The well-child checkup: Bright futures or dim economics?

May 2005

The well-child checkup is the bread and peanut butter and jelly of pediatric practice. Although both are often sticky and messy, without checkups general pediatricians would become like the proverbially advertised Maytag repairmen — twiddling their thumbs a lot.

As their primary medical physician, we perform a host of valuable services for each of our patients — advocating and providing immunizations, along with dispensing sage advice about safety, child development and lifestyle. However, like my wife’s daunting “to-do list” for each Saturday, the laundry list of 20 to 30 items for discussion advocated by the AAP Bright Futures for preventive care has become quite time-consuming.

Within the span of about 15 minutes, we are supposed to allow parents to ask multiple open-ended questions about child care and dispense a laundry list of advice, which must usually be learned on the job, as a recent editorial by Stein and Stanton in April 2005 Journal of Pediatrics surmises.

So what can we do? Should we skimp on the physical examination? The open-ended questions? The litany of advice? The exchange of pleasantries? I can emphasize first-hand, that we had better not short-cut or relinquish the physical examination, even for seemingly minor problems or healthy children.

Case vignettes

A) The time crunch.

In my allotted 15 minutes for a newborn check-up, I was discussing the routine issues about breast-feeding, later introduction of solids, importance and safety and adverse effects of vaccines, sibling rivalry/jealousy, etc., with the mother of a growing 2-month-old infant. Winding down, time had become quite short, so I wondered if I should just examine the “major” systems?

In the case of our 2-month-old infant under discussion, the abdominal examination of this perfectly normal child revealed some significant hepatosplenomegaly. Oops! My face became drained. I feared something dreadfully wrong, and this perceptive mother sensed it. She asked me, “What could it be?” Taking my usual non-alarmist position, I answered with my customary, “I don’t know. The list of problems is as long as my arm. Let me perform some more tests.” So then I asked her to submit her child to a venipuncture for CBC and serum chemistries and an abdominal ultrasound. So my “routine checkup” may have saved this child’s life. The incidence of this disease is about one in 500,000.

B) The look in her eyes.

No, this is not some romantic ballad. The mother brings her healthy, active precocious 3-year-old little girl in for her annual checkup. “Oh by the way, for the last week, she has also been complaining of some headaches and something ‘funny’ in her eyes,” the mother said.

I was able to get a glimpse into this youngster’s fundi. The venous pulsations were absent, and the disc had a peculiar appearance, almost protuberant. Honestly I had no clue what I was seeing. But I had looked at hundreds of normal fundi over the years in children with headaches, etc., to know that my friendly pediatric ophthalmologist, Craig Douglas, MD, deserved a frantic phone call. The incidence of this disease approaches one in 270,000.

C) Famous last words.

Last month, an intelligent, charming 16-year-old female, who is active on her high school soccer and softball teams, returned for a recheck because one of her knees was still bothering her. On her routine checkup four months previously, she was complaining of bilateral knee pain, and her otherwise normal knee examination revealed an obvious painful unilateral tibial tuberosity, consistent with Osgood Schlatter’s disorder — a diagnosis we probably observe twice weekly in our heavily adolescent-populated practice. She was instructed to rest her knee when needed, and to use NSAID’s as necessary. But she was also asked to return if the problem worsened or significant changes occurred.

Although her father thought that she had the same problem of atypical gout as he suffered from in his youth, the daughter had normal serum uric acid and no other pattern suggestive of gout. After a two-month interlude of near normal sports activity, the mother again became worried about recurrence of her daughter’s knee pain. But my cardinal rule is always listening to the mother. The daughter’s current examination revealed complete resolution of Osgood Schlatter’s disorder. Now she had mild pain with compression or motion of her patella, and a slight effusion. We concluded the visit, in which I had discussed her presumptive chondromalacia patella, but also her acne flare-up, her oligomenorrhea and her dysmenorrhea — each of which required prescriptions. She implores, “But Doctor Block, this week she has begun crying whenever she straightens her knee.” Hysterical teenager? Manipulative teenager? I observed that when her knee was fully extended, tears rolled for the first time. This was not my usual case of chondromalacia patella. Spooked by a gut reaction and a healthy respect for adolescent female lacrimation (in the office!), I ordered a radiograph of the knee. Incidence of this disease is one in 200,000.

D) A “spinous process” or medical process?

A family friend of mine — a quite athletic attractive brunette — saw my partner, Rebecca Findlay, MD, for her soccer sports physical. She is one of a handful of students in our area who sought her sports physical from a physician, rather than the cut-rate “quickie” physical by the chiropractor in the school gymnasium. Yes, chiropractors have been granted the privilege to perform sports physicals by many state legislatures, including Kentucky and California.

Her rapid but thorough examination revealed a few too many bruises for our pediatrician’s comfort. The CBC is abnormal, and as uncovered, she may have saved this girl’s life from either hemorrhage or infection. I suppose the clinical acumen behind a spinous evaluation and adjustment would have the same outcome? The incidence of this disorder is about one in 200,000.

E) The pert 5-year-old girl was finished with her routine preschool checkup, when on second glance, I noticed that her lips seemed a tad ruddy.

When I received her routine finger-stick hematocrit report, alarms went off in my “poor-encephalic” brain. Her hematocrit was 51 mg/L. I decided she needed further evaluation for her polycythemia, especially since she lacked any chronic or even acute cardiac or respiratory symptoms. Trying not to alarm the parent, I obtained a pulse oximeter (92%), chest radiograph (normal), ECG (normal), and blood urea nitrogen and creatinine (normal). Her skin was normal, but the family history was positive for recurrent epistaxis. Suspicious for a “zebra,” I ordered a chest CT, which revealed the diagnosis. The incidence of this familial disorder is 1 in 50,000.

F) A “lengthy” discussion.

During the routine hip examination of a 6-month-old infant, when his legs were fully extended, the right leg was observed to be somewhat longer than the left when the medial malleoli were juxtaposed. As part of the routine examination for developmental dysplasia of the hips at 4- and 6-months of age, clinicians should include the following triad of observations: 1) symmetrical leg length, 2) symmetrical hip flexibility, and 3) symmetrical gluteal creases. If any discrepancies are observed, become highly suspicious for late onset developmental dysplasia of the hips. Upon further physical examination of this child, the right leg appeared somewhat larger than the left. And so did the right arm when I looked at it. Early detection prevented likely dissemination of this process that occurs in 1 in 125,000 children.

Answers to case vignettes:

A) Congenital leukemia. Her chemotherapy failed but she received a successful bone marrow transplant in infancy. She has been tumor free for six years.

B) Retinoblastoma. Both her life and her eye were saved with chemotherapeutic implants and she has been tumor free one year.

C) Osteosarcoma. Therapeutic regimen being decided.

D) Aplastic anemia-idiopathic. Successful bone marrow transplant received from her older sister.

E) Rendu-Osler-Weber’s syndrome (hereditary hemorrhagic telangiectasia syndrome). Successful embolization twice for AV malformations in the lungs; asymptomatic thereafter, but later developed substance use disorder and, sadly, killed in a motor vehicle accident in adolescence.

F) Hemihypertrophy with underlying Wilms tumor, as revealed by renal sonogram. Successful chemotherapy, tumor free for 20 years.

So, as one can appreciate, pediatricians should continue their due vigilance, as learned during seven rigorous years of medical training, to recognize and differentiate subtle but important anomalies on complete or directed physical examination. Someone’s life may depend upon it.

For more information:

• Stein RE, Stanton B. Changing needs for pediatric education in the twenty-first century. J Pediatr. 2005; 146: 445-446.

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children Editorial Advisory Board.