THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES
PHYSICAL EXAMINATION
A
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
PHYSICAL EXAMINATION
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
Susanne Tanski, MD, and Lynn C. Garfunkel, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Blood Pressure
Marc Lande, MD, and William Varade, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Early Childhood Caries
Burt Edelstein, DDS, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Fluoride Varnish Application Tips
Suzanne Boulter, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
In-toeing and Out-toeing
Donna Phillips, MD COMING SOON
Sexual Maturity Stages
Marcia Herman-Giddens, MD, and Paul B. Kaplowitz, MD COMING SOON
Spine, Hip, and Knee
Stuart Weinstein, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Sports Participation
Eric Small, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
1

THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES
SUSANNE TANSKI, MD
LYNN C. GARFUNKEL, MD
ASSESSING GROWTH AND
NUTRITION
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,
PHYSICAL EXAMINATION
weight, and head circumference and calculation of body mass index (BMI).
Why Is It Important to Assess Growth increased blood pressure, total cholesterol, low-density
and Nutrition During the Physical lipoprotein cholesterol, and triglycerides and low levels of
high-density lipoprotein cholesterol.5
Examination?
The American Academy of Pediatrics and American
Growth measurements correlate directly to Academy of Family Physicians endorse universal screening
nutritional status and can indicate whether a child’s of BMI and use of BMI growth curves for plotting BMI
health and well-being are at risk.1 Deviations from percentiles to identify obese and overweight children.
normal growth patterns may be familial patterns but
may indicate medical problems.2 For example, abnormal Measuring head circumference, especially within the
linear growth or poor weight gain could indicate a variety first 3 years, may identify neurologic abnormalities
of medical problems, including malnutrition, chronic as well as malnutrition.5,6 Identification of abnormal
illness, psychosocial deprivation, hormonal disorders, or growth patterns can lead to early diagnosis of treatable
syndromes with dwarfism.3 Similarly, growth trajectories conditions, such as hydrocephalous, or identification of
that deviate above the norm (increased weight for height disorders associated with slowed head growth, such as
[or increased BMI]) can also indicate medical problems Rett syndrome.7
with adverse consequences. Monitoring growth and
deviations from normal patterns can help detect and How Should You Take These
allow intervention for many medical conditions and Measurements?
abnormalities.2
Calculating and tracking BMI provides vital General Considerations
information about weight status and risk of
The measurement process has 2 steps—measure and
overweight and obesity. Body mass index is a clinically
record. Accurate weighing and measuring have 3 critical
useful weight-for-height index that reflects excess body
components—technique, equipment, and trained
fat as well as nutritional status.4,5
measurers. You must use the appropriate techniques for
Obesity in childhood is associated with immediate and each measurement.
long-term adverse health and psychosocial outcomes,
Your choice of whether to use English or metric units for
leading to health problems in as many as 50% of US
measurements and plotting can depend on a variety of
children.2 Obesity in children has been associated with
circumstances. If the available equipment is accurately
calibrated and the measurers follow standard procedures,
2

ASSESSING GROWTH AND NUTRITION
then you can record data in either English or metric units. ••Align the measuring bar perpendicular to the wall
The use of metric measures is encouraged when weighing and parallel to the floor (on a stadiometer or other
infants, children, and adolescents in a clinical setting. To measuring rod) with the top of the head.
convert from kilograms to pounds, multiply the kilogram
amount by 2.2 (eg, 50 kg x 2.2 = 110 lb). ••If a scale with a measuring bar is not available, place
a flat object such as a clipboard on the child’s head in
Consistent procedures must be used. If measures are in a horizontal position and read the height at the point
error, then the foundation of the growth assessment is at which the object touches a measuring tape on the
also in error. It is important to record the date, age, and back of the scale or a flat wall surface.
actual measurements so the data can be used by others
or at a later time. ••Plot height measurements on a standardized growth
chart for age and gender, or one appropriate for the
Measure Stature (Length or Height) child.
Infancy and Early Childhood (0–2 years) Measure Weight
••Until they can stand securely (age 2 years), measure Infancy and Early Childhood
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
calibrated beam or electronic scale. Weigh older infants
••Align the infant’s head snugly against the top bar of the in a clean, disposable diaper.
frame and ask an assistant to secure it there. Parents
can help restrain infants for length measurements, as it ••Position the infant in the center of the scale tray.
is a painless procedure. ••It is desirable for 2 people to be involved when
••Straighten the infant’s body, hips, and knees. weighing an infant. One measurer weighs the infant
and protects him or her from harm (such as falling) and
••Hold the infant’s feet in a vertical position (long axis of reads the weight as it is obtained. The other measurer
foot perpendicular to long axis of leg). Bring the foot immediately notes the measurement in the infant’s
board snugly against the bottom of the foot. Some chart.
authorities suggest measuring twice and taking an
average. ••Weigh the infant to the nearest 0.01 kg or 1/2 oz.
••If an examining table is used, mark the spots at the ••Record the weight as soon as it is completed.
top of the child’s head and bottom of feet and then
measure between the marks. (Note that this is not ideal
••Then reposition the infant and repeat the weight
measurement. Note the second measurement in
as it is difficult to get an accurate length using this writing. Compare the weights. They should agree
technique.) within 0.1 kg or 1/4 lb. If the difference exceeds this,
••Plot length measurements on a standard growth chart reweigh the infant a third time. Record the average of
the 2 closest weights.
for age and gender, or one appropriate for the child
(eg, low birth weight infant, infant with trisomy 21, If an infant is too active or too distressed for an accurate
infant with Turner syndrome). weight measurement, try the following options:
Child (2 years and older) ••Postpone the measurement until later in the visit when
••Have the child remove his or her shoes. the infant may be more comfortable with the setting.
••Have the child stand up with the bottom of the heels ••If you have an electronic scale, use this alternative
measurement technique: Have the parent stand on the
on floor and back of foot touching the wall, knees
scale and reset the scale to zero. Then have the parent
straight, scapula and occiput also on the wall, looking
hold the infant and read the infant’s weight.
straight ahead with head held level.
3 PRE VENTIVE SER VICES MANUAL

Child to calculate both the BMI and age- and sex-adjusted
••A child older than 36 months who can stand without BMI percentile (http://apps.nccd.cdc.gov/dnpabmi/
Calculator.aspx). See the Resources section for further
assistance should be weighed standing on a scale
details.
using a calibrated beam balance or electronic scale.
••Have the child or adolescent wear only lightweight Measure Head Circumference
undergarments or a gown. Obtain an accurate head circumference, or occipital
••Have the child or adolescent stand on the center of the frontal circumference, by using a flexible non-stretchable
measuring tape. Head circumference is generally
platform of the scale.
••Record the weight of the individual to the nearest 0.01
measured on infants and children until the age of 3 years.
kg or 1/2 oz. (If the scale is not digital, record to the Measure head circumference over the largest
nearest half-kilo or pound). Record the weight on the circumference of the head, namely the most prominent
chart. part on the back of the head (occiput) and just above the
••Reposition the individual and repeat the weight
eyebrows (supraorbital ridges).
PHYSICAL EXAMINATION
measure. ••Place a tape measure around an infant’s head just
••Compare the measures. They should agree within 0.1
above the eyebrows and around the most prominent
portion of the back of the head, the occipital
kg or 1/4 lb. (If the scale is not digital, compare to the prominence.
••Pull the tape snugly to compress the hair and
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 underlying soft tissues. Read the measurement to the
of the 2 measures in closest agreement. nearest 0.1 cm or 1/8 inch and record on the chart.
In the standardized scale for children, all weights between ••Reposition the tape and remeasure the head
the 5th and 85th percentiles are considered normal. As circumference. The measures should agree within 0.2
important as the fact that a child’s weight falls between cm or 1/4 inch. If the difference between the measures
these percentiles on a growth chart is that over time exceeds the tolerance limit, the infant should be
the weight follows one of the percentile curves. In other repositioned and remeasured a third time. The average
words, a child who is at the 80th percentile the first time of the 2 measures in closest agreement is recorded.
he or she is weighed and at the 40th percentile a month
later is cause for concern. A child is defined as having
••Plot measurements on a standardized growth chart for
age and gender.
a failure to thrive syndrome (a medical diagnosis) if
height or weight drops below the third percentile on a ••Head circumference should correlate with the child’s
standardized growth chart. length (eg, if length is in the 40th percentile, head
circumference should also be 40th percentile).
Calculate BMI
••Choose English or metric calculation for BMI. What Should You Do With an Abnormal
Result?
`• English: (Weight (lb) / [Stature (in) x Stature (in)]) x
703 Stature
`• Metric: Weight (kg) / [Stature (m) x Stature (m)] ••Children who fall off their height curves (decline in
••Plot the child’s or adolescent’s BMI on a growth chart stature/length percentiles or present with extreme
short stature) may need to undergo evaluations for
for age and sex to determine BMI percentile. In the
United States, BMI growth charts are available for underlying medical problems.
ages 2 to 20. Alternatively, the Centers for Disease
Control and Prevention (CDC) has a Web-based tool
••First, be sure that the measurements are accurate,
make sense, and are appropriately plotted.
4

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

What Results Should You Document?
ICD-9-CM Codes
Plot height, weight, and BMI measurements in the child’s 259.4 Dwarfism
growth charts. It is essential to select the appropriate
253.0 Gigantism (cerebral, hypophyseal,
chart for the age and sex of the child or adolescent. The
pituitary)
CDC growth charts are presented as
331.4 Hydrocephalus (acquired, external,
internal, malignant, noncommunicating,
Sex and Age Charts obstructive, recurrent)
Boys, birth to 36 mos Weight-for-length 756.0 Macrocephaly
Boys, birth to 36 mos Weight-for-age 742.4 Megalencephaly
Boys, birth to 36 mos Length-for-age 742.1 Microcephaly
Boys, birth to 36 mos Head circumference-for-age 278.00 Obesity (constitutional, exogenous,
Girls, birth to 36 mos Weight-for-length familial, nutritional, simple)*
PHYSICAL EXAMINATION
Girls, birth to 36 mos Weight-for-age 278.01 Obesity, morbid*
Girls, birth to 36 mos Length-for-age 278.01 Obesity, severe*
Girls, birth to 36 mos Head circumference-for-age 278.00 Overweight*
Boys, 2 to 20 yrs BMI-for-age 783.2 Abnormal loss of weight and
underweight (use BMI code if known,
Boys, 2 to 20 yrs Weight-for-age
V85.0)
Boys, 2 to 20 yrs Stature-for-age
783.21 Loss of weight
Girls, 2 to 20 yrs BMI-for-age
783.22 Underweight
Girls, 2 to 20 yrs Weight-for-age
783.41 Failure to thrive, poor weight gain
Girls, 2 to 20 yrs Stature-for-age
783.43 Short stature
Boys 2 to 5 yrs Weight-for-stature (optional)
783.3 Feeding problem
Girls 2 to 5 yrs Weight-for-stature (optional)
779.3 Newborn feeding problem
* Obesity codes are not reimbursed in all jurisdictions.
For children between ages 2 and 3, the measurement you
Practitioners may select additional diagnoses.
obtain must match the graph you use (eg, if supine length The American Academy of Pediatrics publishes a complete line of coding publications
is measured, use the 0–3 years length-for-age graph, not including an annual edition of Coding for Pediatrics. For more information on these
excellent resources, visit the American Academy of Pediatrics online bookstore at
the 2–20 stature [standing height]-for-age graph). www.aap.org/bookstore/.
A straight edge, right angle triangle or commercially
available plotting aid is recommended to locate the
Resources
intersecting point of the axis values. After graphing a
Articles
set of measurements, check to see if they are consistent
with those from previous visits (ie, the child is on roughly Childhood Obesity Working Group, US Preventive
the same percentile lines as before). If not, check the Task Force. Screening for overweight in children and
measurements, graphing, or both. adolescents: where is the evidence? A commentary by the
When you have made accurate measurements, calculated Childhood Obesity Working Group of the US Preventive
age correctly, and plotted them on the appropriate Services Task Force. Pediatrics. 2005;116(1):235–238
growth chart, use the information in the clinical
assessment process. Share the information with the family
(ie, translate the measurements into a form that is useful
to them).
6

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

THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES
MARC LANDE, MD
WILLIAM VARADE, MD
BLOOD PRESSURE
The following guidelines are adapted directly from the “Fourth Report on the
Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and
Adolescents.” 1
Why Is It Important to Assess How Is Hypertension Defined in Children
PHYSICAL EXAMINATION
Blood Pressure During the Physical and Adolescents?
Examination?
Blood pressure falls into several categories.
High blood pressure is a growing health concern for
children and adolescents. A large national database
••Prehypertension is systolic BP and/or diastolic BP
≥90th percentile but <95th percentile for age, sex, and
shows that the prevalence of high blood pressure (BP) in
height.
children and adolescents is increasing. These increases are
even larger than would be expected from the increase in
Adolescents with BP ≥120/80 should be considered
obesity prevalence.
prehypertensive, even if 120/80 is less than the 90th
Primary hypertension is detectable in children and percentile.
adolescents. Moreover, it is a common problem.
••White-coat hypertension is BP at ≥95th percentile
The long-term health risks of hypertension can in the office, normal outside of the office setting.
be substantial. Target-organ damage is commonly Ambulatory BP monitoring is often needed to make
associated with hypertension in children and adolescents. this diagnosis.
Left ventricular hypertrophy, the most prominent finding,
is present in up to 36% of hypertensive children.
••Hypertension is defined as systolic BP and/or diastolic
BP ≥95th percentile for age, sex, and height on 3 or
In addition, elevated BP in childhood correlates with the more occasions. Hypertensive children are further
presence of hypertension in adulthood. categorized into 2 stages.
Obesity and hypertension are linked. The prevalence `• Stage 1: BP ≥95th percentile but <5 mm Hg above
of children who are overweight is increasing. Children the 99th percentile (<99th percentile + 5 mm Hg)
and adolescents with hypertension are frequently
`• Stage 2: BP is >5 mm Hg above the 99th percentile
overweight, with hypertension present in approximately
(>99th percentile + 5 mm Hg)
30% of overweight children. Given the marked increase in
childhood obesity, hypertension is becoming a significant See the Resources section of this chapter for National
health issue. Heart, Lung, and Blood Institute blood pressure tables for
children and adolescents.
8

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

What Results Should You Document? Article
Document routine blood pressures in the medical record Muntner P, He J, Cutler JA, Wildman RP, Whelton
with other vital signs. Record prehypertension and stage PK. Trends in blood pressure among children and
of hypertension in the problem list. adolescents. JAMA. 2004;291:2107–2113
Web Sites
ICD-9-CM Codes
American Heart Association: http://www.heart.org/
796.2 Elevation of blood pressure, no diagnosis HEARTORG/
of hypertension
High Blood Pressure in Children: http://www.
401.1 Hypertension, benign americanheart.org/presenter.jhtml?identifier=4609
401.0 Hypertension, malignant
International Pediatric Hypertension Association: http://
The American Academy of Pediatrics publishes a complete line of coding publications
including an annual edition of Coding for Pediatrics. For more information on these www.pediatrichypertension.org
PHYSICAL EXAMINATION
excellent resources, visit the American Academy of Pediatrics online bookstore at
www.aap.org/bookstore/.
Reference
Resources
1 National High Blood Pressure Education Program Working Group
on High Blood Pressure in Children and Adolescents. The fourth
Tools report on the diagnosis, evaluation, and treatment of high blood
pressure in children and adolescents. Pediatrics. 2004;114:555–576
National Heart, Lung, and Blood Institute
Blood Pressure Tables for Children and Adolescents:
http://www.nhlbi.nih.gov/guidelines/hypertension/child_
tbl.htm
10

B LO O D P R E S S U R E
11 PRE VENTIVE SER VICES MANUAL

PHYSICAL EXAMINATION
12

B LO O D P R E S S U R E
13 PRE VENTIVE SER VICES MANUAL

PHYSICAL EXAMINATION
Reproduced from: National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The
fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–576
14

THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES
BURT EDELSTEIN, DDS, MPH
EARLY CHILDHOOD CARIES
Bright Futures recommends that all children establish a dental home by 12 months.
In children whose teeth have erupted, “Lift the Lip” represents the basic physical
examination required to assess for dental caries. Some children need early referral
to a dentist before tooth eruption, and a screening tool for assessing caries risk is
included in this chapter.
PHYSICAL EXAMINATION
What Is Early Childhood Caries? ••Head Start children aged 3 to 5 years experience the
highest rates of tooth decay, the most unmet dental
The American Academy of Pediatric Dentistry (AAPD) care needs, the highest rates of dental pain, and the
defines early childhood caries (ECC) as one or more fewest dental visits despite enjoying the highest rates
decayed, missing, or filled teeth in children younger than of dental coverage because of Medicaid and SCHIP. 4
6 years.
By race
Why Is It Important to Assess for ECC ••Hispanic children experience higher rates of ECC (36%)
During the Physical Examination? than do black (30%) or white (23%) children. 5
Early childhood caries is highly prevalent and ••Native American and Asian-Pacific Islander children
becoming more so. Currently 28% of US children aged experience the highest rates of ECC.
2 to 5 have visible cavities, and 75% of these children are Certain groups are at high risk of developing ECC.
in need of treatment.2 Caries prevalence in children is 5 Children at high risk of ECC include
••Children with special health care needs
times that of asthma.1 The percentage of children with
ECC increased 15% over the past decade.2
Early childhood caries has strong social, cultural, ••Children of mothers/caregivers with a high caries rate
biological, dietary, and environmental determinants.
These determinants interact at multiple levels and result
••Children with demonstrable caries, plaque,
demineralization, and/or staining
in inequitable distribution of ECC by income and race.
By income
••Children who sleep with a bottle or continuously
breastfeed throughout the night
••Poor children younger than 5 years are 5 times more ••Children in families of low socioeconomic status
likely to have cavities than are children from families
living at 3 times the poverty level.3 Children should be referred to a dentist so that a dental
••Poor and working poor children have 3.5 times more home can be established by 1 year of age. For those
children at high risk as listed above, the referral should
decayed teeth than higher-income children.3 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).
15

E A R LY C H I L D H O O D C A R I E S
The ECC process becomes established at an early How Should You Perform an Early
age, with consequences for future dental health. Childhood Caries Examination (“Lift the
This process is typically established before age 2, well
Lip”)?
before most children obtain their first dental visit. Once
established, an individual’s caries process tends to be Early signs of ECC are subtle but significant. They include
stable over the lifetime. Children with ECC are therefore heavy soft plaque accumulation on the maxillary incisors
more susceptible to long-term dental problems. and “white spot” lesions that indicate early enamel
Early childhood caries also has varied and serious decalcification.
consequences for growth and development. Pain and Have Your Tools and Equipment Ready
infection resulting from the rapid progression of ECC
into the dental pulp distracts from play and learning, and ••2 x 2 gauze
••A source of good direct overhead light
often results in disturbances of eating, sleeping, behavior,
and growth.
Early childhood caries is preventable. It can be stopped ••Gloves
through a combination of
Position Yourself Correctly
••Delay in acquisition of Streptococcus mutans and other Visualize the infant or toddler’s mouth from above by
cariogenic bacteria, which are typically acquired
by infants from their mothers by direct salivary positioning yourself behind the child’s head with the child
transmission. lying on the examining table, in a carrying seat, or in your
lap as you sit knee-to-knee with the parent.
••Appropriate frequency and duration of nursing and Conduct the Examination
bottle use.
••Exclusion of sugar-laden liquids, including juice, in the ••Pull down on the lower lip and examine the mucosa.
bottle or sippy cup when used ad libitum as pacifiers.
••Lift the upper lip to examine mucosa and the maxillary
••Age- and risk-appropriate use of fluorides and anterior teeth. The first signs of ECC occur on the front
exposure to fluoridated water. surfaces of these teeth. Note that the front surface
of the lower front teeth are almost never affected by
Unmet needs for dental care among all US children
caries in young children.
are 3 times greater than unmet needs for medical
care. The ECC process typically begins well before most
children obtain their first dental visit but long after they
••Look for soft whitish plaque accumulation. Gently
scrape with your fingernail or a tongue blade to see
have begun medical care visits. Young children are more if this plaque is present along the gum line of these
likely to have a first dental visit for pain relief than for upper teeth before wiping them dry.
preventive care or anticipatory guidance.
American Academy of Pediatrics and AAPD policies
••Look closely at the dry teeth along the gum line for
crescent shaped or linear white opacities (white spots).
support establishing an early dental home. These
policies recommend that children have a dental home ••Check for color and translucency (shininess). Primary
teeth should be uniform in these aspects. Any
at the time of the first tooth or first birthday, particularly
discoloration is cause for concern.
children at high risk of ECC or other oral problems.
Infant oral health care provides an opportunity to ••Press gently on the teeth to assess that all are firmly
in place and that the child does not react to pressure,
examine children and counsel families on a range of
particularly on obviously decayed teeth.
issues in addition to ECC. These issues include oral and
dental development, digit sucking and occlusion, oral
soft tissues, home care, use of fluorides, oro-facial injury
••Compare the appearance of the upper and lower front
teeth. Any difference in tooth surface appearance is
prevention, and age-appropriate engagement of children cause for concern.
in their own oral hygiene.
16 PRE VENTIVE SER VICES MANUAL

••With gentle pressure, press down on—or in front of— For other children, counsel parents to establish a dental
the lower teeth to open the child’s mouth. home at the time of the first tooth or first birthday. Ensure
••Examine the buccal mucosa, palate, tongue, and referral of all children older than age 1 for routine dental
care.
oropharynx.
••Examine at the dentition for numbers, color, form, and Prioritize those children whose parents report a history of
problems with tooth decay in themselves or their other
disturbances that may relate to development, trauma,
children.
or caries.
••Look closely at the back surface of the maxillary What Results Should You Document?
incisors as this is another common place for first
cavities to appear; a disposable or sterilized dental Document that an intraoral examination was performed
mirror is recommended for use. and report findings that may indicate hard and soft tissue
••Grasp the child’s chin gently and guide the mouth pathologies, abnormal development, and occlusion.
PHYSICAL EXAMINATION
closed along the midline until the teeth touch. Examine
for bite. Look for normal occlusion. All of the upper
ICD-9-CM Codes
teeth should drape closely over all of the lower teeth. 521.0 Dental caries
Any disturbance from this pattern is cause for concern. The American Academy of Pediatrics publishes a complete line of coding publications
including an annual edition of Coding for Pediatrics. For more information on these
Summary: Causes of Concern excellent resources, visit the American Academy of Pediatrics online bookstore at
www.aap.org/bookstore/.
••Plaque accumulation Document fluoride varnish application as applicable.
••White opacities Document referral to the dentist, including any specific
••Discoloration of primary teeth recommendations to parents facilitating the referral.
••Differences in tooth surface appearance Resources
••Any disturbance from normal occlusion
Photographs
What Should You Do With the Results?
Normal primary dentition
For any findings of concern, refer children for further
evaluation by a dentist comfortable with young children.
••Make an urgent dental referral for any young child
with oral or dental symptoms, including stimulated or
unstimulated pain.
••Make an urgent dental referral for a child with any
intraoral or extraoral swelling that you suspect is of
dental origin.
••Make an immediate dental referral for any young child Normal primary dentition shows normal
mucosa and white, opalescent teeth
with dental discoloration, developmental irregularity, with spacing.
soft tissue lesion, malocclusion, or evidence of oral
trauma.
17

E A R LY C H I L D H O O D C A R I E S
Subtle Manifestations of ECC—Early Signs Crossbite
Note linear “white spot” decalcification Note that the posterior upper teeth are
along the gum line on these dried, inside the lower teeth and the upper
illuminated teeth. This is the first clinical and lower midlines do not coincide.
manifestation of tooth damage and
typically progresses rapidly. Tools
Overt Manifestations of ECC American Academy of Pediatric Dentistry: http://www.
aapd.org/
••Reference manual guidelines on infant oral health care,
ECC, dental home, age 1 dental visit
••Caries Risk Assessment Tool
American Academy of Pediatrics: http://www.aap.org/
12-month-old with extreme ECC. oralhealth
••Policy statements: http://aap.org/oralhealth/policy-
statements.cfm
••Tools and resources: http://aap.org/oralhealth/links-
tools.cfm
••Training and videos: http://aap.org/oralhealth/links-
training.cfm
18-month-old with extreme
ECC and abscessed incisor. Association of Clinicians for the Underserved: http://www.
clinicians.org/
••Pocket cards
Web-based Self-education Materials
Children’s Dental Health Project: http://www.cdhp.org/
The Children’s Dental Health Project is a national
nonprofit organization with the vision of achieving equity
22-month-old child with extensive ECC.
in children’s oral health. The project designs and advances
Note that the lower incisors remain intact.
research-driven policies and innovative solutions by
engaging a broad base of partners committed to children
and oral health, including professionals, communities,
policymakers, and parents.
18 PRE VENTIVE SER VICES MANUAL

Opening the Mouth: http://ccnmtl.columbia.edu/projects/ References
otm/index.html
1. US Department of Health and Human Services. Oral Health in
Oral Health Risk Assessment: Training for Pediatricians America: A Report of the Surgeon General—Executive Summary.
and Other Child Health Professionals: http://aap.org/ Rockville, MD: US Department of Health and Human Services,
National Institute of Dental and Craniofacial Research, National
oralhealth/ohra-cme.cfm Institutes of Health; 2000
The purpose of this free training is to provide a concise
2. Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for
overview of how to perform an oral examination and
dental caries, dental sealants, tooth retention, edentulism, and
conduct an oral health risk assessment and triage for enamel fluorosis—United States, 1988–1994 and 1999–2002.
infants and young children. MMWR. 2005;54(03):1–44
Protecting All Children’s Teeth (PACT): A Pediatric 3. US Department of Health and Human Services, Centers for Disease
Control and Prevention. Third National Health and Nutrition
Oral Health Training Program: http://aap.org/oralhealth/ Examination Survey (NHANES III). 1988-1994. http://www.cdc.gov/
pact.cfm nchs/nhanes.htm
Protecting All Children’s Teeth (PACT): A Pediatric Oral
4. Edelstein BL. Access to dental care for Head Start enrollees. J Pub
Health Training Program aims to educate pediatricians,
PHYSICAL EXAMINATION
Health Dent. 2000;60:221–229
pediatricians in training, and others interested in infant,
5. US Department of Health and Human Services. Healthy People
child, and adolescent health about the important role that
2010. 2nd ed. With Understanding and Improving Health and
oral health plays in the overall health of patients. The goal Objectives for Improving Health. Washington, DC: US Government
of this curriculum is not to train pediatricians to become Printing Office; 2000
dentists, but to become more knowledgeable about child
oral health, more competent in providing oral health
guidance and preventive care, and more comfortable
sharing the responsibility of oral health with dental
colleagues.
19

THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES
SUZANNE BOULTER, MD
FLUORIDE VARNISH
APPLICATION TIPS
Fluoride varnish is not a substitute for fluoridated water, toothpaste, or sealants, but
it can decrease tooth decay rates by as much as 38%. Varnish applications are most
effective if done 4 times per year, after the first primary tooth erupts for high-risk
children. 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.
How to Apply Flouride Varnish
Supplies needed
Gloves
Wipes
Light source
Varnish packets
Technique
••Position the patient on the lap of the parent/guardian
(facing the parent/guardian) with legs wrapped around
parent/guardian’s waist, or on an examination table, or
sitting on caregiver’s lap
••Sit with your knees touching knees of parent/guardian.
••If possible, have a medical assistant, older sibling, or ••Have the parent/guardian pull the child back up into a
other parent/guardian hold the light source (your
otoscope light will work fine) directed toward the sitting position.
mouth; other options include a well-positioned goose ••Give the child something cold to drink; it will help set
neck lamp or head light lamp. up the varnish.
••Have supplies ready to go and gloves on. THAT’S IT!
••Have the parent/guardian drop the patient’s head back Instructions after
onto your lap and have them hold the child’s hands. No brushing until the following morning.
••Open the varnish packet; consider brushing most of the Depending on the brand of fluoride varnish, there may
material on the non-dominant glove to retrieve quickly. be a slight temporary discoloration of the teeth; it will go
••Wipe the teeth with 2 x 2 gauze; do 1 quadrant at a away in 2 to 3 days due to brushing and eating. The teeth
will return to their natural color.
time if applying to more that 12 teeth.
••Quickly brush the varnish on all tooth surfaces. Varnish After varnish at: aap.org/ORALHEALTH/fluoride.cfm (in
are available
instructions that can be shared with parents
dries almost instantly on contact with saliva, so there is
very low risk of toxicity from swallowing. multiple languages).
20

F 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
States With Medicaid Funding for Physician Oral Health Screening and Fluoride
Varnish
(see aap.org/oral health for future updates)
Billing Reimbursement for oral health risk assessment and
Current Dental Terminology (CDT) codes are included as fluoride varnish application vary from state to state. (See
part of the standard procedural code set (along with CPT) Figure 1.)
under HIPAA. The most common codes that Medicaid
will reimburse are D-1203, D 1206, and D-0145. (see Oral
Health Reimbursement Table available at: http://www.
aap.org/ORALHEALTH/pdf/OH-Reimbursement-Chart.pdf.)
21 PRE VENTIVE SER VICES MANUAL

Resources
Suppliers of fluoride varnish
Multiple
Fluoride Manufacturer Colophonium Supply Unit Doses in
Name Resina Company Dose 1 Tube Fluoride
AllSolutions Dentsply Patterson 0.25 mL 5% NaF
Professional 800/552-1260
800/989-8826
www.dentsply.com
Cavity Shield Omnii/3M ESPE Yes Patterson, RJM, 0.25 mL 5% NaF
800/445-3386 Darby, 0.40 mL
Sullivan-Schein,
PHYSICAL EXAMINATION
others
White Varnisha 3M ESPE No Same as above 0.25 mL 5% NaF
800/445-3386 0.4 mL
0.4 mL
Durafluor Medicom Yes Patterson 0.25 mL 10-mL tube, 5% NaF
800/361-2862 800/552-1260 0.4 mL brushes
separate
Duraphat Colgate Oral Yes Colgate Oral No 10-mL tube 5% NaF
Pharmaceuticals Pharmaceuticals (Purchase
brushes
separately
from Henry
Schein:
800/372-4346.)
Fluo-Protector Ivoclar North Polyurathane Patterson 0.4 mL 0.1%
America Vivadent base difluoro-
800/327-4688 silane
VarnishAmerica Medical Product No Direct sales 0.25 mL 5% NaF
Laboratores 04 mL
800/523-0191
Topex Sultan Healthcare Yes + xylitol Patterson or 0.4 mL 5% NaF
DuroShield 800/238-6739 Darby
a
White Varnish from 3M ESPE is available without the colophonium resin. Omni claimed that some people are allergic to colophonium and
this offers an alternative. It also has a total of 0.5 mL in each unit dose container, and the practitioner would use a dispensing guide to use
the desired amount (eg, 0.25, 0.4, or 0.5 mL). Since it is a unit dose intended for one person, the amount not used is wasted. if you have a
child that doesn’t have a full set of primary teeth.
The listing of brand names does not imply endorsement.
Dental Supply Companies
Darby 800/645-2310
Patterson 800/328-5536
Dental City 800/292-7910
Sullivan Schein 800/372-4326
22

THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES
STUART WEINSTEIN, MD
SPINE, HIP, AND KNEE
Although this manual is not intended to replace books that review physical
examination techniques, screening for specific diseases of high incidence, such
as developmental hip dysplasia, is specifically described in Bright Futures. This
chapter reviews and illustrates several of the skills and findings from the orthopedic
examination of the spine, hip, and knee.
PHYSICAL EXAMINATION
Why Is It Important to Assess Spine, `• Observation of gait for screening is primarily
Hip, and Knee During the Physical concerned with symmetry and secondarily with
difficulty in basic movements.
Examination?
`• Asymmetry should raise suspicion for underlying
An accurate examination is key to appropriate pathology.
referral. A number of pathologic conditions can arise
or present in the spine, hip, and knee during childhood. `• Unilateral refusal to bear weight in the very young
Specific incidences of each vary with age. child or significant exacerbation of pain with weight
bearing in the verbal child can be worrisome and
Some of these conditions will require further evaluation requires further evaluation.
and treatment by a specialist in general or pediatric
orthopedic surgery. Examination findings are often the ••Examine the extremities.
key to appropriate referral.
••Assess neurologic function, including, at minimum,
light touch sensation in the major dermatomes and
How Should You Perform This peripheral nerve distributions.
Examination?
••Test muscle strength in the major flexion and extension
The examination will vary with the age of the patient and groups for each joint, deep tendon reflexes, abdominal
the suspected anatomy involved. reflexes, and gag reflex.
When evaluating any presenting complaint anywhere in Perform a Spine Examination
the lower extremities or back, it is critical to evaluate the
spine, hip, and knee, at a minimum. Specifically, a number Observe. A spine examination begins
of pathologic hip conditions will present with knee with inspection of the skin overlying
symptoms. the spine. Dimples, hair tufts, or
disruption of the skin in the midline
Perform an Overview Examination of the raises concern for underlying spina
Musculoskeletal System bifida.
This examination includes the following components: Assess. Visually and manually note
••Take a careful history of developmental milestones.
the symmetry in the height of the
shoulders, the scapula, and the iliac
••Observe gait and other movements. crests with the patient in a 2-leg
27

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

••Abduction/adduction: This maneuver is especially subluxes or dislocates from the acetabulum. A negative
important in toddlers. Developmental dysplasia of the test should yield firm, smooth resistance without yield
hip (DDH) may have no obvious sign other than limited or clunk.
hip abduction unilaterally and/or bilateral waddling
gait. ••Ortolani test: Also for DDH screening, this test is
performed in infants 0 to 3 months of age. Hold hips as
With the child supine on the examination table, the in Barlow, grasping knee between thumb and fingers,
knees are brought maximally away from midline but place the tip of (second or third digit) finger(s) over
both at full hip extension and at 90 degrees’ hip the infant’s greater trochanters. Abduct hips with the
flexion. Measure abduction by recording the angle thumbs and simultaneously apply medial and anterior
subtended between the midline axis and the femur pressure with the long fingers. A positive test will
at the extremes of abduction. Adduction is measured reduce the femoral heads into the acetabulum during
similarly in hip extension but with the knees brought abduction.
toward and past midline.
Perform a Knee Examination
PHYSICAL EXAMINATION
Observe. With the child
standing in a 2-leg stance,
observe the overall alignment
of the lower limbs. When the
ankles are centered under
the anterior-superior iliac
spines, the patella should be
roughly vertically aligned
between them. The normal
degree of coronal plane
Conduct a provocative test angulation across the knee
••Trendelenburg sign: Intra-articular hip pathology
will vary with age. Infants are
born with physiologic varus
frequently induces weakness in hip abduction. Hip or bow-legged alignment of
abduction raises the joint reactive forces across the their lower extremities. This
painful hip, and is avoided. Weakness will be evident corrects to neutral alignment
when the patient stands on the ipsilateral lower by 18 to 24 months of
limb. A positive Trendelenburg sign is defined as the age. Maximal valgus, or
contralateral pelvis dropping below level, or the patient knock-kneed alignment,
leaning over the painful hip for balance. Compare is characteristic of 3- to
side to side. Single-leg stance on the normal hip with 5-year-olds. Normal adult
normal abductor strength will maintain a level pelvis. alignment of 7 degrees of
••Barlow provocative test: This maneuver is intended to valgus between the tibia and
the femur is reached by early
screen an infant (0–3 months of age) for DDH. With
the infant supine on a firm surface and sufficiently school age. Watch the child
calm, flex the both hips to 90 degrees (thighs will walk and look for a lateral
be perpendicular to the trunk if the knees are also thrust of the knee, or an
at 90-degree flexion). Hold the infant’s thighs with opening up of the knee into a
thumbs medially and fingers laterally. The infant’s more varus position. This may
knees are nested in the examiners first web space. indicate that the bowing is
Apply posterior (downward) pressure. A positive Barlow not physiologic.
test will yield a clunk sensation as the femoral head
29

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

Adolescent children may develop Blount’s disease. It
is often a unilateral disorder in obese children with ICD-9-CM Codes
complaints of knee pain; referral to an orthopedic or 1130 The only coding specific to these
pediatric orthopedic surgeon is recommended. musculoskeletal screening examinations
Genu valgum may is V82.3 for screening for developmental
represent a variety of dysplasia of the hip. It is a non-billable
pathologic conditions. code unless a diagnosis is attached.
Use laboratory studies 737.30 Scoliosis (and kyphoscoliosis) idiopathic
to rule out renal
737.31 Resolving infantile idiopathic scoliosis
osteodystrophy and
rickets. Use radiographs 737.32 Progressive infantile idiopathic scoliosis
to rule out tumors, 736.41 Genu valgum
fractures, and skeletal 736.42 Genu varum
dysplasias, especially
268.0 Active rickets
PHYSICAL EXAMINATION
poor linear growth. Refer
severe, progressive, 588.0 Renal osteodystrophy
or asymmetric genu 754.30 Congenital dislocation of hip unilateral
valgum to an orthopedic
754.31 Congenital dislocation of hip bilateral
surgeon or pediatric
orthopedist for 754.32 Congenital subluxation of hip unilateral
evaluation. 754.33 Congenital subluxation of hip bilateral
754.35 Congenital dislocation of one hip with
What Results Should You Document? subluxation of other hip
754.43 Congenital bowing of tibia and fibula
Findings for each of these examination maneuvers
can be documented in a typical clinical note by simple 754.44 Congenital bowing of unspecified long
description of both normal and abnormal findings. Be bones of leg
certain to perform and document an examination of the 754.5 Congenital varus deformities of feet
knee and hip for any patient with complaints near either
754.53 Congenital metatarsus varus
joint. It is especially important to examine and document
hip findings, as well as knee, thigh, and leg findings, with 754.6 Congenital valgus deformities of feet
any knee complaint in children, since hip pathology often The American Academy of Pediatrics publishes a complete line of coding publications
including an annual edition of Coding for Pediatrics. For more information on these
presents with knee pain. excellent resources, visit the American Academy of Pediatrics online bookstore at
www.aap.org/bookstore/.
Resources Web Sites
Books The Family Practice Notebook: http://www.fpnotebook.
com/Ortho/Exam.
Bickley LS. Bates’ Guide to Physical Examination & History Provides information on various orthopedic screening
Taking. 9th ed. Philadelphia, PA: Lippincott Williams and examinations for children.
Wilkins; 2002:507–557, 686–694, 745–778
Wheeless’s Textbook of Pediatric Orthopaedics: http://www.
Morrissey R. and Weinstein SL (eds) Lovell and Winters wheelessonline.com/.
Pediatric Orthopaedics: 6th ed. Lippincott, Williams and Provides information on screening examinations and
Wilkins, Philadelphia, PA 2006. techniques for the spine, hip, and knee.
31

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