The Pediatric Physical Exam:

Who, When, What and Why?

Colin Kopes-Kerr, MDAugust 2007

Is it worth being born if you have to go through a physical exam?

Healthy, asymptomatic newborns:

What do they need?

What are Your Suggestions?

?

Assumptions: The professional conducting the routine

examination of the baby will have received specific training, which meets the standard and provides the core competencies outlined in this document.

Professionals trained in the routine examination of the baby will have the opportunity to maintain their knowledge and skills through practice and periodic updating.

Routine Examination of the Newborn: Best Practice Statement April 2004 NHS

Without this…

Is any exam worth anything?

How was your training?

Any experts around?

What feature of the newborn or infant exam are you truly expert in?

Candidate exam parts:Newborn nursery

Vital signs: If they’re normal, then what? Head: presence/absence/shape/size Ears: presence/absence/shape &

position/function (hearing), ear cartilage for gestational age

Eyes: presence (closed) Mouth: presence, suck Nose: presence Neck: presence

Candidate exam parts: Chest: presence, noises(?),

clavicles(?), breast buds (for gestational age)

Heart: presence, noises Abdomen: presence, organs (they’ve

got to be in there somewhere), umbilicus, skin thickness and color (gestational age, jaundice), lesions

Back: sacral dimples, hair

Candidate exam parts:

Hips: presence, symmetry, movement of femoral head over acetabular rim, Barlow & Ortolani (?) [See handout.]

Genitalia: testicles, hernias, hydroceles

Femoral pulses??? Extremities: motor tone, palmar

creases (?)

Counting parts is not very useful.

The Dysmorphic Exam

Kind of fun—like a treasure hunt Up to 61 varieties to choose from

[See handout.]

AFP 1987: p. 307; citing J Peds 1987; 110: 531

Probably the only real point to the newborn exam is to have some fun with the infant. See who s/he is.

Is Anything Important? Red Reflex: @2 weeks: eye exam for

red reflex - (x 1 in all of childhood) Testicles: document both descended

x 1 in childhood (the earlier the better)

Eyes: Hirschberg (symmetric light reflex) and cover/uncover test each visit for strabismus.

Genitalia: only if ambiguous

Important?

6 months: ability to sit, say “mama” 12-15 months:

Walking # of words # of teeth (~1 per month after 6

months) > 24 months: gait (CDH/DDH)

Quality of speech

Important? Age 4-5 years:

Eye exam: visual acuity for amblyopia (x 1 in childhood between 4-5 years)

Femoral pulses: (if you must, x 1) Ing FF. Pediatrics 1996; 98: 378

Teeth: Dental screening exam (See handout)

Testicles: if they’re still there, forget about them.

Not Important: Heart murmurs: Hip exam (just observe gait later)

[See handouts.] Language delay (if hearing is OK) Hearing: if language is OK (Almost all

abnormals are conductive.) Development (DDST, etc.): the range of

normal is just too great Scoliosis: ever!!!

[See handouts.]

Comment on Heart Murmurs

Systolic murmurs are very common—up to 50% at various ages. There are no known primary care physicians who are any good at listening to them.

1% of births have CHD: 50% VSD, 24% PDA, 24% PS, 2% other. In the absence of symptoms they don’t need to be fixed.

No evidence that unrecognized, asymptomatic CHD is associated with significant morbidity/mortality in childhood.

COMMENTS Vision:

Myopia: “In the absence of measurable educational benefit, the only justification for myopia screening is to enhance the ability to enjoy life visually. To date, no studies support this rationale.”

Amblyopia: Prevalence 0.8-2.1% among 4-6 year old children. “The AAP recommends further evaluation of any child who has even a one-line acuity difference between the two eyes even when both eyes are within the normal range (e.g., 20/20 and 20/30). Others have suggested a two-line difference as the cutoff for referral. There are no studies of the sensitivity or specificity of either criterion, nor do we know the natural history of children with a one-line difference, to judge the likelihood of progression.

Vision Comments “The target population should

therefore be kindergarten and first-grade students. Each eye should be tested separately for distance visual acuity, referring any child with vision 20/40 or worse in either eye or a two-line difference between the eyes.”

Cross AW. School screening studies. J Peds 1985; 107: 487-94; 653-61.

COMMENTS

Dental exam: “Untreated caries is therefore by far the greatest current health problem of the school-aged child, despite the decline in caries associated with better fluoride use.”

COMMENTS: Growth:

Weight: fat children know they’re fat; skinny children know they’re skinny. What value are you adding? (Do you have the secret cure for childhood obesity?)

Height: no evidence that it matters or that intervention improves outcomes.

Head circumference: no evidence that screening improves outcomes.

[See handouts.]

COMMENTS: Blood pressure:

“From 26,200 initial measurements taken in adolescents, Fixler and Laird found that 10.2% had systolic or diastolic pressures above the 95th percentile. When measured on two additional occasions, only 1.7% had persistent elevations.”

“The goal of blood pressure screening [in schools] is to identify efficiently those children in whom hypertension will persist into adulthood and to institute treatment that will have an outcome superior to that achieved by delaying treatment until adulthood…

Comments “Blood pressure measurements in school-aged

children, taken at a single point in time, are very poor at predicting persistent pressure elevation in those children. Even persistent elevation for 1 year is a poor predictor of elevation 2 years later. Even if screening were precise, the benefits of early treatment are not established for the adolescent with mild or moderate blood pressure elevation. The extremely high false positive rate will result in the significant hazards of false labeling as well as unnecessary medical evaluations.”

Wrap Up

Children are healthy. Yields are low.

Parents are motivated! Most often they’ll tell you what’s wrong.

Your own instincts in interacting with a child are great!

Wrap Up The data say that we are not doing enough for kids in

the following areas: [roughly in order of priority]

1. Immunizations!!! 2. Dental inspection and follow-up 3. Fluoride prescriptions 4. Exercise Counseling 5. Safety Counseling 6. Reading Promotion 7. Amblyopia screening

Do Something That Matters!

Why would we want to do anything else (generally unnecessary) before we’ve completed our tasks in these 7 areas?

[Remember: You’ve only got 15 minutes per child.]