Pediatric Primary Care (127 page)

d.  780.52, insomnia, unspecified.

e.  780.54, hypersomnia.

f.  780.57, unspecified sleep apnea.

g.  780.71, chronic fatigue syndrome.

8.  Skin and subcutaneous tissue.

a.  701.2, Acquired acanthosis nigricans.

9.  Respiratory.

a.  Asthma.

•  786.05, shortness of breath.

10.  Orthopedic.

a.  Hip pain.

b.  Knee pain.

c.  Blount's disease.

d.  SCIFES.

III.  OBESITY ASSESSMENT

A.  Vital signs and BMI calculation.

1.  Obesity is a chronic condition involving an excess of body fat. It is often defined by body mass index (BMI). BMI varies in children by age and sex. BMI for age is weight in kilograms divided by height in meters squared (kg/m
²
).

a.  Measure height.

b.  Measure weight.

c.  Calculate BMI and plot on gender-specific growth chart (see 2000 CDC Growth Charts:
www.cdc.gov/growthcharts/
).

•  85th-94th percentile for BMI is overweight and in need of consistent education on healthy eating and physical activity.

•  BMI at 95th percentile or above is obese and in need of intervention based on severity of obesity.

d.  BMI should be tracked at each well care visit.

e.  BMI calculators are available online (see:
www.statcoder.com/growthcharts.htm
; and for parents:
www.nhlbisupport.com/bmi
).

f.  Blood pressure, (correct cuff size) documented and compared to norms for age and sex, hypertension if systolic or diastolic blood pressure higher than 95th percentile for age, gender, and height on more than three occasions.

B.  Patient history of current habits.

1.  Nutrition.

a.  24-hour recall.

b.  Fruits and vegetables.

c.  Sugar-sweetened beverages.

d.  Milk–type and quantity.

e.  Noncaloric beverages.

f.  Snacking–types and quantity.

g.  Portion size.

h.  Eat at home or eat out in sit-down restaurants or fast food–how often.

i.  Eat breakfast, lunch, and dinner or skip meals.

j.  Eat at table or in front of TV; eat alone or with other family members.

k.  Binge eating.

2.  Physical activity.

a.  Assess family's physical activity habits.

b.  Type and quantity.

c.  Access to gym, playground, boys or girls club.

d.  Physical education.

e.  Organized sports.

f.  Walking to school or in daily activities.

g.  Any shortness of breath with activity.

h.  Joint pain, knee, hip, feet, type of footwear, any use of orthotics.

3.  Screen time.

a.  Type and quantity.

b.  TV/computer in room.

C.  Review of systems.

1.  Constitutional; sleep habits, fatigue, and lethargy.

2.  Respiratory; snoring, wheezing, coughing, difficulty breathing.

3.  Cardiovascular; chest pain.

4.  Gastrointestinal; abdominal, pain, vomiting, constipation.

5.  Skin; striae.

6.  Neurologic; developmental delay, headache.

7.  Genitourinary; menarche, oligo/amenorrhea.

D.  Family history.

1.  Obesity.

2.  Diabetes.

3.  Hypertension.

4.  Cardiovascular disease.

5.  Depression.

6.  Polycystic ovarian syndrome.

E.  Social history.

1.  School/daycare.

2.  Who lives at home?

3.  Who helps parent?

4.  Are there multiple caregivers?

F.  Past medical history.

1.  Birth weight–IUGR/LGA.

2.  Complications at birth.

3.  Mental health.

a.  Anxiety, school avoidance, social isolation.

b.  Sleepiness.

c.  Recent stressors.

G.  Medications.

1.  Neuropsychiatric medications may affect weight gain.

H.  Physical exam.

1.  Skin.

a.  Acanthosis nigricans indicates increased risk of insulin resistance.

b.  Hirsutism, acne may indicate polycystic ovary syndrome.

c.  Irritation and inflammation–a complication of severe obesity.

d.  Violaceous striae indicate possible Cushing's syndrome.

2.  Eyes.

a.  Papilledema, cranial nerve V1 paralysis–possible pseudotumor cerebri.

3.  Throat.

a.  Tonsillar hypertrophy–possible obstructive sleep apnea.

4.  Neck.

a.  Goiter may indicate hypothyroidism.

5.  Chest.

a.  Wheezing–possible asthma and exercise intolerance.

6.  Abdomen.

a.  Tenderness may indicate gastroesophageal reflux disorder, gall bladder disease, nonalcoholic fatty liver disease (NAFLD).

7.  Reproductive.

a.  Tanner stage–premature puberty age younger than 7 years in Caucasian girls, age younger than 6 years in African American girls, and age younger than 9.years in boys.

b.  Micropenis–may be normal penis buried in fat.

c.  Undescended testis/micropenis may be Prader-Willi syndrome.

8.  Extremities.

a.  Abnormal gait, limp, limited hip range of motion–possible slipped capital femoral epiphysis.

b.  Bowing of tibia–possible Blount's disease.

c.  Small hands and feet, polydactyl–possible Prader-Willi syndrome, Bardet-Biedl syndrome.

I.  Laboratory tests.

1.  Complete blood count (CBC).

2.  Comprehensive metabolic panel (CMP).

3.  Fasting lipid profile.

4.  Fasting glucose.

5.  Fasting insulin.

6.  Hemoglobin A1C.

7.  Alanine aminotranferease (ALT), aspartate aminotransferase (AST).

8.  Sleep study if signs of snoring, napping, headaches, daytime sleepiness, restless sleep, and unrefreshed sleep.