Pediatric Physical Exam

A 9-year-old female presents for well child care with her parent. She is in the 4th grade, doing well academically, plays soccer on a local team, and reports, “I have 3 best friends”. Health history per parent and child reveals no concerns. On physical exam the clinician's notes the child is at about 40th percentile height and weight for age, and has breast budding and downy, straight, slightly pigmented pubic hair long the labia majora.

These physical findings are consistent with:

A. Precocious puberty

B. Early onset normative puberty

C. Age-appropriate pubertal findings

D. Concern for a GNrH producing lesion
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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 9-year-old female presents for well-child care with her parents. She's in the fourth grade, doing well academically, plays soccer on a local team and reports, “I have three best friends.” Health history per parent and child reveals no concerns. On physical exam, the clinician notes that the child is in about 40th percentile height and weight for age, has breast budding, and downy, straight, slightly pigmented pubic hair along the labia majora. 

These findings are consistent with: 
 

A: Precocious puberty.  

B: Early-onset normative puberty. 

C: Age-appropriate pubertal findings. 

D: Concern for gonadotropin-releasing hormone (GNrH) lesion. 

And the correct answer is C: Age-appropriate pubertal finding. Where should we start with a question like this? First, determine what kind of a question it is. This is one of those questions that straddles between differential diagnosis. 

So, it's likely not the appropriate term because we're talking about what sounds like a really healthy child, and assessment, in other words, findings on her physical exam that are age-normative. Providing well-child care is truly one of the greatest joys of practicing in family primary care. I say this as a person who has had the privilege of following some families for more than 30 years and caring for multiple generations of children. 

While we need to be alert to issues of concern, part of our role is to be aware of what's normative so we can provide appropriate counseling and reassurance. That's what's at the core of this question: is this child on target or is there a problem? Puberty is part of the process of physical changes in the body, where the child matures and transitions into an adult body capable of sexual reproduction. 

This occurs through a complex process with the interplay of the brain and the gonads. While the terms ‘puberty’ and ‘adolescence’ are often used interchangeably, puberty by definition is focused on the development of secondary sexual characteristics and attainment of reproductive capability, and adolescence is a term that's more inclusive of the psychosocial as well as the physical development. Puberty consists of a series of early, predictable physical development of events outlined in the Tanner stages, also known as the Sexual Maturation Rating or the SMR, There are five Tanner stages: one is pre pubertal. 

In other words, the body of a child with no secondary sexual characteristics. Tanner stage 5, which is full adult. And we understand that Tanner 1 is that that would be a child with evidence of no pubic hair, no growth velocity, and in a female, no breast development. And we know what adult sexual secondary characteristic maturation looks like. 

What you really do need to learn is what Tanner 2, 3, and 4 look like. Regardless of birth gender assignment, 2 marks the onset of pubertal changes. This question in the podcast is focused on recommending the normative pubertal onset versus what would be of concern. In females, the earliest Tanner changes include breast budding and the development of what looks like pubic hair, but tends to be shorter, straighter with light pigmentation, and along the labia majora only at this point. 

There might be a minor increase in growth velocity. And so, you're looking at this and you go, ‘Yeah, but the kids only 40th percentile height and weight.’ Remember that the growth spurt starts at Tanner 3, not Tanner 2. And so normal onset of Tanner 2 staging in females happens between the ages of 8 and 14 years. 

In other words, an 8.5-year-old girl who's Tanner stage 2 is perfectly normal, but so would be a 13.5-year-old who's Tanner stage 2. By the way, quite often you will hear people refer to as the onset of puberty and females as marked by the first menstrual period. That's also incorrect. The first menstrual period, or menarche, typically occurs about 2 to 3 years after the onset of Tanner 2 changes. 

And so, if I was to predict with this child today, given she's 9 and Tanner 2, she will be probably 11 and maybe as late as age 12 when she starts her period. It's usually more like 2 years after the onset of Tanner stage 2. Early onset, or precocious puberty, is defined as the onset of the secondary sexual characteristics in females before the eighth birthday. 

So, there is a trend to state that most children who have breast budding between the ages of 7 and 8 have normative puberty variant. As a result, the most common reason for precocious puberty in females is early-onset normal puberty and females age 6 or younger with pubertal changes, there is significant underlying pathology and prompt referral to pediatric endo is a rule. 

With this information, let's take another look at this question. A 9-year-old female presents for a well-child care with her parent. She's in the fourth grade, doing well academically, plays soccer on a local team, and reports, “I have three best friends.” Health history per parent and child revealed no concerns. On physical exam, the clinician notes that she is at about 40th percentile height and weight for age, has breast budding, and downy, straight, slightly pigmented pubic hair along the labia majora. 

These physical findings are consistent with A: Precocious puberty, and this is of course, incorrect. Precocious puberty is defined as secondary sexual characteristics in the female, depending on whose work you look at, prior to the eighth birthday, and it might even be as low as prior to the sixth birthday. B: Early-onset normative puberty. That's also incorrect. She's well within the bell curve, if you will, for onset of puberty. 

Very often, the parent and the child will need some reassurance that these changes are perfectly normal in a 9-year-old and in fact, normative. But they don't qualify even as early-onset. C: Age-appropriate pubertal finding. This is, of course, the correct answer. You could also follow up at this visit and ask when these changes occurred. And you'll probably hear, ‘Just a few months ago.’ 

And then that can open up a dialogue about anticipating onset of menses within the next 2 to 3 years. As I said, probably more like 2 rather than 3 years. And when the child's growth spurt will start over the next year or so, these are just such helpful pieces of information to share with child and caregivers, to reassure them that this child is spot on track wise.  

By the way, I smile even looking at this-it's very common for kids this age to have multiple best friends and in fact, it is a wonderful marker that they are socializing appropriately for a child of this age. And D: Concern for gonadotropin-releasing hormone (GNrH) lesion. This is of course, incorrect as this scenario presents us with a healthy child with no particular concerns revealed. 

Key takeaway: so often in healthcare we're focused at looking at something that is a problem or a concern. 

But we also have to remember, particularly when providing well-child care, those kids are healthy and knowing what's normative in the physical exam is key to seeing an effective, clear, and counseling. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com.