Health Maintenance in Older Children and Adolescents
Monica Sifuentes, MD
Before a 13-year-old girl enters a new school, she is required to undergo a physical examination. She has not seen a primary care physician in many years and has been healthy. Currently she has no medical complaints. Her examination is completely normal.
1. What are the important components of the history and physical examination in healthy older children and adolescents?
2. What immunizations are recommended for older children and adolescents?
3. What laboratory tests should be performed at health maintenance visits? Why?
4. What are significant topics to cover for anticipatory guidance in this age group?
Older children and adolescents are generally healthy individuals who infrequently visit physicians. If they are seen by a doctor, the visits are often for acute complaints, such as upper respiratory infections or sports-related injuries, and are, therefore, generally problem oriented. Statistics on health maintenance visits in this age group are not readily available because patients may go to several different sites for health care and often do not receive consistent comprehensive care at any of these places for a variety of reasons. Older children and adolescents seek treatment for acute and chronic conditions in private offices, urgent care centers, public health clinics, community and school health clinics, hospitals, and emergency departments. It has been reported that fewer than 50% of adolescents consistently receive a preventive health care visit during any given year, and the same percentage probably applies to older children as well.
This all-too-common practice of inconsistent health care contributes to missed opportunities for anticipatory guidance, health education, and screening for preventable conditions. Screening tests also can be used to identify treatable conditions such as hypertension, anemia, and tuberculosis. Ideally, older children and adolescents should receive recommended immunizations beginning at 11 to 12 years of age; screening for depression; counseling concerning sexual activity, contraception, and sexually transmitted infections (STIs), including HIV; reassurance to address their emotional well-being; guidelines for adequate nutrition, sleep hygiene, and screen time; education about tobacco, e-cigarettes and vaping, illicit drugs, and alcohol; and information about physical fitness and exercise as well as violence and injury prevention.
Guidelines for preventive child and adolescent health care have been published by the American Academy of Pediatrics (AAP) in conjunction with the Maternal and Child Health Bureau, US Child Health and Disability Prevention Program, AAP Section on Adolescent Health, and American Medical Association. Box 38.1 is a brief summary of these guidelines for older children and adolescents.
Health Maintenance Visit
The purpose of the health maintenance visit for an older child or adolescent is to assess their general physical health, mental and psychological health, and overall well-being and establish an independent relationship between the patient and health professional for open communication and trust for future visits. Initial questions asked during this visit should be simple and focused on how the patient feels in general about his or her health, physical growth and development, and existing relationships with family and friends. More specific questions can then be formulated depending on the patient’s responses. In healthy patients, the medical history can be obtained using a questionnaire that parents and children complete in the waiting room. If this method is used, a separate form should be given to the adolescent if they are accompanied by a parent or guardian. The information is then reviewed at the start of the interview. Chronic medical conditions should be addressed at this time.
Older children and adolescents should always be questioned directly about their medical history (Box 38.2). The parent or guardian should be encouraged to participate only after the child or adolescent has responded to questions or if invited by the child or adolescent to assist with the interview. The degree of parental participation also is influenced by the current cognitive and developmental stage of the patient.
Box 38.1. Guidelines for Adolescent Health Maintenance Evaluation
•Sexual activity (consensual and nonconsensual)
•Tobacco, e-cigarettes, or vaping use
•Drug use/abuse (CRAFFT questionnairea)
•Risk for suicide
Universal and Selective Screening Laboratory Tests/Studies
•Hemoglobin or hematocrit
•Tuberculin skin test or blood test (IGRA)
•Cholesterol (If the patient is obese or there is a significant family history of hyperlipidemia, consider other laboratory tests, such as fasting glucose and lipid panel.)
•If sexually active
— Urine or vaginal NAAT for gonorrhea/chlamydia
— Serum HIV, RPR, hepatitis Cc
— Papanicolaou testb
Anticipatory Guidance and Counseling
•Diet/nutrition, including calcium and vitamin D supplementation
•Screen time/social media
•Educational or vocational plans/goals
— Gender and sexual identity
— Safe sexual activity
— Other reproductive health issues
— Avoidance of tobacco, e-cigarettes, vaping, alcohol, and prescription and illicit drugs
— Identifying feelings of sadness/anger
Abbreviations: BMI, body mass index; CRAFFT, car, relax, alone, forget, friends/family, trouble; hCG, human chorionic gonadotropin; HIV, human immunodeficiency virus; IGRA, interferon gamma release assay; NAAT, nucleic acid amplification test; RPR, rapid plasma reagin.
b A pelvic examination with a Papanicolaou test is recommended within 3 years of the onset of sexual activity (American Cancer Society) or age 21 years (American Congress of Obstetricians and Gynecologists). For indications for a pelvic examination, see Chapter 58.
c If patient engaged in injection drug use or young man having sex with men.
Box 38.2. What to Ask
Screening in Older Children and Adolescents
Questions for Patient and Parent
•How has the child or adolescent been doing lately? Does the parent have any complaints or concerns?
•How does the child or adolescent like school? How is he or she doing academically and socially? What are his or her future goals?
•What activities does the child or adolescent currently participate in, including work?
•Does he or she have any hobbies?
•With whom does the child or adolescent live?
•Are there any significant illnesses in the immediate or extended family, such as hypertension, diabetes, or cancer?
•Does the child or adolescent take any medications, herbs, or supplements (prescribed or over-the-counter) regularly?
Questions for Child or Adolescent Alone
•Do you have any questions or concerns?
•How are things at home? Are there any problems with parents or siblings? Do you feel safe at home and school?
•Are you attending school?
•Do you like school? Who do you hang out with at school?
•Have you ever been truant, suspended, or expelled?
•What do you like to do for fun?
(See Chapter 4 for the rest of the interview.)
The psychosocial component of the interview should be conducted with older children or adolescents alone as well as together with parents or guardians after the issue of confidentiality has been reviewed (see Box 38.2). General questions about school, outside activities or hobbies, and family are often less threatening than inquiries about friends and high-risk behavior such as tobacco use. More sensitive topics relating to drug use, sexuality, gender identification, sexual orientation, and sexual activity should be addressed confidentially after parents or guardians have left the room. Subjects initially discussed with parents should be reviewed once again with teenagers alone.
A useful tool for conducting the psychosocial interview has been developed and refined by physicians who specialize in pediatrics and adolescent medicine. Known by the acronym HEADSS, it reviews the essential components of the psychosocial history: home, employment and education, activities, drugs, sexuality, and suicide/depression (see Chapter 4). Additional inquiries should be made about social media usage, including its influence on sleep hygiene. Some authors have suggested that this should be the third S in the HEADSS acronym.
A general dietary history should be obtained, with particular focus on eating habits, level of physical activity, and body image. Dietary restrictions, if any, should be investigated to assess for possible deficiencies in minerals and vitamins as well as the presence of disordered eating. Daily calcium, vitamin D, and iron intake should be reviewed, especially in adolescent females. Adolescent males should be asked about nutritional supplements.
Significant illnesses, such as hypertension, hyperlipidemia, obesity, and diabetes, in first- and second-degree family members should be reviewed. Family use of alcohol, tobacco, and illegal as well as prescribed substances also should be determined. Age and cause of death in immediate family members should be recorded.
Medications and Allergies
Prescription as well as nonprescription (over-the-counter) medications, herbs, and supplements should be reviewed along with the indications and frequency of usage.
The height and weight of patients should be plotted on a growth curve, with particular attention paid to the velocity of growth and body mass index (weight [kg]/(height [m])2). Blood pressure also should be noted and compared with age- and height-related reference values.
Aspects of the physical examination that are influenced by puberty should be emphasized. The skin should be carefully inspected for acne and hirsutism; clinicians should offer treatment whether or not patients acknowledge that they have skin problems. Tattoos, piercings, and signs of abuse or self-inflicted injury (ie, cutting) also should be noted. The oropharynx should be examined for any evidence of gingivitis or other signs of poor dental hygiene or malocclusion. The neck should be palpated for adenopathy and the thyroid gland for hypertrophy or nodules, especially in adolescent females. The back should be examined for any evidence of scoliosis, which is important to diagnose during this time of rapid growth.
Assessment of the pubertal development of the breasts and genitalia in preadolescent or adolescent females and the genitalia, including presence of pubic hair, in adolescent males is essential. The sexual maturity rating (SMR) (ie, Tanner stage) can then be correlated with other signs of puberty, such as the appearance of acne and body odor. For example, the adolescent female with SMR 4 breasts and immature pubic hair distribution may have an underlying problem, such as complete androgen insensitivity syndrome (also called testicular feminization syndrome).
The abdomen should be palpated for organomegaly and the testicles for masses, hydroceles, hernias, or varicoceles. Lesions such as warts or vesicles also should be documented. The external female genitalia should be inspected for similar lesions and to document Tanner stage development. A speculum examination should be performed in females who are sexually active and report vaginal discharge, unexplained vaginal bleeding, or lower abdominal pain. (See Chapter 58 for additional indications for a pelvic examination.) A speculum examination is otherwise not indicated in an asymptomatic sexually active female. In general, virginal girls with normal pubertal development do not require a speculum examination; gentle inspection of the external genitalia is adequate in most cases, with special attention to the SMR and hymenal patency. A rectal examination is generally reserved for patients with chronic abdominal pain or other specific acute gastrointestinal symptoms.
Many recent modifications have been made to the preadolescent/ adolescent vaccination schedule (Table 38.1). As always, health professionals should verify that patients have completed the primary immunization series. If not, they should be given catch-up doses according to the most recent Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention recommendations. The tetanus and diphtheria toxoids and acellular pertussis (Tdap) (eg, Adacel, Boostrix), human papillomavirus (HPV) (eg, Gardasil 9), and meningococcal conjugate (MCV4) (eg, Menactra, Menveo) vaccines should be given to preteens at the 11- to-12-year visit. The Tdap vaccine has replaced the tetanus/diphtheria booster previously given at this age. Pertussis was added to the booster because immunity to pertussis has been noted to wane 5 to 8 years after vaccination, and there has been an increasing prevalence of pertussis detected in adolescents and adults with chronic cough in many communities. A conjugate vaccine against Neisseria meningitidis (MCV4) was approved by the US Food and Drug Administration in 2005. The Advisory Committee on Immunization Practices recommends that MCV4 be given to all 11- to 18-year-olds. Although there are 3 different vaccines (ie, Gardasil, Cervarix, and Gardasil 9) available that include protection against 2 of the HPV types that cause most cervical cancers (oncogenic types 16 and 18), only the 9-valent product is currently used in the United States. Licensed in 2015, Gardasil 9 protects against 5 additional HPV types that cause an additional 10% of HPV-associated cancers in the United States. While there has been much publicity and some controversy surrounding the HPV vaccine, current recommendations state that all adolescents should begin the HPV vaccination series routinely at 11 to 12 years of age with the goal of completing the series by age 13 years. The vaccine is approved for patients as young as 9 years. For those who initiate the series at 9 to 14 years of age, a 2-dose series is administered rather than the 3-dose series for those who begin vaccination at age 15. Gardasil 9 also should be routinely administered to young adults through the age of 26 years who have not received the vaccine. Ideally, the vaccine should be administered before the initiation of sexual activity because Gardasil 9 is only preventive and does not treat or cure HPV infection, dysplasia, or cancer that has already developed in response to HPV exposure. However, regardless of previous sexual exposure, the HPV vaccine should be administered to all adolescents, even if they are already sexually active.
|Table 38.1. Recommended Immunization Schedule Affecting Adolescents|
Recommended Age (years)
Tetanus, diphtheria, pertussis
HPV (2 doses)
HPV (catch-up) (2 or 3 doses)a
Meningococcal serogroup B
MCV4 (booster at 16 years)
Individual clinical decision at age 16–23 years if not at increased risk
Varicella 2-dose series
Abbreviations: HPV, human papillomavirus; MCV4, meningococcal conjugate vaccine; Tdap, tetanus and diphtheria toxoids and acellular pertussis.
Modified from Centers for Disease Control and Prevention. Child and adolescent immunization schedule (birth through 18 years). www.cdc.gov/vaccines/schedules. Reviewed February 5, 2019. Accessed September 2, 2019.
Recommendations concerning some of the older, traditional vaccines have changed, as have the catch-up schedules. The adolescent (13 years and older) with no evidence of immunity to varicella should receive 2 doses of the vaccine at least 4 weeks apart. If an adolescent or preadolescent has received only 1 dose of the varicella vaccine, a second dose should be administered. Routine vaccination against hepatitis B also is recommended, regardless of sexual activity, if it has not been administered previously. The 2-dose hepatitis A series should be given to all teenagers not previously vaccinated if they reside in high-incidence communities. Influenza vaccine should be given annually to all infants 6 months and older, children, and adolescents and to those who come into close contact with individuals with high-risk conditions. Two meningococcal serogroup B vaccines (ie, Bexsero, Trumenba) are currently licensed for use among persons aged 10 to 25 years in the United States and are used routinely for individuals 10 years and older who are at high risk for serogroup B meningococcal disease, such as those with anatomical or functional asplenia or persistent complement deficiencies. Adolescents and young adults aged 16 to 23 years also may be vaccinated to provide short-term protection during serogroup B meningococcal disease outbreaks. Pneumococcal vaccine should be offered to high-risk groups, such as those with chronic lung disease, cyanotic congenital heart disease, and diabetes mellitus. In addition, a Mantoux skin test for tuberculosis should be performed if the adolescent resides in a high-risk environment. A tuberculosis blood test (also called an interferon gamma release assay) is preferred if the patient has received the tuberculosis or BCG vaccine or has a difficult time returning for a second appointment to look for a reaction to the Mantoux skin test. (For complete recommendations, see Chapter 37.)
A hemoglobin level should be obtained to evaluate for anemia. Although previously included in laboratory screening, a urinalysis is no longer recommended to assess for protein, blood, and pyuria because most abnormal findings resolve spontaneously. Other suggested screening tests include hearing and vision tests and a cholesterol and lipid profile, once between 9 and 11 years and a second time between 17 and 21 years of age.
In addition to these laboratory tests, sexually active adolescents should be screened for STIs. If a pelvic examination is performed, an endocervical specimen should be obtained for nucleic acid amplification testing for gonorrhea and chlamydia. However, if a pelvic examination is not indicated, routine screening for gonorrhea and chlamydia may be performed with a urine or vaginal sample alone using nucleic acid amplification testing methods. The 2015 recommendations from the Centers for Disease Control and Prevention state that all sexually active women younger than 25 years should be screened annually. Males should be screened in high-prevalence clinical settings, such as adolescent clinics, correctional facilities, or STI clinics; if they are symptomatic; if they have a history of multiple partners and unprotected intercourse; or if they are having sex with men. In addition, a rapid plasma reagin test for syphilis and an HIV test should be obtained, especially if another STI is suspected or confirmed. All these tests should be offered in the clinically appropriate setting after patients have received adequate education on STIs, with a follow-up visit scheduled to discuss the results.
At the conclusion of the health maintenance visit, positive as well as negative findings should be reviewed with patients and their parents or guardians. Depending on the nature of these findings and the age of the patient, the health professional may initially choose to address these findings with the patient alone, keeping in mind issues of confidentiality. All recommended screening laboratory studies and immunizations should be reviewed before their administration, including the need for further follow-up. Subsequent vaccine doses must be outlined for patients and parents or guardians. The timing of the next visit and reasons for this visit should be discussed.
The remainder of the health maintenance visit should be spent addressing any specific concerns of patients and parents or guardians, highlighting health care problems (eg, obesity, high blood pressure), and identifying any factors that may be contributing to high-risk behavior, such as drug or alcohol use. Older children or adolescents who are not participating in any deleterious activities should be praised for their positive behavior as well as provided with educational information such as materials addressing injury prevention and sleep hygiene.
Preparticipation Physical Evaluation for School-age and Adolescent Athletes
The preparticipation physical evaluation (PPE) is essentially the “sports physical” that many schools require for participation in organized athletic programs. The primary objective of the PPE is to assess the athlete’s readiness to compete safely and effectively in training and competition. Ideally, it also should identify athletes at risk of injury, reinjury, or sudden death, as well as those with an underlying medical condition that may preclude safe athletic participation.
Historically, controversy existed about the appropriate location for performance of the PPE. Community physicians were often asked to perform limited en masse examinations at schools, or a group of clinicians was asked to perform the examinations in the gymnasium using “stations.” Either way, the patient did not truly receive a complete physical examination or assessment, and neither approach lent itself to privacy. In addition, parents had a false sense of security and believed that their children had received adequate medical care. The AAP, in conjunction with other professional organizations, has developed a monograph that includes guidelines for the PPE. Ideally, primary care physicians should perform the PPE annually in their office during a scheduled visit at least 4 to 6 weeks before the beginning of the athletic season. Pediatricians can also use this required visit as an opportunity to perform an annual comprehensive health maintenance examination on older children and adolescents, including providing important anticipatory guidance, administering catch-up immunizations, and performing the various screening tests recommended for this age group.
The most challenging aspect of the PPE is reviewing the past medical and family history with the athlete to uncover previously unrecognized abnormalities of the cardiovascular system that warrant further investigation by a cardiologist prior to participating in a given sport. Red flags include a history of congenital heart disease, cardiac channelopathies (eg, long QT syndrome), a history of Kawasaki disease and associated coronary artery anomalies, and a history of myocarditis. The rest of the medical history for the PPE should focus on previous athletic participation and any current or past injuries that have required immediate evaluation and subsequent bracing, casting, surgery, or missed practice or play (Box 38.3). A standard questionnaire codeveloped by the AAP for this purpose may be used in the office setting. In addition, many health professionals record the results of the physical examination as well as their recommendations for the degree of athletic participation on this standard form (Figures 38.1 through 38.4). A review of systems should specifically include an inquiry about a history of syncope, near-syncope, chest pain, palpitations, and excessive shortness of breath or fatigue with exertion.
Box 38.3. What to Ask
Preparticipation Physical Evaluation
•What sport(s) does the child or adolescent wish to participate in? Has he or she participated in this sport in the past?
•Has the child or adolescent ever experienced a sports injury? If so, how much time did the athlete refrain from sports activities as a result of this injury?
•Has the athlete ever experienced a lapse of consciousness or concussion?
•Does the child or adolescent have a significant underlying health problem?
•Is the child or adolescent taking any prescribed or over-the-counter medications, supplements, or caffeine?
•Does the child or adolescent have any allergies?
•Has the child or adolescent ever had syncope or near-syncope, palpitations, chest pain, discomfort, or shortness of breath during exercise or at rest?
•Does the child or adolescent have a family history of sudden, early, nontraumatic deaths in a first- or second-degree relative younger than 50 years?