MIAMI — Physicians performing the preparticipation physical evaluation (PPE) required for children to participate in sports activities should be aware of some changes to the recommended exam based on the third edition of the PPE monograph, Dr. Andrew Gregory said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.
The new monograph, published in 2005, includes a separate clearance form that incorporates a more extensive cardiovascular history, additional medical history questions, administrative and legal concerns, and a greater emphasis on athletes with special needs.
Dr. Gregory, a pediatrician at Vanderbilt University in Nashville, Tenn., reviewed these changes and encouraged pediatricians to purchase the new monograph through the AAP to learn more.
The cardiovascular history has been revised based on the American Heart Association guidelines. New questions ask families about any previous denial of participation by a physician, previous orders for cardiac tests, and family history regarding deaths of unknown cause, heart problems, and Marfan syndrome.
Dr. Gregory explained that the cardiovascular physical exam should include the following components:
▸ Precordial auscultation with child supine and standing to identify heart murmurs related to dynamic left ventricular outflow obstruction.
▸ Measurement of femoral artery pulse to rule out coarctation of the aorta.
▸ Assessment for physical signs of Marfan syndrome.
▸ Measurement of brachial blood pressure with child sitting.
One new element of the medical history addresses supplement use. In using the old forms, families might not have considered supplements to be medication and they might have omitted them from the medication list. Now, asking specifically about supplements gives physicians the chance to talk with families about any supplements the child may be taking.
There are also questions about previous anaphylaxis and paired organs. Dr. Gregory said in general, the absence of a paired organ does not limit the athlete from competing if protective devices are used.
Children are now asked about their recent history of viral illness, in hopes of identifying children with mononucleosis who should avoid activity for 3 weeks and contact sports for 4 weeks.
Also included are questions about sickle cell trait or disease. “We really need to counsel our patients with even sickle cell trait [about] the importance of acclimatization and hydration in the heat,” explained Dr. Gregory, noting recent accounts of an increased risk of sickling, rhabdomyolysis, or death in extreme conditions.
To comply with HIPAA regulations, the physicians should treat the PPE like a medical record and secure it appropriately. The layout of the PPE form has been altered to ensure privacy—the clearance form is now separated from the remainder of the document containing the more detailed health information. A signed release is required for someone to receive the entire form.
Some situations do require health information to be disclosed to public health authorities. Examples would include reactions to medication, reportable diseases, or disease exposures.
The new monograph also addresses the status of athletes with special needs. The benefits of sports for these children are clear in terms of health, proprioception, and proficiency with prosthetic devices. However, there are issues that should be investigated during the PPE, such as seizures in children with mental retardation and cardiac, renal, joint, and spinal problems in children with Down syndrome.
During the physical exam, clinicians should be especially thorough in evaluating cardiovascular, neurologic, dermatologic, and musculoskeletal problems and vision in athletes with disabilities.
Even patients with sickle cell trait should be counseled about acclimatization and hydration in the heat. DR. GREGORY