death before age 50? such as hypertrophic cardiomyopathy or dilated cardiomyopathy. musculoskeletal. MD SPORTS PARTICIPATION In the past.1 withhold participation clearance until you complete further diagnostic workup. Marfan syndrome. fourth edition (forms at the end of this chapter). Randomized clinical trials to test screening questions for cardiac sports participation clearance have not yet been conducted. but the American Heart Association and other organizations have published several consensus statements on this topic. ••Have you fainted/passed out (or nearly fainted) during or after exercise? ••Have you ever had discomfort. Marfan syndrome. The fourth edition of the preparticipation physical evaluation form is an excellent tool for documenting the history and physical evaluation for athletes as discussed below.

S P O R T S PA R T I C I PAT I O N Syncope. the athlete can typically run and jump but may have difficulty with lateral movement. An athlete should not return to play until full range of motion and 90% of baseline strength are achieved. The return to play may be anywhere from 2 to 12 weeks. In such cases. Acute (ankle sprain. patella dislocation) and chronic (Osgood-Schlatter disease. Perform a Musculoskeletal History and Examination A musculoskeletal history and examination are important because these types of conditions and injuries are identified more than any other conditions and injuries. such as wrestling or full-contact martial arts. determine clearance. Noncontact sports are permitted in all cases of decreased visual acuity. In the case of a patella dislocation. the athlete can usually walk but not run and jump. Syncope occurring during exercise is concerning for a cardiac disorder (both anatomical abnormalities [HCM] and conduction [WolfeParkinson-White syndrome. ••In a severe sprain. however. These injuries are most commonly lateral and are graded for function as mild. Noncontact sports may be permitted at the time of the examination. Range of motion is easy to test but strength may be difficult. 94 PERFORMING PREVENTIVE SERVICES . which may be differentiated from medial tibial stress syndrome by well-localized. and determine scope of participation. is not recommended. This injury is defined as diffuse pain over the anteromedial tibia. functional testing. •• ••In a moderate sprain. or severe. Syncope occurring while standing or sitting with no other pertinent historical events is not a contraindication to sports participation. protective eyewear is recommended. athletes may participate as long as they are not limping at the end of a game or practice and have full range of motion and 90% strength. Nonsteroidal anti-inflammatory drugs may be used for analgesia and anti-inflammatory effects. Ankle sprains. such as sprinting and jumping on one foot. Neither is a contradiction to full participation. Like Osgood-Schlatter disease. is needed. moderate. Nutrition counseling. Perform a Neurologic History and Examination The neurologic history is important because many athletes who have experienced concussions return to play but still experience symptoms. such as inability to concentrate and learning difficulties. After taking the history and performing the examination. The patient will have pain at the distal Achilles tendon insertion into the calcaneous. but limited duration is advised. he or she may begin to practice. Athletes with poor vision and best-corrected visual acuity of 20/40 in one eye are considered functionally one-eyed. Participation in high-contact sports. Perform Eye and Kidney Histories and Examinations Conduct a funduscopic examination for cataracts and screening for visual acuity. Syncope is a sudden. Stretching and strengthening is suggested. with particular attention to salt and hydration status. Sever’s disease. Running and jumping may not be permitted for 4 to 6 weeks following tibial stress fractures. These conditions are typically diagnosed at the time of the physical examination. Osgood-Schlatter disease (tibial tuberosity inflammation at patella tendon insertion). Scoliosis and kyphosis. may be performed. In a mild sprain. The athlete may participate if he or she is not limping at the end of a game or practice. prolonged QT] abnormalities). shoulder dislocation. pinpoint pain and tenderness. Shoulder and patella dislocations. establish a referral mechanism. Sever’s disease (calcaneal apophysitis). shin splints) conditions may present themselves during the history or the physical examination. not due to head injury or seizure. walking may be difficult. Shin splints should not be confused with a tibial stress fracture. Shin splints (medial tibia stress syndrome). Once the athlete can demonstrate function. you may need to conduct an assessment for underlying genetic or neuromuscular disorder. transient loss of postural tone and consciousness with spontaneous recovery.

every effort should be made for some type of sports participation. James FW.121. American Academy of Family Physicians. collision. IN: National Collegiate Athletic Association. Physical Activity. Protective eyewear for young athletes.115:1643 McCory P. it is extremely important to have a coordinated approach with the team coach. American Academy of Pediatrics. the athlete needs individual assessment for contact. 2007:51 PHYSICAL EXAMINATION What Should You Do With an Abnormal Result? The results of your history and examination will lead to 1 of 3 categories for sports participation: cleared. In: Klossner D. Indianapolis. Br J Sports Med. 1994. NCAA Staff. Johnston K. ed. It is quite straightforward when an athlete is cleared. 2007. The confusing area is when a student athlete is temporarily not cleared or is in need of further evaluation. 2005. et al. American Orthopaedic Society for Sports Medicine. J Am Coll Cardiol. 2004. For athletes who have one paired organ. 2005.26(10 suppl):S223–S283 Grinsell MM. and limited-contact sports and a clear discussion about the risks of participation in sports and recreational activities that may have incidental or deliberate contact.For patients who have a single kidney or a single functioning kidney. Pediatrics. and Metabolism: endorsed by the American College of Cardiology Foundation. the Preparticipation Physical Evaluation. 2006. Single kidney and sports participation: perception versus reality. Reference 1. family. IL: American Academy of Pediatrics. 4th ed. Med Sci Sports Exerc. This category may result from an injury (eg. Pediatrics. Meeuwisse W. Showalter S. a fracture or recent surgery) or medical condition (infectious mononucleosis or concussion). Task Force 12: legal aspects of the 36th Bethesda Conference recommendations. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition. with protective gear if necessary. Strong WB. NCAA Sports Medicine Handbook 2003–2004. What Results Should You Document? The patient’s health record and school forms need to indicate the student’s participation or restrictions. Burners (brachial plexus injuries): sports medicine guidelines.39:196–204 Mitten MJ.118. Norwood VF.841–848 Schluep C. American College of Sports Medicine. Gordon KA.45:1373–75 Rice SG. Bricker JT. et al. and in need of further evaluation. providing such equipment remains in place during activity. Maron BJ. American Medical Society for Sports Medicine. Protective equipment may reduce risk of injury to the remaining kidney sufficiently to allow participation in most sports. Ackerman MJ.1019–1027 Maron BJ. In these circumstances. Zipes DP. Graham TP Jr. Circulation. Thompson PD. American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. 2010 Resources Articles American Academy of Pediatrics Committee on Sports Medicine and Fitness.113:619–622 95 . and athlete. not cleared. 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Prague 2004. Pediatrics. 2008. Elk Grove Village. Summary and agreement statement of the 2nd International Conference on Concussion in Sport. and American Osteopathic Academy of Sports Medicine.






. . . . . . . . . . . CCC-A . . . . . . . . . . . PhD. . . . DelMonte. . . . . . . . . . . S Adolescent Alcohol and Substance Use and Abuse Cervical Dysplasia John Knight. . . . . . 137 Susan M. . . . . . . . MD. . . MD. . . . . Certain screenings are universal (ie. . . . . . Timothy Roberts. . . . . . . . . . . . . . . . The chapters in this section of the book were selected because they provide important “how-to” information to guide health care professionals. . . . . . . . a child will receive a tuberculin skin test at the 7-year visit if he or she answers positively on risk screening questions. .PERFORMING PREVENTIVE SERVICES: A BRIGHT FUTURES HANDBOOK SCREENING creening occurs at each Bright Futures health supervision visit. . . . and Monte A. . . . . . 103 Susan M. . . Newborn Screening. . . . . . . . . . . MD. . and Shari Van Hook. Joy Gabrielli. . . . . . all children at the 1-year visit are screened for lead exposure. MD. . . . . . Yussman. . . . . . . . . . MPH. . . . . . . . . . . . . . . . . . they are applied to each child at a particular visit). . . . . . . . . . . . MPH. . . . . . Other screenings are selective (ie. . The Immunizations. . Yussman. . . . MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MD. . . . . . . . . . . . . . and Capillary Blood Tests Sexually Transmitted Infections Vision Lynn C. For example. . MS. . . . . . . . MPH . . . 147 Alex Kemper. . . . . . . . . . . . . . . . . . . . . . . and Susanne Tanski. they occur only if a risk assessment is positive). . MD. . . . . . . . For example. Ensuring that all children’s and adolescents’ immunizations are complete is an essential element of preventive health services and a key component of each Bright Futures visit. . . . . MD . . . . 155 101 . . . . . . . . . . . . . . . . MPH . . . . . and Capillary Blood Tests chapter provides up-to-date information on all the immunization schedules. . MPH . . . . . . . . MD. . . . . . . . . . . Garfunkel. . 117 Ann Clock Eddins. . . 113 Developmental and Behavioral Considerations Hearing SCREENING Frances Page Glascoe. . . . . . 129 Immunizations. Newborn Screening. . . . . . . . . . . . . . . . MD . . . . . . . . MPH. . . .

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