Pediatric Primary Care Case Studies (26 page)

   
Immunization history:
A review of Maria’s immunization history reveals that she is up to date with all required immunizations for a child of 3 years.

   
Physical activity:
You ask about the type of physical and play activities Maria did yesterday. Mrs. Smith took the kids for a walk around the block before she went to work and then grandma babysat. Maria told her mom that she and her brother and grandma watched her grandma’s “soaps,” played with their toys and dolls, and then watched her favorite videos in the afternoon until her dad picked the children up. Maria and her dad played his favorite video games after they went home from grandma’s house at 7 p.m. Mrs. Smith got off from work at 8 p.m.

Psychosocial History

   
School adjustment:
Maria seems happy at school and is doing well. The only issue has been that some of the kids call her “fatso,” which prompted the teacher to call Mrs. Smith and talk to her about Maria’s weight.

   
Discipline:
You ask Mrs. Smith how she disciplines Maria when her behavior is not appropriate and how she rewards Maria for good behavior. Mrs. Smith says that Maria has a short time-out in her room and that she rewards Maria with praise. When asked whether she uses food as a reward, Mrs. Smith said, “I try not to reward her with candy like her grandparents do, but I’ve been giving her a piece of chocolate every day that she doesn’t fight with her baby brother. That seems to be the only way to control the fighting between Maria and Bobby.”

What aspects of the physical examination will be important in this case?

A developmentally appropriate approach to conducting the physical examination of a 3-year-old such as Maria involves approaching her slowly and keeping her mother close to her, gaining her involvement in the examination process, and giving attention to issues of modesty that may now surface as an area of concern for some preschoolers. A complete physical examination is needed, with the primary care provider being diligent to investigate for signs of secondary complications associated with obesity (e.g., obstructive sleep apnea, hypertension, orthopedic issues, etc.).

Physical Examination

Maria is in the 75th percentile in height and well above the 95th percentile in weight. Her BMI places her in the 97th percentile; her BP is normal for age, sex, and height percentile. Her general appearance is that of a happy but noticeably overweight preschooler. The general physical examination is within normal limits for age with the following positive findings: multiple caries involving the upper incisors and lower molars, and purple striae on her thighs. Chafing marks of her inner thighs are noted, and her vulvar area is erythematous, but without discharge. Inspection for acanthosis nigricans is negative.

The cardiovascular examination is within normal limits for age and reveals a normal S1 and S2 with no murmurs noted. She has full range of motion in all joints with bilateral
symmetry and good strength in all extremities. A waddling gait is noted when she walks back and forth in the room. The EENT (eyes, ears, nose, and throat) exam is normal for age with 3+ tonsils bilaterally.

Making the Diagnosis

Do you need to do anything else, such as laboratory studies, to confirm the diagnosis?

Routine urine and hemoglobin screening is a standard practice in your clinic at the 3-year health supervision visit.
Maria’s urine dip is negative for glucose and ketones and all other urine parameters are negative. Her hemoglobin is 11 g/dL, which is normal for her age.
These results provide baseline data to help you rule out anemia as well as glucosuria and ketonuria. A baseline fasting lipid profile for triglycerides, total serum cholesterol was ordered because of the paternal grandfather’s history of a heart attack at age 52 years. In addition, a thyroid screen was ordered because Mrs. Smith wanted reassurance that Maria’s overweight was not due to hypothyroidism. Otherwise, thyroid testing is not necessary at this age if the only symptom is overweight with no other symptoms such as goiter, brittle hair, stunted growth, or fatigue consistent with hypothyroidism present (Libman, Sun, Foley, & Becker, 2008). Although type 2 diabetes in children is predominantly seen after 10 years of age, you order a fasting blood glucose because Maria is at high risk due to her family history and ethnic background.

What are your diagnoses?

Maria’s Hispanic/African American ethnic status puts her in a high risk category for obesity. Her history and physical examination with a BMI > 95th percentile are consistent with the diagnosis of obesity due to poor nutritional practices and an inactive lifestyle. Obesity is a family issue that must also be addressed. She has multiple caries. In addition, the possibility of obstructive sleep apnea needs further assessment and monitoring of symptoms. You will await the results of her lipid, thyroid, and fasting glucose readings to determine whether additional problems are identified. Maria’s cognitive, gross and fine motor skills, and language development are appropriate for age. Her thigh and vulvar skin irritation can be easily treated with topical barrier agents. In summary, your diagnoses are:

•   Obesity with a BMI at the 97th percentile

•   Normal cognitive, language, social, and fine and gross motor development for age

•   Caries

•   Thigh and vulvar skin irritation secondary to obesity

Management

Overview of Nutrition and Physical Activitiy Guidelines

The U.S. Department of Agriculture provides guidelines and recommendations for structuring a healthy diet for children 2 years of age or older at
http://www.mypyramid.gov/KIDS/
. The healthy diet emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products and is low in saturated fats, trans fats, cholesterol, sodium, and added sugars. Appropriate food portion size for age is stressed. This Web site contains information about developing personal MyPryamid goals and planning meals. Another important point to stress with parents of young children is the need to limit fruit juice to ≤ 4 ounces per day at any age (Spear et al., 2007), excessive milk intake, and sweetened beverage intake.

Sixty minutes or more of daily moderate to vigorous intense physical activity is recommended to maintain weight. For preschool children, this is interpreted as active play. The benefits of moderate and intense levels of physical activity also include improved mood and attention (Berkey, Rockett, Gillman, & Colditz, 2003) and reduction of cardiovascular risk factors, whether or not weight loss occurs (McGavok, Sellers, & Dean, 2007; McMurray, Harrell, Creighton, Wang, & Bangdiwala, 2008). Limiting a child’s daily screen time to no more than 2 hours is important. Sedentary activities are often a way of life for obese children or adults who may find physical activity difficult. Thus, the obese child will need to start with shorter periods of moderate to vigorous physical activity and gradually increase to these recommended levels over time. To lose weight, at least 90 minutes of vigorous daily physical activity are needed.