How is overall health determined in a pediatric patient?

Determining Overall Health in Pediatric Patients

Overall health in a pediatric patient is determined through a systematic assessment that prioritizes growth parameters, vital signs, comprehensive physical examination findings, and targeted laboratory testing only when indicated by history or examination abnormalities.

Core Assessment Components

Growth and Anthropometric Measurements

• Weight, length/height, and head circumference (under 3 years) must be plotted on CDC or WHO growth curves to identify percentiles and detect growth abnormalities 1, 2
• Body Mass Index (BMI) should be calculated and plotted on age- and sex-specific percentile curves, with the 85th percentile identifying mild-to-moderate overweight and the 95th percentile identifying significant overweight requiring further evaluation 3
• For premature infants, correct for gestational age when assessing growth and development through at least 24 months 1, 2

Vital Signs Documentation

• All five vital signs are essential: heart rate, respiratory rate, blood pressure, room air oxygen saturation, and temperature 1
• If the child is uncooperative and vital signs cannot be obtained, explicitly document this circumstance rather than leaving fields blank 1
• Vital signs provide objective markers of physiologic stability and are fundamental to distinguishing well from ill children 3

Physical Examination Priorities

General appearance and behavior assessment:

• Overall appearance, activity level, and interaction with caregivers distinguish ill-appearing from well-appearing children 1, 2
• Level of arousal and environmental interaction, as alterations may indicate systemic illness 2

Head and neurological examination:

• Head circumference measurement is mandatory in children under 3 years 2
• Fontanelle assessment for size, tension, and closure status 1, 2
• Tone, posture, and spontaneous movements to detect neuromotor abnormalities 1, 2

Cardiovascular and respiratory:

• Auscultation of heart for rate, rhythm, and murmurs 1, 2
• Lung auscultation for air entry and abnormal sounds 1, 2

Developmental surveillance:

• Ask parents: "Is there anything your child is not doing that you think he or she should be able to do?" and "Is there anything your child is doing that you are concerned about?" 2
• Age-appropriate milestone achievement is a critical health indicator 1, 2

Laboratory Testing: A Targeted Approach

Laboratory tests should NOT be obtained routinely for screening in healthy pediatric patients. The evidence strongly supports that screening laboratory tests in children with noncontributory history and physical examination rarely change management 4.

When Laboratory Testing IS Indicated

For children with BMI >95th percentile, obtain:

• Blood pressure measurement
• Lipoprotein analysis
• Fasting insulin and glucose determination 3

Before initiating psychotropic medications:

• Targeted medical testing may be appropriate to establish baseline (e.g., height and weight for stimulants; height, weight, and lipid testing for antipsychotics) 3
• Medical history to identify medication allergies, current medications, and family history of conditions that increase risk for side effects 3

For specific clinical concerns identified by history or examination:

• Laboratory testing should be directed by specific findings, not obtained as routine screening 4
• In one study of 1,082 pediatric psychiatric emergency visits with 13,725 laboratory tests, abnormal results changed disposition in only 0.8% of cases and changed management in 5.7%, with only one disposition change in patients with noncontributory history and physical examination 4

Critical Documentation Elements

Medical History Components

• Allergies and previous adverse drug reactions 3
• Current medications including prescription, over-the-counter, herbal, or illicit drugs 3
• Relevant diseases, physical abnormalities, and neurological impairment 3
• Prenatal and birth history 5
• Developmental history 5
• Immunization history 1, 5
• Feeding history 5
• Social history 5

Physical Examination Documentation

• Complete skin examination looking for bruising in unusual locations or patterned injuries, as concerning findings warrant consideration of non-accidental trauma 1
• If history or mechanism seems inconsistent with findings, explicitly document this discrepancy 1

Common Pitfalls to Avoid

Avoid routine screening laboratory tests in children with normal history and physical examination. This practice increases length of stay (by 117 minutes on average) without meaningful clinical benefit 4.

Do not overlook growth parameter plotting. Failure to plot measurements on standardized curves can miss critical growth abnormalities that indicate underlying health problems 3, 2.

Do not assess development without correcting for prematurity. For premature infants, subtract weeks born early from chronological age when assessing milestones through 24 months 1, 2.

Avoid incomplete vital sign documentation. All five vital signs should be recorded; if unobtainable, document why rather than leaving blank 1.

Health Outcome Measures

The most important factors for determining overall pediatric health prioritize morbidity, mortality, and quality of life outcomes 3:

• Clinical measures of physical and mental health (e.g., hemoglobin A1C, mortality rate) recommended by professional societies 3
• Quality constructs including timeliness of care, equity of access, disease screening rates, and harm indices 3
• Growth trajectory as abnormal patterns predict increased morbidity 3
• Cardiovascular risk factors in overweight children, as childhood obesity is associated with increased risks of hypertension, adverse lipid profiles, type II diabetes, early atherosclerotic lesions, and obesity-related mortality in adulthood 3