Physical Examination: General Approach

Techniques of Examination
Recording Your Findings
CHAPTER 25 Health Promotion and Counseling: Evidence and
Recommendations
Children: Infancy through Adolescence
Peter G. Szilagyi, MD, MPH This chapter highlights clinical assessments for each pediatric age group:
newborns or neonates (0–30 days of age), infants (1 month–1 year),
preschool children (1–5 years), school-aged children (6–11 years), and
The Bates’ suite offers these additional resources to enhance adolescents (12–18 years), as shown in Figures 25-1 to 25-3. It begins with
learning and facilitate understanding of this chapter: general principles of development and key components of health promotion.
Each age group is then covered in separate sections, with relevant
Bates’ Pocket Guide to Physical Examination and History
discussions of history taking, development surveillance, techniques of
Taking, 9th edition examination, and health promotion and counseling.
Bates’ Visual Guide to Physical Examination (Vol. 2: Head-to-
Toe Assessment: Infant; Vol. 3: Head-to-Toe Assessment: Child)
online resources, for students and instructors:
[Link]

Chapter Content Guide

General Principles of Child Development

Surveillance of Development
Key Components of Health Promotion
Sections
Newborns and Infants
Preschool and School-Aged Children FIGURE 25-1. Infants have surprising abilities.
Adolescents
Section Organization: Inexperienced examiners are often intimidated when approaching a tiny baby
or an upset child, especially under the watchful eyes of anxious parents.
Health History: General Approach When examining infants and children, the sequence should vary according to
Surveillance of Development the child’s age and comfort level. Perform less invasive maneuvers early
Physical Development and potentially distressing maneuvers near the end of the examination. For
Cognitive and Language Development example, auscultate the heart and lungs early and examine the ears and mouth
Social and Emotional Development and palpate the abdomen near the end. If the child reports pain in one area,
examine that area last. Although it is initially challenging, you will come to
enjoy almost all pediatric encounters.

FIGURE 25-3. Social interactions become important in adolescence.

Box 25-1. Four Principles of Child Development

1. Child development proceeds along a predictable pathway.

FIGURE 25-2. A drive for independence appears in school-aged children. 2. The range of normal development is wide.
3. mVarious physical, social, and environmental factors, as well as diseases, can affect
child development and health.
4. The child’s developmental level affects how you conduct the history and physical
GENERAL PRINCIPLES OF examination.

CHILD DEVELOPMENT
Childhood is a period of remarkable physical, cognitive, and social growth
—by far the greatest in a person’s lifetime. Within a few short years,
children’s weight increases 20-fold, they acquire sophisticated language and
reasoning, develop complex social interactions, and progress toward mature
adults (Fig. 25-4 and Box 25-1). Understanding the normal physical,
cognitive, and social development of children facilitates effective interviews
and physical examinations and is the basis for distinguishing normal from
abnormal findings.1–3

FIGURE 25-4. Parents can enhance the development of their children through play.
(Used with permission from Shutterstock. By Marcos Mesa Sam Wordley.)

Principle #1: Child development proceeds along a predictable pathway

governed by the maturing brain. You can measure age-specific milestones
and use them to characterize development as normal or abnormal (i.e.,
typical or atypical). Because your health care visit and physical
examination take place at one point in time, you need to determine where
the child fits along a developmental trajectory. Milestones are achieved in
a predictable order. Loss of milestones is always concerning.
Principle #2: The range of normal (typical) development is wide.
Children mature at different rates. Each child’s physical, cognitive, and
social development should fall within a broad developmental range.
Principle #3: Various physical, social, and environmental factors, as
well as diseases, can affect child development and health. For example,
chronic illnesses, child abuse, and adverse childhood experiences (ACEs)
can all cause detectable physical abnormalities or alter the rate and course
of development. Additionally, children with physical or cognitive
disabilities may not follow the expected age-specific developmental
trajectory (Fig. 25-5).
Principle #4: The child’s developmental level affects how you conduct
the clinical history and physical examination. For example, interviewing
a 5-year-old is fundamentally different than interviewing an adolescent.
Both the order and style differ from the adult examination. Before
performing a history and physical examination, attempt to ascertain the FIGURE 25-5. Child development is affected by many factors including genetics (this
child’s approximate developmental level and adapt your evaluation to that child has Down syndrome).
level. An understanding of typical child development helps you achieve
these tasks.4
SURVEILLANCE OF DEVELOPMENT
A child’s development proceeds along a predictable pathway. They progress
through milestones in an orderly fashion, attaining these functions in a clear
and sequential process. Developmental assessment is the process of mapping
the status of a child compared with other children of similar age. Information
about the child’s development and behavior are gathered from multiple
sources which can involve direct observation of the child’s behavior as well
as expressed concerns from parents and others.5–7

In general, pediatric clinicians assess five critical domains of development:

physical including gross and fine motor skills, cognitive (or problem-
solving), language (communication), and social–emotional domains.
Physical Development validated in many nations and include the Ages and Stages Questionnaire
(ASQ),11 the Early Language Milestone Scale (ELM Scale-2),12,13 the
Physical development encompasses both gross and fine motor abilities. Modified Checklist for Autism in Toddlers (MCHAT),13 the Parents’
Examples of gross motor skills include walking, sitting, or transferring from Evaluation of Developmental Status (PEDS),14 and the Survey of Well-Being
one position to another. Manipulation of objects with the hands in order to of Young Children (SWYC).15
eat, draw, or play are examples of fine motor skills.8,9 Milestones in these
two developmental domains are what most parents and caregivers are most Pediatric clinicians should use these standardized instruments periodically
familiar with. Any delay in achieving a physical development milestone often during preventive health visits because they perform better than a clinician’s
prompts visits to clinicians due to parental concern. physical examination in identifying developmental delays, which can often be
subtle and challenging to determine because of the wide spectrum of normal
Cognitive Development development in children. Suspected delays warrant further examination.
Cognitive development is a measure of the child’s ability to problem solve If a cooperative child fails items on a standardized screening
through intuition, perception, and verbal and nonverbal reasoning.7 It also instrument, developmental delay is possible, necessitating more
involves the child’s ability to retain information and then to apply it when precise testing and evaluation.
appropriate.8,9
Developmental Quotient
Language Development A normative measure of development is the developmental quotient:16
Language development consists of the ability of a child to articulate,
receive, and express information. It also involves nonverbal modes of
communication such as waving and head nodding. A child develops these
skills through their ability to put words together to express a thought which Developmental Quotients:
can also be influenced by their interaction with their environment.8,9
>85 = Normal
Social and Emotional Development 70–85 = Possibly delayed; follow-up needed
Social and emotional development encompasses the child’s ability to form <70 = Delayed
and maintain relationships. It also measures their responsiveness to the
presence of others. It involves the formation of self-help skills in various Assess the development of an infant or child using standard scales for each
activities of daily living, such as feeding, dressing, and toileting.8,9 type of development. Assign to each child a gross motor developmental
quotient, a fine motor developmental quotient, a cognitive developmental
The American Academy of Pediatrics (AAP) recommends the use of quotient, and so forth. Importantly, these estimates are never a perfect
standardized screening instruments to assess these developmental domains.10 assessment of a child’s development or potential because both can change
These screening instruments should be used as adjuncts to a comprehensive over time (see Box 25-2 for an example of its application).17
developmental examination and are practical to use in clinical settings with
reasonable sensitivity and specificity for identifying developmental delays.
Several developmental screening instruments have been tested widely and
Box 25-2. Case Examples of Gross and Fine Motor
Developmental Quotients

Gross Motor Development Fine Motor Development

A 12-month-old child who is just A 12-month-old child can transfer objects from hand to
pulling to stand (gross motor hand (a fine motor developmental age of 6 months),
developmental age of 9 months), rake objects into his palm (7 months), and pull things
cruising (10 months), and walking (7 months). He cannot hold blocks in each hand and
when both hands are held (10 does not have thumb and finger grasp (8–9 months).
months) has a gross motor He has normal primitive reflexes (most absent),
developmental age of 10 months. increased tone, scissoring of legs when held,
This child’s gross motor spasticity, and delays on the gross motor part of a
developmental quotient is: standardized developmental screening instrument. FIGURE 25-7. Clinician with a 3-year-old child. (Used with permission from
This child’s fine motor developmental quotient is: Shutterstock. By didesign021.)

This child is in the gray zone, is

likely to do well without intervention,
but requires close follow-up.
This child is delayed in fine motor development and
has signs of cerebral palsy.
KEY COMPONENTS OF HEALTH
PROMOTION
Benjamin Franklin noted that “an ounce of prevention is worth a pound of
cure.” This adage is particularly true for children and adolescents because
prevention and health promotion at a young age can result in improved health
outcomes for decades (Figs. 25-6 to 25-8). Pediatric clinicians dedicate
substantial time to health supervision visits and health promotion activities.

FIGURE 25-6. Clinician examining an infant. (Used with permission from Shutterstock.
By Olha Birieva.)

FIGURE 25-8. Clinician with an adolescent. (Used with permission from Shutterstock.
By Alexander Raths.)
Several national and international organizations have developed guidelines Age-specific screening procedures are performed at specific ages. These
for health promotion in children.18–20 Current concepts of health promotion include: newborn genetic and metabolic screening, newborn screening for
include the detection and prevention of disease as well as active promotion hearing and critical congenital heart disease (oximetry), and (if appropriate)
of the well-being of children and their families spanning physical, cognitive, newborn screening for bilirubin, growth parameters and developmental
emotional, and social health. screening and behavioral/mental health screening at all ages, blood pressure
screening after age 3 years, BMI screening after age 2 years, and vision and
Every interaction with a child and family is an opportunity for health hearing screening at key ages. In addition, health experts now recommend
promotion. From the interview to the physical examination, think of your screening for poverty and social risk factors on a regular basis because these
interactions as an opportunity for two important tasks: the detection of social determinants greatly affect a child’s health. Increasingly, standardized
clinical problems and the promotion of health. Capitalize on the examination screening instruments are being used to assist clinicians in identifying
to offer age-appropriate guidance about the child’s development. Provide abnormalities and risks. In addition, screening procedures recommended for
suggestions about reading, conversing, playing music, and optimizing all children at certain ages or for specific high-risk patients (depending on
opportunities for gross and fine motor development. Advise parents about the test) include tests for lead poisoning, anemia, tuberculosis exposure,
upcoming developmental stages and strategies to encourage their child’s dyslipidemia, and sexually transmitted infections. There is variation
development. Parents are the major agents of health promotion for children worldwide in recommendations for screening tests; the AAP
and your advice is implemented through them. recommendations are provided at [Link]
us/Documents/periodicity_schedule.pdf.
The AAP publishes guidelines for health supervision visits and the key age-
appropriate components of these visits (see [Link]). Anticipatory guidance is a major component of the pediatric visit.19 Key
Remember that children and adolescents who have a chronic illness or high- areas cover a broad range of topics, from clinical to developmental, social,
risk family or environmental circumstances will probably require more and emotional health (Box 25-3).
frequent visits and more intensive health promotion. Key health promotion
issues and strategies, tailored for specific age groups, are found throughout
Box 25-3. Key Components of Pediatric Health Promotion
this chapter.
1. Age-appropriate developmental achievement of the child
Integrate explanations of your physical findings with health promotion.
Physical (maturation, growth, puberty)
Provide advice about expected maturational changes or how health behaviors Motor (gross and fine motor skills)
can affect physical findings (e.g., exercise may reduce blood pressure and Cognitive (developmental milestones, language, school performance)
prevent obesity). Be sure to demonstrate the relationship between healthy Emotional (self-regulation, mood, self-efficacy, self-esteem, independence)
Social (social competence, self-responsibility, integration with family and
lifestyles and physical health. For example, give parents a copy of their community, peer interactions)
child’s body mass index (BMI) result along with advice for healthy eating 2. Health supervision visits
and exercise. Periodic assessment of physical, developmental, socio-emotional, and oral health
More frequent visits for children with special health care needs
3. Integration of physical examination findings with health promotion
Childhood immunizations are a mainstay for health promotion and have been 4. Immunizations
heralded as the most significant clinical achievement in public health 5. Screening procedures
6. Oral health
worldwide. The childhood immunization schedule is updated yearly. Updates
7. Anticipatory guidance19,21
are published widely and disseminated on websites of the Centers for Healthy habits
Disease Control and Prevention (CDC) (see [Link]) and the AAP.21,22 Nutrition and healthy eating
 Safety and prevention of injury with anticipatory guidance, so that the history feels like a conversation with
Physical activity
Sexual development and sexuality
new parents. An empathetic, calm, and helpful clinician can be a source of
Self-responsibility, efficacy, and healthy self-esteem incredible guidance and comfort to parents and serves to create an important
Family relationships (interactions, strengths, supports) bond between parents and clinicians. Important parts of the health history are
Positive parenting strategies
Reading aloud with the child shown in Box 25-4.
Emotional and mental health
Oral health
Recognition of illness Box 25-4. Key Components of the Health History for the
Sleep Newborn Visit18
Screen time
Prevention of risky behaviors
School and vocation Questions and concerns by parents
Peer relationships Questions about the newborn, home, prenatal course or delivery
Community interactions Concerns about newborn’s physical features
8. Partnership among health care provider, child/adolescent, and family Concerns and questions about newborn care
Prenatal history, labor, and delivery
Pregnancy history, complications, prenatal diagnoses
Maternal and paternal physical and mental health
NEWBORNS AND INFANTS Maternal use of tobacco, alcohol, drugs
Labor and delivery experience or complications
Prior pregnancies and siblings
The first year of life, or infancy, is divided into the neonatal period (the first
Neonatal course prior to the visit
28 days) and the post neonatal period (29 days to 1 year). Health and well-being of mother, other family members
Plans for breastfeeding or bottle feeding (or both)
Neonatal history
HEALTH HISTORY: GENERAL APPROACH How it is going overall, specific issues of concern
Cultural beliefs
The newborn visit, which is generally performed within the first 12 to 24 Family history
Comprehensive history if time permits
hours after delivery, is a critical opportunity for the health care provider to
engage with the family, learn about the newborn’s family and environment, Social history
Social determinants (living situation, concerns about food, housing, utilities, parental
understand key aspects of the pregnancy, bond with the family, and observe relationship, adults caring for the newborn, family support, family violence, concerns
the family’s interactions with the newborn. It is also a time to demonstrate the about finances)
newborns’ abilities, and to role-model interactions with the newborn. Alcohol, tobacco, drug use (even if not during pregnancy)
Any social concerns by parents
Remember that although parents will be elated with the birth of their Siblings, other family members, babysitter
newborn, they will also be exhausted, anxious about whether their baby is Parents’ observation of their newborn’s behavior and activity
healthy, and filled with questions about the care and nurturing of their What the newborn has been able to do so far
newborn. It is vital to address any concerns of parents and to empathize with Level of activity, attachment
their natural anxieties and questions. Feeding and nutrition
Type of feeding, how feeding is going
Details of feeding (breast or bottle)
The initial visit can be challenging because there is a lot to learn about the
Sleeping, stooling, urination
newborn and parents. Experienced clinicians learn to combine history-taking Frequency and color of stools and urine
 Sleeping duration, falling asleep
Safety
Car safety seats
Safe sleep
Anticipatory guidance about newborn care
Illness prevention
Dressing, protection against heat, pets, safe home environment
Care of newborn’s body (umbilicus, penis including circumcision decision, etc.)
Upcoming visits, when to call for advice

Source: Adapted from Bright Futures.

SURVEILLANCE OF DEVELOPMENT

Physical Development
Newborns have surprising abilities, such as fixing upon and following human
faces. Neurologic development progresses centrally to peripherally. Thus,
FIGURE 25-9. Sitting up is a developmental milestone among infants.
newborns learn head control before trunk control and use of arms and legs
before use of hands and fingers (Fig. 25-9).
Box 25-5. Developmental Milestones: Birth to 12 Months
Physical growth during infancy is faster than at any other age (Box 25-5).23
By 1 year, the infant’s birth weight should have tripled and height increased
by 50% from weight and height at birth.
Activity, exploration, and environmental manipulation contribute to learning. FIGURE 25-10. Children often take their first steps after 1 year.
By 3 months, typical infants lift their heads and clasp their hands. By 6
months, they roll over, reach for objects, turn to voices, and possibly sit with Cognitive and Language Development
support. With increasing peripheral coordination, infants reach for objects,
transfer them from hand to hand, crawl, stand by holding on, and play with Exploration fosters increased understanding of self and environment. Infants
objects by banging and grabbing. At 1 year, children may be standing and reach for objects and learn cause and effect (e.g., shaking a rattle produces
even trying to walk (Fig. 25-10).24 sound), object permanence, and use of toys. By 9 months, they imitate sounds,
orient to their own name and they may recognize the examiner as a stranger
deserving wary cooperation. Infants seek comfort from parents during
examinations. They will actively manipulate reachable objects such as your
stethoscope. Language development proceeds from cooing at 2 months, to
babbling at 6 months, to saying one to three words by 1 year.25
If infants are not making age-appropriate sounds and language,
consider testing for a hearing deficit.

Social and Emotional Development

Understanding of self and family also matures. By a month of age infants can
recognize parents’ voice and follow a face, and by 4 months they smile back
at you. Social tasks include bonding, attachment to caregivers, and trust that
caregivers will meet their needs.

Temperaments vary. Some infants are predictable, adaptable, and respond

positively to new stimuli; others are less so and respond intensely or
negatively. Because environment affects social development, observe the
infant’s interactions with caregivers. An infant’s cognitive and social–
emotional development are often assessed together with the comprehensive
neurologic examination.
FIGURE 25-11. Physical examination starts soon after birth.
An infant or toddler who has developmental skills that plateau or
are out of sequence needs evaluation for an underlying
developmental disability such as autism or cerebral palsy. Refer to the section, “Techniques of Examination: Infants,” for a
complete physical examination, p. 948.

Subsequent physical examinations of newborns occur at regular intervals or

PHYSICAL EXAMINATION: GENERAL when the infant is ill. If possible, do the physical examination in front of the
APPROACH parents so that they can interact with you and ask questions (Box 25-6). This
is an excellent opportunity to educate parents about their baby and what their
baby can do.
Newborns
Some abnormalities on physical examination are actually
The first pediatric examination is performed immediately after delivery by identified by parents who have noted an abnormality in their
obstetrical or pediatric clinicians. Examining newborns immediately after
infant. Therefore, asking parents to point out any concerns or
birth is important for determining general condition, developmental status,
questions may help identify subtle abnormalities. Some examples
abnormalities in gestational development, and any congenital abnormalities.
include birthmarks, skin tags, asymmetries, dimples along the
A comprehensive pediatric examination is generally performed within 24
hours of birth (Fig. 25-11). This examination may reveal diseases of cardiac, lower spine, or abnormal movements.
respiratory, or neurologic origin. Listen to the anterior thorax with your
stethoscope, palpate the abdomen, and inspect the head, face, oral cavity, Box 25-6. Tips for Examining Newborns
extremities, genitalia, and perineum.
Examine the newborn in the presence of the parents.
Swaddle and then undress the newborn as the examination proceeds.
Dim the lights and rock the newborn to encourage the eyes to open.
Observe feeding, if possible, particularly breastfeeding.
Demonstrate calming maneuvers to parents (e.g., swaddling).
Observe and teach parents about transitions as the newborn arouses.
A typical sequence for the examination of the newborn:
Careful observation before (and during) the examination
 Heart
Lungs Box 25-7. What a Newborn Can Do
Head, neck, and clavicles
Ears and mouth
Hips Core Elements26
Abdomen and genitourinary system Newborns use all five senses. For example, they will look at human faces and turn to a
Lower extremities, upper extremities, back parent’s voice.
Eyes, whenever they are spontaneously open or at end of examination Newborns are unique individuals. Marked differences exist in temperaments, personality,
Skin, as you go along behavior, and learning.
Neurologic system Newborns interact dynamically with caregivers—a two-way street!

Examples of Complex Newborn Behavior

Studies by Dr. T. Berry Brazelton and others have demonstrated the wide
Habituation Ability to selectively and progressively shut out negative stimuli (e.g., a repetitive
range of abilities in newborns (Box 25-7).26 Parents will be delighted by sound)
these abilities. You can demonstrate some of these abilities during your
Attachment A reciprocal, dynamic process of interacting and bonding with the caregiver
physical examination. For example, you can show how newborns quiet down
as you speak softly to them and how they follow you with their eyes if you State Ability to modulate the level of arousal in response to different degrees of
regulation stimulation (e.g., self-consoling)
move your face slowly back and forth while talking to them and smiling.
Perception Ability to regard faces, turn to voices, quiet in presence of singing, track colorful
Asymmetric movements of the arms or legs (if persistent and objects, respond to touch, and recognize familiar scents
substantial) may suggest central or peripheral neurologic
Newborns who do not demonstrate these behaviors may have a
deficits, birth injury (such as a fractured clavicle or brachial
neurologic condition, drug withdrawal, or a serious illness such
plexus injury), or congenital anomalies.
as infection.
Parents may have questions about their newborn’s physical appearance, so
stating normal findings as you go can be reassuring. Observe parents’ Infants
interacting with their newborn and reinforce positive parenting behaviors. If Start with the infant sitting or lying in the parent’s lap (Fig. 25-12). If the
a mother has concerns about breastfeeding technique, observe how well the infant is tired, hungry, or ill, ask the parent to hold the baby against the
newborn latches on and sucks. Breastfeeding is physiologically and parent’s chest. Make sure appropriate toys, a blanket, or other familiar
psychologically ideal, but many mothers need help and support at first. Be objects are nearby. A hungry infant may need to be fed before you initiate the
empathetic to the normal stress of breastfeeding. Early detection of examination (Box 25-8).
difficulties and anticipatory guidance can promote and sustain breastfeeding.

Newborns are most responsive 1 to 2 hours after a feeding, when they are
neither too satiated and sleepy nor too hungry. Start with the newborn
swaddled and comfortable. Then, for gradual stimulation and arousal,
undress the newborn as the examination proceeds. If the newborn becomes
agitated, with the parents’ permission use a pacifier or a bottle of formula (if
not breastfeeding) or allow the baby to suck on your gloved finger.
Reswaddle the baby long enough to complete the parts of the examination that
require a quiet baby.
 FIGURE 25-12. Start the examination while the child is still on the parent’s lap.
FIGURE 25-13. Children can have fun during the developmental examination.
Many neurologic conditions can be diagnosed during this general
part of the examination. For example, you can detect hypotonia, Observation of the infant’s communication with the parent can
conditions associated with irritability or signs of cerebral palsy reveal abnormalities such as developmental delay, language
(see neurologic examination below). delay, hearing deficits, or inadequate parental attachment.
Likewise, such observations may identify maladaptive nurturing
Box 25-8. Tips for Examining Infants patterns that may stem from maternal depression or inadequate
social support.
Approach the infant gradually, using a toy or object for distraction.
Perform as much of the examination as possible with the infant in the parent’s lap. Infants do not object to having their clothing removed. To keep yourself and
Speak softly to the infant or mimic the infant’s sounds to attract attention.
If the infant is cranky, make sure he or she is well fed before proceeding. your surroundings dry, it is wise to leave the diaper in place throughout the
Ask a parent about the infant’s strengths to elicit useful developmental and parenting examination; remove it only to examine the genitals, rectum, and hips.
information.
Don’t expect to do a head-to-toe examination in a specific order. Work with what the
infant gives you and save the mouth and ear examination for last.
Use developmentally appropriate methods such as distraction and play to
examine the infant. Because infants pay attention to one thing at a time, it is
relatively easy to distract the infant from the examination as it is performed.
Close observation of an awake infant sitting on the parent’s lap can reveal You can use a moving object, a flashing light, a toy, a game of peek-a-boo
potential abnormalities of tone, conditions with abnormal skin color, (for older infants), tickling, or any sort of noise.
jaundice or cyanosis, jitteriness, or respiratory problems. Observe parent–
infant interactions. Watch the parent’s affect when talking about the infant. If you cannot distract the infant or engage the awake infant with
Note the parent’s manner of holding, moving, dressing, and comforting the an object, your face, or a sound, consider a possible visual or
infant. Assess and comment on positive interactions, such as the obvious hearing deficit.
pride in the mother’s face in Figure 25-13.

TECHNIQUES OF EXAMINATION: INFANTS

 extremities
Assessment at Birth
1-Minute Apgar Score 5-Minute Apgar Score
Apgar Score.
8–10 Normal 8–10 Normal
The Apgar score is an assessment of the newborn immediately after birth.22
Its five components classify the newborn’s neurologic recovery from the 5–7 Some nervous 0–7 High risk for
0–4 system depression subsequent central
stress of birth and immediate cardiopulmonary adaptation to extrauterine life. Severe depression, nervous system and
Score each newborn at 1 and 5 minutes after birth (Box 25-9). Scoring is requiring immediate other organ system
based on a 3-point scale (0, 1, or 2) for each component. Total scores range resuscitation dysfunction
from 0 to 10. Scoring may continue at 5-minute intervals until the score is >7. a Reaction to suction of nares with bulb syringe.
If the 5-minute Apgar score is 8 or more, proceed to a more complete
examination.23 Example of Apgar score calculation for a newborn with hypoxia:
Heart rate = 110 [2]
Gestational Age and Birth Weight.
Classify newborns according to their gestational age of maturity and birth Respiratory effort = slow, irregular [1]
weight (Box 25-10). These classifications help predict clinical problems and Muscle tone = some flexion of arms/legs [1]
morbidity.22 Some clinical practice guidelines address the potential Reflex irritability = grimace [1]
challenges of infants born before a certain gestational age or below a Color = blue, pale [0]
specific birth weight.
Apgar score = 5
Gestational age is based on specific neuromuscular signs and physical
characteristics that change with gestational maturity. The Ballard Scoring Box 25-10. Classification by Gestational Age and Birth Weight
System24 estimates gestational age to within 2 weeks, even in extremely
premature infants. A complete Ballard Scoring System, with instructions for Gestational Age Classification Gestational Age
assessing neuromuscular and physical maturity, is included in Figure 25-14. Preterm <37 weeks
Late preterm 34–36 weeks
Box 25-9. Apgar Scoring System Term 37–41 weeks
Postterm >42 weeks
Assigned Score
Birth Weight Classification Weight
Clinical Sign 0 1 2
Extremely low birth weight <1,000 g
Heart rate Absent <100 >100
Very low birth weight <1,500 g
Respiratory effort Absent Slow and irregular Good; strong
Low birth weight <2,500 g
Muscle tone Flaccid Some flexion of the Active movement
arms and legs Normal birth weight ≥2,500 g

Reflex irritabilitya No responses Grimace Vigorous cry, sneeze, Preterm infants are at risk for both short-term complications
or cough
(mainly respiratory and cardiovascular) as well as long-term
Color Blue, pale Pink body, blue Pink all over
sequelae (e.g., neurodevelopmental).
Late preterm infants are at considerable risk for prematurity- A useful classification (Box 25-11) is derived from the gestational age and
related complications but at less risk than preterm infants. birth weight on the intrauterine growth curve.
Postterm infants are at increased risk of perinatal mortality or
morbidity (relative to term infants) such as asphyxia and Box 25-11. Newborn Classifications
meconium aspiration. Abbreviation Percentile
Category
Small for gestational age SGA <10th
Appropriate for gestational age AGA 10th–90th
Large for gestational age LGA >90th

LGA infants may experience difficulties during birth. Infants of

mothers with diabetes are often LGA and may have metabolic
abnormalities shortly after birth, as well as congenital anomalies.
A common complication among LGA newborns is hypoglycemia,
which can result in jitteriness, irritability, cyanosis, or other health
issues.

Figure 25-15 displays the intrauterine growth curves for the 10th and 90th
percentiles and depicts the categories of maturity for newborns based on
gestational age and birth weight.

FIGURE 25-14. The sum of the scores for all of the neuromuscular and physical
maturity items provides an estimate of gestational age in weeks, using the maturity rating
scale at the lower right potion of the figure. (Redrawn from Ballard JL et al. J Pediatr.
1991;119(3):417–423. Copyright © 1991 Elsevier. With permission.)
 The three babies shown in Figure 25-16 were all born at 32 weeks’
gestational age and weighed 600 g (SGA), 1,400 g (AGA), and 2,750 g
(LGA). Each of these categories has a different mortality rate, highest for
preterm SGA and LGA infants, and lowest for term AGA infants.
Preterm infants are more prone to respiratory distress
syndrome, apnea, patent ductus arteriosus (PDA) with left-to-
right shunt, and infection.

FIGURE 25-16. Infants who are small, average, and large for their gestational age.
(Reprinted from Korones SB. High-Risk Newborn Infants: The Basis for Intensive
Nursing Care. 4th ed. CV Mosby; 1986. Copyright © 1986 Elsevier. With permission.)

FIGURE 25-15. Level of intrauterine growth based on gestational age and birth weight
of liveborn, single, white infants. Point A represents a premature infant; point B indicates General Survey.
an infant of similar birth weight who is mature but SGA. (Adapted from Sweet YA.
Classification of the low-birth-weight infant. In: Klaus MH, Fanaroff AA, eds. Care of
During the first day of life, newborns should have a comprehensive
the High-Risk Neonate. 3rd ed. WB Saunders; 1986. Copyright © 1986 Elsevier. With examination. Wait until 1 or 2 hours after a feeding, when the baby is most
permission.) responsive, and ask the parents to remain in the room. Follow the sequence
shown in Box 25-6 on p. 946.
While no etiology is noted for many SGA infants, known causes
include fetal, placental, and maternal factors. Maternal smoking Observe the undressed newborn. Note the newborn’s color, size, body
proportions, nutritional status, and posture, as well as respirations and
is associated with SGA newborns. SGA newborns are at risk for
movements of the head and extremities. Most normal, full-term newborns lie
hypoglycemia.
in a symmetric position, with the limbs semi-flexed and the legs partially The most important tools for assessing somatic growth are the growth charts
abducted at the hip. which are published by the National Center for Health Statistics
([Link]/nchs)27 and also the WHO
In breech babies (buttock first), the knees are flexed in utero; in
([Link] All charts include height,
a frank breech baby, the knees are extended in utero. In both, weight, and head circumference for children up to 36 months and height and
the hips are flexed. weight for children 2 to 18 years. Charts plotting weight by length as well as
BMI are also available. These growth charts have percentile lines indicating
Note the baby’s spontaneous motor activity with flexion and extension
the percentage of normal children above and below the child’s measurement
alternating between the arms and legs. The fingers are usually flexed in a
by chronologic age. Comparison with normal standards is essential because
tight fist but may extend in slow posturing movements. You will observe
growth velocity is normally less during the second year than during the first
brief tremors of the body and extremities during vigorous crying, and even at
year. Special growth charts are available for use in infants born prematurely
rest.
(to correct for the level of prematurity).
By 4 days after birth, tremors at rest signal central nervous
Growth charts are also available for children with specific
system disease from various possible causes, ranging from
conditions such as Down syndrome or Turner syndrome.
asphyxia to drug withdrawal.
Although many healthy infants cross percentiles on growth
Somatic Growth. Tables on the World Health Organization (WHO) charts, a sudden or significant change in growth may indicate
website ([Link] show norms for systemic disease due to various possible organ systems or
height, weight, BMI (starting age 2 years), and head circumference. Compare inappropriate excess weight gain usually due to overfeeding.
body proportions with age-specific norms because they change dramatically
as children grow. Abnormalities that can cause deviation from normal growth
patterns include chronic childhood disease or prematurity.
Measurement of growth is one of the most important indicators of infant
health. Deviations may provide an early indication of an underlying problem. The AAP, National Institutes of Health (NIH), and CDC now recommend that
Compare growth parameters with respect to normal values for age and sex, clinicians use the 2006 WHO international growth charts for children 0 to 23
as well as prior readings on the same child, to assess trends. Confirm months of age.27 CDC growth charts should be used in the United States to
abnormalities in somatic growth by repeat measurement to account for assess growth in children 2 to 19 years of age.
potential measurement error. Measure growth parameters carefully using
[Link] children younger than age 2 years, measure body length by placing
consistent technique and, optimally, the same scales to measure height and
the child supine on a measuring board or in a measuring tray, as shown in
weight.
Figure 25-17. Direct measurement of the infant using a tape measure is
Variations beyond two standard deviations for age or above the inaccurate unless an assistant holds the child still with hips and knees
95th percentile or below the 5th percentile are indications for extended. Velocity growth curves are helpful for older children, especially
more detailed evaluation. These deviations may be the first and those who are suspected of having endocrine disorders.
only indicators of a variety of chronic childhood diseases (see
examples in [Link]
 FIGURE 25-17. Accurate length measurement requires careful assistance.

Reduced growth velocity, shown by a drop in height percentile on

a growth curve, may signify a chronic childhood condition. FIGURE 25-18. Head circumference is a vital metric during early childhood.
Chronic childhood conditions of many types can cause reduced
length or height. Some important ones include neurologic, renal, A small head size is called microcephaly, which may be familial
cardiac, gastrointestinal, and endocrine disorders. or due to chromosomal abnormalities, congenital infections,
maternal metabolic disorders, and neurologic insults.
Weigh infants directly with an infant scale. Infants should be weighed
Weight. Microcephaly may also result from premature closure of the
naked or be clothed only in a diaper. It is particularly important to use the sutures.
same scale as used previously if at all possible.
An abnormally large head size (>95th percentile or 2 standard
Failure to thrive is defined as: (a) growth <5th percentile for age; deviations above the mean) is macrocephaly, which may result
(b) drop >two quartiles in 6 months; or (c) weight for length <5th from hydrocephalus, intracranial hemorrhage, or rare causes like
percentile. Causes include psychosocial and family conditions brain tumor or inherited syndromes. Familial megaloencephaly
and a variety of gastrointestinal, neurologic, cardiac, endocrine, (large head) is a benign familial condition.
renal, and other diseases.
Vital Signs. Measure the infant’s vital signs—blood pressure, pulse rate,
Head Circumference. The head circumference should always be measured
respiratory rate, and temperature. Pediatric clinicians also assess pain
during the first 2 years of life, but measurement can be useful at any age to regularly, using standardized pain scales. Another measure that can be
assess growth of the head (Fig. 25-18). The head circumference in infants
helpful is the capillary refill time.
reflects the rate of growth of the cranium and the brain.
See pain severity assessment in Chapter 8, General Survey,
Vital Signs, and Pain, p. 234.
Blood Pressure. Systolic blood pressure gradually increases throughout studies of infants 1 year and older and from relatively small studies of blood
childhood. For example, normal systolic pressure in males is about 70 mm pressure in newborns.
Hg at birth, 85 mm Hg at 1 month, and 90 mm Hg at 6 months.
Causes of sustained hypertension in newborns include renal
Although obtaining accurate blood pressure readings in infants is challenging artery disease (stenosis, thrombosis), congenital renal
(Fig. 25-19), this measurement is nevertheless important for some high-risk malformations, and coarctation of the aorta.
infants. Blood pressure measurements should be routinely performed after
age 3 years. An automatic cuff is an alternative to a manual blood pressure Pulse [Link] heart rate of infants is more sensitive to the effects of illness,
cuff. For either method, using an accurate cuff size for age and placement are exercise, and emotion than that of adults (Box 25-12).
critical for obtaining accurate blood pressure readings. While sinus tachycardia may be extremely rapid, a pulse rate
that is too rapid to count (usually >220/min in infants) may
indicate paroxysmal supraventricular tachycardia (PSVT).

Box 25-12. Heart Rates of Healthy Children from Birth to 1

Year30

Age Average Heart Rate (per Range (1st to 99th percentile) per
minute) minute
Birth–1 140 90–165
month
1–6 months 130 80–175
6–12 months 115 90–170
FIGURE 25-19. Practice is required to accurately measure blood pressure in early
childhood.
Bradycardia may be from drug ingestion, hypoxia, intracranial or
neurologic conditions, or, rarely, cardiac dysrhythmia such as
heart block.
See pages 1006–1007 for more on blood pressure cuff size and
placement for children. See Table 25-1, Abnormalities in Heart Rhythm and Blood
Pressure, p. 1062.
You will need your skills in distraction or play to perform blood pressure
measurements on infants. With some practice, it is possible to calm and You may have trouble obtaining an accurate pulse rate in a squirming infant.
distract infants and obtain blood pressure readings at the same time. Palpate the femoral arteries in the inguinal area or the brachial arteries in the
antecubital fossa or auscultate the heart.
The AAP has updated guidelines for screening and management of elevated
blood pressure in children and adolescents, although these guidelines cover As with heart rate, the respiratory rate in infants has a greater
Respiratory Rate.
children who are 1 years and older.29 Normal blood pressure values for the range and is more responsive to illness, exercise, and emotion than that of
newborn period and for infants below 1 year tend to be extrapolated from adults or older children. The rate of respirations per minute ranges between
30 and 68 in the newborn (1st and 99th percentiles) and between 25 and 60 Fever (>38°C or >100.4°F) in infants younger than age 2 to 3
per minute in infants 6 to 12 months of age.30 months may be a sign of serious infection or disease and is an
Extremely rapid and shallow respiratory rates are seen in emergency. Potentially sick febrile infants under 3 months of age
newborns with cyanotic cardiac disease and right-to-left may have serious bacterial infection and should have
shunting, metabolic acidosis, and pulmonary diseases, and can temperatures assessed using a rectal thermometer.
be seen in infants with neurologic diseases.
The technique for obtaining a rectal temperature is relatively simple. One
The respiratory rate may vary considerably from moment to moment in the method is illustrated in Figure 25-20. Place the infant prone, separate the
newborn, with alternating periods of rapid and slow breathing (called buttocks with the thumb and forefinger on one hand and with the other hand
“periodic breathing”). The respiratory pattern should be observed for at gently insert a well-lubricated rectal thermometer to a depth of 2 to 3 cm.
least 60 seconds to asses both the rate and the pattern. The sleeping Keep the thermometer in place for at least 2 minutes.
respiratory rate is most reliable. Respiratory rates during active sleep
compared with quiet sleep may be up to 10 breaths per minute faster. In
infancy and early childhood, diaphragmatic breathing is predominant;
thoracic excursion is minimal.
Fever can raise respiratory rates in infants by up to 10
respirations per minute for each degree centigrade of fever.

Commonly accepted cutoffs for defining tachypnea are >60/min from birth to
2 months, and >50/min from 2 to 12 months.
Tachypnea and increased respiratory effort in an infant can be
signs of upper respiratory conditions and of lower respiratory
disease such as bronchiolitis or pneumonia.

Temperature. Body temperature in infants and children is less constant than in

FIGURE 25-20. Rectal thermometers are the most accurate tool for infants.
adults. The average rectal temperature is higher in infancy and early
childhood, usually above 99°F (37.2°C) until after age 3 years. Body
temperature fluctuates during a single day with vigorous activity and ambient Excessive bundling of infants may elevate skin temperature but
temperature. Two standard deviations above the mean for infants below 1 not usually core temperature, although temperature readings
month is 38.0°C31; thus pediatric clinicians often define fever in an infant should be repeated in an infant who is over-bundled.
below 3 months as having a temperature above 38.0°C.
Temperature instability (either high or low temperature) in a
Because fever is so common in infants and children, obtain an accurate body newborn may result from sepsis, metabolic abnormality, or other
temperature when you suspect infection. Rectal temperatures are the most serious conditions. Older infants rarely manifest temperature
accurate for infants. Axillary and thermal-tape skin temperature recordings in instability.
infants and children are inaccurate. Auditory canal temperatures are accurate.
Capillary Refill Time. Although it is not a vital sign, the capillary refill time infection and moisturizes the fetus to pass through the birth canal. Some
(CRT) can be a helpful measure as a “red flag” indicator of a potentially newborns have edema over their hands, feet, lower legs, pubis, and sacrum;
serious condition among sick infants and young children. It has high this disappears within a few days. Superficial desquamation of the skin is
specificity though varying and often low sensitivity as a tool to help discern often noticeable 24 to 36 hours after birth, particularly in post term babies
seriousness of illness in a sick child.32 (>40 weeks’ gestation), and it can last for 7 to 10 days.

Press the infant or child’s finger for 5 seconds with moderate pressure and Both erythema toxicum and pustular melanosis may appear
use a watch to time the number of seconds it takes for the finger to regain its similar to the pathologic vesiculopustular rash of herpes simplex
original color. Normally, CRT is less than 2 seconds in children older than 1 or Staphylococcus aureus skin infection.
week of age and a CRT over 3 to 4 seconds is considered prolonged.
Note any signs of trauma from the birth process and the use of forceps or
A prolonged CRT in a sick infant or young child is a nonspecific suction; these signs disappear but should prompt a careful neurologic
“red flag” for potentially serious condition such as dehydration, examination.
urinary tract infection, and other serious infections.
Midline hair tufts over the lumbosacral spine region suggest a
Skin possible spinal cord defect.
Inspection. Examine the skin of the newborn or infant carefully to identify
Vasomotor Changes. Vasomotor changes in the dermis and subcutaneous tissue
both normal markings and potentially abnormal ones. The photos on pp. 953–
—a response to cooling or chronic exposure to radiant heat—can produce a
954 demonstrate normal markings. The newborn’s skin has a unique
lattice-like, bluish mottled appearance (cutis marmorata), particularly on the
characteristic texture and appearance. The texture is soft and smooth
trunk, arms, and legs. This response to cold may last for months in normal
because it is thinner than the skin of older children. Within the first 10
infants. Cutis marmorata is a common, benign vascular condition, frequent
minutes after birth a normal newborn progresses from slight cyanosis
among premature infants, in which the skin shows a red/blue or purplish
(“bluish”) to pinkness. Some premature infants will be intensely
mottled lacy blood vessel pattern that is temporary and resolves with
erythematous (red).
warming.
Some newborns with polycythemia have a “ruddy” or purplish
color. [Link] amount of melanin in the skin of newborns varies, affecting
pigmentation. Some infants who will eventually have dark skin may have a
At birth, there is a fine, downy growth of hair called lanugo over the entire lighter skin color initially, except in the nail beds, genitalia, and ear folds
body, especially the shoulders and back. This hair is shed within the first few which are dark at birth. A dark or bluish pigmentation over the buttocks and
weeks. Lanugo is prominent in premature infants. Hair thickness on the head lower lumbar regions is common in newborns of African, Asian, Hispanic,
varies considerably among newborns and is not predictive of later hair and Mediterranean descent. These areas, called congenital dermal
growth. All of the original hair is shed within months and is replaced with a melanocytosis, result from pigmented cells in the deep layers of the skin;
new crop, sometimes of a different color. they become less noticeable with age and usually disappear during
childhood. Document these pigmented areas to avoid later concern about
Inspect the newborn closely for a series of common skin conditions. At birth, bruising.
a cheesy white material called vernix caseosa, composed of water, proteins
and lipids, covers the body and forms a barrier against maceration and Pigmented light-brown lesions (<1 to 2 cm at birth) are café-au-
lait spots. Isolated lesions have no significance, but multiple
 lesions with sharp borders may suggest neurofibromatosis. Carefully examine and touch the newborn’s skin to assess the level of
jaundice. Jaundice is best seen in natural daylight rather than artificial light.
See Table 25-2, Common Skin Rashes and Skin Findings in To detect jaundice, apply pressure to the skin (Fig. 25-21) to press out the
Newborns and Infants, p. 1063. normal pink or brown color. A yellowish “blanching” indicates jaundice.
Cyanosis. Observe the infant carefully for any cyanosis. Recognizing minimal
degrees of cyanosis requires care. Look inside the body (i.e., the inside of
the mouth, the tongue, or the conjunctivae) in addition to assessing skin color.
Acrocyanosis, a blue cast to the hands and feet when exposed to cold (see p.
959), is very common in newborns for the first few days and may recur
throughout early infancy. Central cyanosis is present if in addition to the
hands and feet, the lips, tongue, and sublingual tissues are also involved.
If acrocyanosis does not disappear within 8 hours or with
warming, cyanotic congenital heart disease should be
considered. FIGURE 25-21. Pressing the red color from the skin allows better recognition of the
yellow of normal skin (left) or jaundice (right). (From Fletcher M. Physical Diagnosis in
See discussion of central cyanosis on p. 973. Neonatology. Lippincott-Raven; 1998.)

Occasionally in newborns, a remarkable color change (harlequin

dyschromia) appears with transient cyanosis of one-half of the body or one Vascular Markings. A common, benign vascular marking is the “salmon patch”
extremity, presumably from temporary vascular instability. (also known as nevus simplex, “flame nevi,” telangiectatic nevus, or
capillary hemangioma). These flat, irregular, light pink patches (see p. 960)
Jaundice. Normal “physiologic” jaundice, which occurs in half of all are most often seen on the nape of the neck (“stork bite”), upper eyelids,
newborns, appears on the second or third day, peaks at about the fifth day, forehead, or upper lip (“angel kisses”). They are not true nevi but result from
and usually disappears within a week (although it may persist longer in distended capillaries. They often disappear by 1 year of age and are covered
breastfed infants). Newborn jaundice appears to progress from head to toe, by the hairline.
with more intense jaundice on the upper body and less intense yellow color A unilateral dark, purplish lesion, or “port wine stain” over the
in the lower extremities. distribution of the ophthalmic branch of the trigeminal nerve may
be a sign of Sturge–Weber syndrome, which is associated with
A common and nonpathologic type of jaundice during the first couple of
weeks is breastfeeding jaundice, which should completely resolve around 10 seizures, hemiparesis, glaucoma, and mental retardation.
to 14 days of life. Persistent jaundice requires evaluation. A physical
Palpation. Palpate the newborn or infant’s skin to assess the degree of
examination cannot reliably predict the level of bilirubin.
hydration, or turgor. Roll a fold of loosely adherent skin on the abdominal
Jaundice within the first 24 hours of birth may be from hemolytic wall between your thumb and forefinger to determine its consistency. The
disease of the newborn which is always pathologic. Late- skin in well-hydrated infants returns to its normal position immediately upon
appearing jaundice or jaundice that persists beyond 2 to 3 weeks release. Delay in return is a phenomenon called “tenting” and usually occurs
should raise suspicions of biliary obstruction or liver disease. in children with significant dehydration.
 Significant edema of the hands and feet of a newborn girl may Common Benign Rashes
be suggestive of Turner syndrome. Other features such as a Miliaria Rubra Erythema Toxicum
webbed neck would reinforce this diagnosis. Scattered erythematous papules, vesicles, or Usually appearing on days 2–3 of life, this
pustules, usually on the face, neck and trunk, rash consists of erythematous macules with
Dehydration is common in infants. Usual causes are insufficient result from obstruction of the sweat gland central pinpoint pustules on an erythematous
ducts; this condition disappears base, scattered diffusely over the entire body.
intake or excess loss of fluids from diarrhea. spontaneously within weeks. These lesions are of unknown etiology but
disappear within 1 week of birth.
You should be able to identify four common dermatologic conditions in
newborns—miliaria rubra, erythema toxicum, pustular melanosis, and
milia—which are shown on p. 960. None of these is clinically significant
(Box 25-13).

Box 25-13. Newborn Skin Findings

Finding/Description Finding/Description

Common Nonpathologic Conditions

Acrocyanosis Jaundice
This bluish discoloration usually appears in Physiologic jaundice occurs during days 2–5
the palms and soles. Cyanotic congenital of life and progresses from head to toe as it
heart disease can present with severe peaks. Extreme jaundice may signify a
acrocyanosis, which persists despite hemolytic process or biliary or liver disease. Transient Neonatal Pustular Melanosis Milia
warming. Seen more commonly in black infants, the Pinhead-sized white, pearly papules, without
rash presents at birth as some combination surrounding erythema, on the nose (seen
of pustules, scale, and hyperpigmented here), chin, and forehead result from
macules. The pustules and scale resolve by retention of sebum in the openings of the
around 2 weeks, leaving behind sebaceous glands. Although occasionally
hyperpigmented macules that resolve after present at birth, milia usually appear within
several months. the first few weeks and disappears over
several weeks.
Benign Birthmarks
At birth, a baby’s head may seem large relative to the body. A newborn’s
head accounts for one-fourth of the body length and one-third of the body
Eyelid Patch Salmon Patch weight; these proportions change, so that by adulthood the head accounts for
This birthmark fades, usually within the first Also called the “stork bite,” or “angel kiss,”
year of life. this splotchy pink mark fades with age. one-eighth of the body length and about one-tenth of the body weight.
An enlarged posterior fontanelle may be present in congenital
hypothyroidism.
Delayed closure of the fontanelles is usually a normal variant, but
can be due to hypothyroidism, megalocephaly, increased
intracranial pressure, or rickets.

Sutures and Fontanelles. Membranous tissue spaces called sutures

separate the bones of the skull from one another. The areas where the major
sutures intersect in the anterior and posterior portions of the skull are known
as fontanelles. The anterior fontanelle at birth measures 4 to 6 cm in
diameter. In about 80% of infants the anterior fontanelle will close by 18
Café-au-lait Spots Congenital Dermal Melanocytosis months of age, and in about 90% by 22 months.33 The posterior fontanelle
These light-brown pigmented lesions usually These are more common among dark- measures 1 to 2 cm at birth and usually closes by 2 months. Overlap of the
have borders and are uniform. They are skinned babies. It is important to note them cranial bones at the sutures at birth, called molding, results from passage of
noted in more than 10% of black infants. If so that they are not mistaken for bruises.
more than five café-au-lait spots exist, the head through the birth canal; it disappears within 2 days.
consider the diagnosis of neurofibromatosis
(see Table 25-2, Common Skin Rashes and A bulging, tense fontanelle is observed in infants with increased
Skin Findings in Newborns and Infants, p. intracranial pressure, which may be caused by bleeding, central
1063).
nervous system infections, neoplastic disease, or
hydrocephalus.
See Table 25-5, Abnormalities of the Head, p. 1066.

Examine the sutures and fontanelles carefully (Fig. 25-22). On palpation, the
sutures feel like ridges and the fontanelles like soft concavities.

Source of photo: Jaundice—From Chung EK et al. Visual Diagnosis and Treatment in

Pediatrics. 3rd ed. Wolters Kluwer; 2015, Figure 7-7.

Head.
 dehydration.
A depressed anterior fontanelle may be a sign of dehydration.

Inspect the scalp veins carefully to assess for dilatation.

Dilated scalp veins are indicative of long-standing increased
intracranial pressure.

Skull Symmetry and Head Circumference. Carefully assess skull

symmetry (Fig. 25-23). The premature infant’s head at birth is relatively long
in the occipitofrontal diameter and narrow in the bitemporal diameter
(dolichocephaly). Usually, the skull shape normalizes within 1 to 2 years.

FIGURE 25-22. Sutures and fontanelles.

Early closure of the fontanelles can be due to developing

microcephaly or to craniosynostosis or some metabolic
abnormalities.

Carefully examine the fontanelle, because its fullness reflects intracranial

pressure. Palpate the fontanelle while the baby is sitting quietly or being held FIGURE 25-23. Skull shape and symmetry should be assessed.
upright. Clinicians often palpate the fontanelles early in the examination. In
normal infants, the anterior fontanelle is soft and flat. A full anterior A common type of localized swelling of the scalp is a
fontanelle with increased intracranial pressure is seen when a baby cries or cephalohematoma, caused by subperiosteal hemorrhage from
vomits. Pulsations of the fontanelle reflect the peripheral pulse and are
the trauma of birth. This swelling does not cross over suture lines
usually completely normal (and parents often inquire about them).
and resolves within 3 weeks.
Learn to palpate the fontanelle because a bulging fontanelle is concerning for See Table 25-5, Abnormalities of the Head, p. 1066.
increased intracranial pressure and a depressed fontanelle may suggest
Various conditions can cause asymmetry; some are benign, while others
reflect underlying pathology. Look for asymmetric head swelling. A useful
strategy is to inspect the baby’s head from the top. Pick up the infant and
examine the skull shape from behind.
A newborn’s scalp may be swollen over the occipitoparietal
region. This is called caput succedaneum and results from
capillary distention and extravasation of blood and fluid resulting
from the vacuum effect of rupture of the amniotic sac. This
swelling typically crosses suture lines and resolves in 1 to 2
days.

Asymmetry of the cranial vault (positional plagiocephaly) occurs when an

infant lies mostly on one side, resulting in a flattening of the parieto-occipital
region on the dependent side and a prominence of the frontal region on the FIGURE 25-24. Careful assessment may reveal plagiocephaly.
ipsilateral side. It disappears as the baby becomes more active and spends
less time in one position, and symmetry is almost always restored. Palpate along the suture lines. A raised, bony ridge at a suture suggests
craniosynostosis.
Interestingly, the current trend to have newborns sleep on their backs to
reduce the risk for sudden infant death syndrome (SIDS) has resulted in more Premature closure of cranial sutures causes craniosynostosis (p.
cases of positional plagiocephaly (Fig. 25-24). This condition can be 1066) and an abnormally shaped skull. Sagittal suture synostosis
prevented by frequent repositioning (providing “tummy time” when the infant causes a narrow head from lack of growth of the parietal bones.
is awake).
Palpate the infant’s skull with care. The cranial bones generally appear
Plagiocephaly may also reflect pathology such as torticollis from “soft” or pliable; they will normally become firmer with increasing
injury to the sternocleidomastoid muscle at birth or lack of gestational age.
stimulation of the infant.
In craniotabes, the cranial bones feel springy. Craniotabes can
Measure the head circumference (p. 953) to detect abnormally large head result from increased intracranial pressure, as with
size (macrocephaly) or small head size (microcephaly), both of which may hydrocephaly, metabolic disturbances such as rickets, and
signify an underlying disorder affecting the brain. infection such as congenital syphilis.

Examine the chin—an abnormally small chin is called micrognathia or

mandibular hypoplasia.
Micrognathia may also be part of a syndrome, such as the Pierre
Robin syndrome.

Facial Symmetry. Check the face of infants for symmetry.

 Asymmetry of the face may reflect facial nerve palsy. If noted at Diagnostic Facies in Infancy and Childhood, pp. 1067–1068).
birth, this may be due to congenital disorders or birth trauma;
new onset in infancy may result from infection or other causes. A child with abnormal shape or length of palpebral fissures:
■ Upslanting (Down syndrome)
Examine the face for an overall impression of the facies; it is helpful to
■ Downslanting (Noonan syndrome)
compare with the face of the parents. A systematic assessment of a child with
abnormal-appearing facies can identify specific syndromes.34 Box 25-14 ■ Short (fetal alcohol effects)
describes steps for evaluating facies. See Table 25-6, Diagnostic Facies in Infancy and Childhood, pp.
1067–1068.
Box 25-14. Evaluating a Newborn or Child with Possible
Chvostek Sign. Percuss the cheek to check for Chvostek sign, which is
Abnormal Facies present in some metabolic disturbances and occasionally in normal infants.
Percuss at the top of the cheek just below the zygomatic bone in front of the
Carefully review the history, especially: ear, using the tip of your index or middle finger.
Family history
Pregnancy A positive Chvostek sign produces facial grimacing caused by
Perinatal history
repeated contractions of the facial muscles. Chvostek sign is
Note abnormalities on other parts of the physical examination, especially:
Growth
noted in cases of hypocalcemic tetany, tetanus, and tetany due
Development to hyperventilation.
Other dysmorphic somatic features
Perform measurements (and plot percentiles), especially: Eyes
Head circumference Inspection. Newborns keep their eyes closed except during brief awake
Height
Weight periods. If you attempt to separate their eyelids, they will tighten them even
Consider the three mechanisms of facial dysmorphogenesis: more. Bright light causes infants to blink, so use subdued lighting. Awaken
Deformations from intrauterine constraint the baby gently and support the baby in a sitting position; often the eyes will
Disruptions from amniotic bands or fetal tissue open.
Malformations from intrinsic abnormality in face/head or brain
Examine the parents and siblings: A newborn who truly cannot open an eye (even when awake and
Similarity to a parent may be reassuring (e.g., large head) but may also be an indication alert) may have congenital ptosis. Causes may include birth
of a familial disorder
trauma and third cranial nerve palsy.
Try to determine whether the facial features fit a recognizable syndrome, comparing with:
References (including measurements) and pictures of syndromes
Tables/databases of combinations of features To examine the eyes of infants and young children, use some tricks to
encourage cooperation. Small colorful toys without sounds are useful as
Most developmental and genetic syndromes with abnormal fixation devices in examining the eyes.
facies also have other abnormalities in other organ systems. Subconjunctival hemorrhages are common in neonates born via
An infant with congenital hypothyroidism may have coarse facial vaginal delivery.
features and other abnormal facial features (see Table 25-6,
Newborns may look at your face and follow a bright light if you catch them examination. The newborn may have visual impairment from
during an alert period. Some newborns can follow your face and turn their congenital cataracts or other disorders.
heads 90º to each side.
During the first 10 days of life, the eyes may stare in one direction if just the
Nystagmus (wandering or shaking eye movements) persisting
head is turned without moving the body (doll’s eye reflex).
after a few days or persisting after the maneuver described on
the left may indicate poor vision or central nervous system Alternating convergent or divergent strabismus persisting beyond
disease. 3 months, or persistent strabismus of any type, may indicate
ocular motor weakness or another abnormality in the visual
Examine infants for eye movements. Hold the baby upright, supporting the system.
head. Rotate yourself with the baby slowly in one direction. This usually
causes the baby’s eyes to open, allowing you to examine the sclerae, pupils, During the first few months of life, some infants have intermittent crossed
irises, and extraocular movements (Fig. 25-25). The baby’s eyes gaze in the eyes (intermittent alternating convergent strabismus, or esotropia) or
direction you are turning. When the rotation stops, the eyes look in the laterally deviated eyes (intermittent alternating divergent strabismus, or
opposite direction, after a few nystagmoid movements. exotropia). These generally resolve.

Look for abnormalities or congenital problems in the sclera and pupils.

Subconjunctival hemorrhages are common in newborns and resolve within a
couple of weeks. The eyes of many newborns are edematous from the birth
process.
Colobomas are missing sections of tissue in the eye (e.g., in the
iris alone or iris plus retina). These may be seen with the naked
eye and represent defects in the iris and may be associated with
vision loss.

Observe pupillary reactions by response to light or by covering each eye

with your hand and then uncovering it. Although there may be initial
asymmetry in the size of the pupils, over time they should be equal in size
and reaction to light.

Inspect the irises carefully for abnormalities.

Brushfield spots (seen with an ophthalmoscope) are a ring of
FIGURE 25-25. Carefully assess gaze and eye movements.
white specks in the iris. Although sometimes present in normal
children, these strongly suggest Down syndrome.
If a newborn fails to gaze at you and follow your face during alert See Table 25-7, Abnormalities of the Eyes, Ears, and Mouth, p.
periods, pay particular attention to the rest of the ocular 1069.
Examine the conjunctiva for swelling or redness. Most newborn nurseries
use an antibiotic eye ointment to help prevent gonococcal eye infection. This Age Sign
sometimes causes temporary swelling around the eyes. 0–2 months Startle response and blink to a sudden noise
Calming down with soothing voice or music
Persistent ocular discharge and tearing beginning at birth may be
2–3 months Change in body movements in response to sound
from dacryocystitis or nasolacrimal duct obstruction. Change in facial expression to familiar sounds
Turning eyes and head to sound
You will not be able to measure the visual acuity of newborns or infants. 3–4 months Turning to listen to voices and conversation
You can use visual reflexes to indirectly assess vision: direct and consensual
6–7 months Appropriate language development
pupillary constriction in response to light, blinking in response to bright light
(optic blink reflex), and blinking in response to quick movement of an object Perinatal problems raising the risk for hearing defects include
toward the eyes. birth weight <1,500 g, anoxia, treatment with potentially ototoxic
medications, congenital infections, severe hyperbilirubinemia, and
During the first year of life, visual acuity sharpens as the ability to focus
meningitis.
improves (Box 25-15). Infants achieve the visual milestones shown here.
Failure to progress along these visual developmental milestones may In the absence of universal hearing screening, many children with
indicate delayed visual maturation. hearing deficits are not diagnosed until 2 years. Clues to hearing
deficits include parental concern about hearing, delayed speech,
The acoustic blink reflex is a blinking of the infant’s eyes
Acoustic Blink Reflex. and lack of developmental indicators of hearing shown here.
in response to a sudden sharp sound. You can produce it by snapping your
fingers or using a bell, beeper, or other noisemaking device approximately 1 Ophthalmoscopic Examination. A thorough ophthalmoscopic
foot from the infant’s ear. Be sure you are not producing an airstream that examination is difficult in young infants but may be needed if ocular or
may cause the infant to blink (Box 25-16). This reflex may be difficult to neurologic abnormalities are noted. The cornea can ordinarily be seen at +20
elicit during the first 2 to 3 days of life. After it is elicited several times diopters, the lens at +15 diopters, and the fundus at 0 diopters.
within a brief period, the reflex disappears, a phenomenon known as
habituation. This crude test of hearing certainly is not diagnostic. Most Congenital glaucoma may cause cloudiness of the cornea.
newborns in the United States undergo hearing screenings, which are
For the ophthalmoscopic examination, with the newborn awake and eyes
mandatory in the majority of states.
open, examine the red retinal (fundus) reflex by setting the ophthalmoscope
at 0 diopters and viewing the pupil from about 10 in. Normally, a red or
Box 25-15. Visual Milestones of Infancy orange color is reflected from the fundus through the pupil.
Birth35 Blinks, may regard face A dark light reflex can result from cataracts, retinopathy of
1 month Fixes on objects prematurity, or other disorders. A white retinal reflex (leukokoria)
1½–2 months Coordinated eye movements
3 months Eyes converge, baby reaches toward a visual is abnormal, and cataract, retinal detachment, chorioretinitis, or
12 months stimulus retinoblastoma should be suspected.
Acuity around 20/60–20/80
Occlusion of the red reflex by the lens may represent a cataract.
Box 25-16. Signs That an Infant Can Hear
Examine the optic disc area as you would for an adult. In infants, the optic The infant’s ear canal is directed downward from the outside; therefore, pull
disc is difficult to visualize but is lighter in color, and there is less macular the auricle gently downward and outward, not upward, for the best view of
pigmentation. The foveal light reflection may not be visible. the eardrum. Once the tympanic membrane is visible, note that the light reflex
is diffuse; it does not become cone shaped for several months.
Papilledema is rare in infants because the fontanelles and open
sutures accommodate any increased intracranial pressure, See techniques in the use of an otoscope on p. 1012.
sparing the optic discs. Acute otitis media (see pp. 1012–1013) can occur in infants.
Small retinal hemorrhages may occur in normal newborns. Nose and Sinuses.
Extensive hemorrhages may suggest severe anoxia, subdural Infants are obligate nasal breathers and have difficulty breathing through
hematoma, subarachnoid hemorrhage, or trauma. Beyond the their mouths. The most important component of the examination of the infant
newborn period, retinal hemorrhages may be a sign of nose is to test for patency of these nasal passages. You can do this by gently
nonaccidental trauma (child abuse). occluding each nostril alternately while holding the infant’s mouth closed.
This usually will not cause stress because most infants are nasal breathers.
Ears. Do not occlude both nares simultaneously, as this will cause considerable
The physical examination of the ears of infants can detect abnormalities such distress.
as structural problems, otitis media, and hearing loss. The goals are to
The nasal passages in newborns may be obstructed in choanal
determine the position, shape, and features of the ear and to detect
atresia. In severe cases, nasal obstruction can be assessed by
abnormalities. Note ear position in relation to the eyes.
attempting to pass a no. 8 feeding tube through each nostril into
An imaginary line drawn across the inner and outer canthi of the eyes should the posterior pharynx. This is usually done in the delivery room to
cross the pinna or auricle; if the pinna is below this line the infant has low- assess for choanal atresia or other sources of unilateral or
set ears. Draw this imaginary line across the face of the baby on p. 964; note bilateral obstruction.
that it crosses the pinna.
Inspect the nose to ensure that the nasal septum is midline.
Small, deformed, or low-set auricles may indicate associated
congenital defects, especially renal disease. At birth, the maxillary and the ethmoid sinuses are present but small and
pneumatization occurs over time. Palpation of the sinuses of newborns is not
Otoscopic Examination. Otoscopic examination of the newborn’s ear can helpful.
detect only patency of the ear canal because accumulated vernix caseosa
obscures the tympanic membrane for the first few days of life. Mouth and Pharynx.
Use both inspection with a tongue depressor and flashlight and palpation to
A small skin tag, cleft, or pit found just forward of the tragus represents a inspect the mouth and pharynx (Fig. 25-26). A parent can help you by
remnant of the first branchial cleft and usually has no significance. stabilizing the infant’s head and arms. The newborn’s mouth is edentulous,
However, occasionally it may also be associated with renal disease and and the alveolar mucosa is smooth with finely serrated borders.
acquired hearing loss if there is a family history of hearing loss. Occasionally, pearl-like retention cysts are seen along the alveolar ridges
and are easily mistaken for teeth; these disappear within 1 or 2 months.
Petechiae are commonly found on the soft palate after birth.
 depressor or your gloved finger to wipe away the coating. If you do use a
tongue depressor, be careful to not stick it too deep into the infant’s mouth or
you will elicit a gag reflex.
Oral candidiasis (thrush) is common in infants. The white plaques
are difficult to wipe away and have an erythematous raw base.
They are found on the buccal mucosa, palate, and tongue. See
Table 25-7, Abnormalities of the Eyes, Ears, and Mouth, p.
1069.
Cysts may be noted on the tongue or mouth. Thyroglossal duct
FIGURE 25-26. Parental assistance helps with oral assessment.
cysts may open at the posterior tongue, or more commonly in
the neck.
Rarely, supernumerary teeth are noted. These are usually
dysmorphic and are shed within days but are removed to prevent Teeth. While there is a predictable pattern of tooth eruption, there is wide
aspiration. variation in the age at which teeth appear. A rule of thumb is that a child will
have 1 tooth for each month of age between 6 and 26 months, up to a
Palpate the upper hard palate to make sure it is intact. Epstein pearls, tiny maximum of 20 primary teeth.
white or yellow, rounded mucous retention cysts, are located along the
posterior midline of the hard palate. They disappear within months. Natal teeth are teeth that are present at birth. They are usually
simply early eruptions of normal teeth, but they can be part of
A congenital fissure of the median line of the palate is a cleft syndromes.
palate.
The pharynx of the infant is best seen while the baby is crying. Do not stick a
Infants produce little saliva during the first 3 months. Older infants produce a tongue depressor more than two-thirds of the way over the tongue to avoid a
lot of saliva and drool frequently. strong gag reflex. Infants do not have prominent lymphoid tissue so you will
probably not visualize the tonsils which increase in size as children grow.
Tongue. Inspect the tongue. The frenulum varies in tightness; sometimes it
extends almost to the tip and other times it is short, limiting protrusion of the Listen to the quality of the infant’s cry. Normal infants have a vigorous cry.
tongue (ankyloglossia or tongue tie).
New-onset stridor that appears following birth can be due to
A prominent, protruding tongue may signal congenital infections such as croup, a foreign body, or gastroesophageal
hypothyroidism, Down syndrome, or Beckwith–Wiedemann reflux.
syndrome.
Inspiratory stridor beginning at birth suggests a congenital
If associated with hypoglycemia and omphalocele, macroglossia abnormality. See Table 25-8, Abnormal Infant Cries, p. 1070.
is likely Beckwith–Wiedemann syndrome.
Neck.
You will often see a whitish covering on the tongue. If this coating is from Palpate the lymph nodes of the neck and assess for any additional masses
milk, it can be easily removed by scraping or wiping it away. Use a tongue such as congenital cysts (Fig. 25-27). Because the necks of infants are short,
it is best to palpate the neck while infants are lying supine, whereas older Thyroglossal duct cysts are located at the midline of the neck,
children are best examined while sitting. Check the position of the thyroid just above the thyroid cartilage. These small, firm, mobile
cartilage and trachea. masses move upward with tongue protrusion or with swallowing.
They are usually detected after 2 years.
Congenital torticollis, or a “wry neck,” is from bleeding into the
sternocleidomastoid muscle during the stretching process during
delivery or to in utero positioning. A firm fibrous mass is felt
within the muscle 2 to 3 weeks after birth and generally
disappears over months.

In newborns, palpate the clavicles and look for evidence of a fracture. If

present, you may feel a break in the contour of the bone, tenderness, crepitus
at the fracture site, and may notice limited movement of the arm on the
affected side.
A fracture of the clavicle may occur during birth, particularly
during delivery of a difficult arm or shoulder extraction.
Thorax and Lungs.
The infant’s thorax is more rounded than that of adults. The thin chest wall
has little musculature; thus, lung and heart sounds are transmitted quite
clearly. The bony and cartilaginous rib cage is soft and pliant. The tip of the
xiphoid process often protrudes anteriorly, immediately beneath the skin.
Two types of chest wall abnormalities noted in childhood include
pectus excavatum and pectus carinatum.
FIGURE 25-27. Nodes and cysts of the head and neck.
Inspection. Carefully assess respirations and breathing patterns.
Newborns, especially those born prematurely, show periods of normal rate
Branchial cleft cysts appear as small dimples or openings
(30 to 40 per minute) alternating respirations that may even cease for 5 to 10
anterior to the midportion of the sternocleidomastoid muscle. seconds. This alternating pattern of rapid and slow breathing is called
They may be associated with a sinus tract. “periodic respiration” or “periodic breathing.” Periodic breathing is one
Preauricular cysts and sinuses are common, pinhole-size pits, reason why it is optimal to measure respiratory rate over 60 seconds.
usually located anterior to the helix of the ear. They are often Apnea is cessation of breathing for more than 20 seconds. It is
bilateral and may be associated with hearing deficits and renal often accompanied by bradycardia and may indicate respiratory
disorders. disease, central nervous system disease, or, rarely, a
cardiopulmonary condition.
Do not rush to the stethoscope. Instead, observe the infant carefully as particularly relevant in assessing both upper and lower respiratory illness.
demonstrated in Figure 25-28, which demonstrates locations for retractions Any of the abnormalities listed in Box 25-17 should raise concern about
among infants. Inspection is easiest when infants are not crying; thus, work underlying respiratory pathology.
with the parents to settle the child.
A combination of respiratory signs such as nasal flaring plus
grunting and tachypnea may indicate lower respiratory infections,
defined as infections below the vocal cords. Examples include
bronchiolitis and pneumonia.

Box 25-17. Observing Respiration

Type of Assessment Specific Observable Pathology

General appearance Inability to feed or smile
Lack of consolability
Respiratory rate Tachypnea (see p. 1008), apnea
Color Pallor or cyanosis
Nasal component of breathing Nasal flaring (enlargement of both nasal openings
FIGURE 25-28. Anatomic locations of retractions (chest indrawing). during inspiration)
Audible breath sounds Grunting (repetitive, short expiratory sound)
Wheezing (musical expiratory sound)
Observe for 30 to 60 seconds, note general appearance, respiratory rate, Stridor (high-pitched, inspiratory noise)
color, nasal component of breathing, audible breath sounds, and work of Obstruction (lack of breath sounds)
breathing (Box 25-17). Because infants are obligate nasal breathers, observe Work of breathing Nasal flaring (excessive movement of nares)
their nose as they breathe. Look for nasal flaring. Observe breathing with the Grunting (expiratory noises)
infant’s mouth closed or during nursing or sucking on a bottle to assess for Retractions (chest indrawing):
Supraclavicular (soft tissue above clavicles)
nasal patency. Listen to the sounds of breathing; note any grunting, audible Intercostal (indrawing of skin between ribs)
wheezing, or lack of breath sounds (obstruction). Substernal (at xiphoid process)
Subcostal (just below the costal margin)
Nasal flaring, grunting, retractions, and wheezing are all signs of
respiratory distress. Acute stridor is a potentially serious condition; causes include
laryngotracheobronchitis (croup), epiglottitis, bacterial tracheitis,
In newborns and young infants, nasal flaring may be the result of foreign body, hemangioma, or a vascular ring.
upper respiratory infections, with subsequent obstruction of their
small nares, but it may also be caused by pneumonia or other In infants, increased work of breathing plus abnormal findings on
serious respiratory infections. auscultation are the best findings for ruling in pneumonia. The
best sign for ruling out pneumonia is the absence of tachypnea.
Observe three aspects of the infant’s breathing: respiratory rate (i.e.,
tachypnea), audible breath sounds and work of breathing. These are
In healthy infants, the ribs do not move much during quiet breathing. Any infants except in extreme instances. The infant’s chest is hyperresonant
outward movement is produced by descent of the diaphragm which throughout, and it is difficult to detect abnormalities on palpation or
compresses the abdominal contents and in turn shifts the lower ribs outward. percussion.
Asymmetric chest movement may indicate a space-occupying Because of the excellent transmission of sounds throughout the
lesion. chest, any abnormalities of tactile fremitus or on percussion
suggest severe pathology, such as a large pneumonic
Chest indrawing is inward movement of the skin between the ribs during consolidation.
inspiration. Movement of the diaphragm primarily affects breathing with
little assistance from the thoracic muscles. As mentioned in the preceding Auscultation. Infant breath sounds are louder and harsher than those of
table, four types of retractions can be noted in infants: suprasternal, adults because the stethoscope is closer to the origin of the sounds. It is often
intercostal, substernal, and subcostal. difficult to distinguish transmitted upper airway sounds from sounds
Pulmonary disease in young children causes increased originating in the chest (Box 25-18). Upper airway sounds tend to be loud,
abdominal breathing and can result in retractions. transmitted symmetrically throughout the chest, and loudest as you move your
stethoscope toward the neck. They are usually coarse inspiratory sounds.
Head bobbing may also be seen in infants with severe Lower airway sounds are loudest over the site of pathology, are often
respiratory distress. asymmetric, and often occur during expiration. You can also hold your
stethoscope just above the infant’s mouth and nose to differentiate upper
Thoracoabdominal paradox, or paradoxical breathing, is inward movement airway from lower airway sounds.
of the chest and outward movement of the abdomen during inspiration
(abdominal breathing). This is a normal finding in newborns (but not older Biphasic sounds imply severe obstruction from intrathoracic
infants). It persists during active, or rapid eye movement (REM), sleep even airway narrowing or severe obstruction from extrathoracic airway
when it is no longer seen during wakefulness or quiet sleep because of the narrowing.
decreased muscle tone of active sleep. As muscle strength increases and
chest wall compliance decreases with age, abdominal breathing should no Box 25-18. Distinguishing Upper Airway from Lower Airway
longer be noted. If observed, it may signify respiratory disease. Sounds in Infants
Airway obstruction or lower respiratory tract disease in infants
Technique Upper Airway Lower Airway
can result in the Hoover sign, or paradoxical (seesaw) breathing
in which the abdomen moves outward while the chest moves Compare sounds from Same sounds Often different sounds
nose/stethoscope
inward during inspiration.
Listen to harshness of sounds Harsh and loud Variable
Children with muscle weakness may be noted to have
Note symmetry (left/right) Symmetric Often asymmetric
paradoxical breathing at several years of age.
Compare sounds at different locations Sounds are louder as Often sounds are louder
(higher or lower) stethoscope is lower in chest toward
Palpation. Although it is challenging in infants, you can try to assess tactile moved up chest abdomen
fremitus by palpation. Place your hand on the chest when the infant cries or Inspiratory vs. expiratory Almost always Often has expiratory
makes noise. Place your hand or fingertips over each side of the chest and inspiratory phase
feel for symmetry in the transmitted vibrations. Percussion is not helpful in
Hold stethoscope above infant’s mouth Inspiratory sounds Often quieter than by Inspection. Before examining the heart, observe the infant carefully for any
remain loud auscultation of the chest
cyanosis. Check particularly for central cyanosis which is involvement of
Diminished breath sounds in one side of the chest of a newborn the lips, tongue and sublingual tissues in addition to the hands and feet
suggest unilateral lesions (e.g., congenital diaphragmatic hernia (Box 25-19). The best area to look for central cyanosis is the tongue and oral
or pneumothorax). mucosa, not the nail beds, lips, or the extremities. Acrocyanosis in the
newborn, which spares the oral mucosa, is discussed on pages 957 and 959.
Expiratory sounds usually arise from an intrathoracic source, whereas Central cyanosis is always abnormal because many congenital
inspiratory sounds can arise from an extrathoracic airway such as the trachea
cardiac abnormalities, as well as respiratory diseases, present
or from an intrathoracic source. During expiration, the diameter of the
with cyanosis.36 See Table 25-10, Cyanosis in Children, p. 1072,
intrathoracic airways decreases because radial forces from the surrounding
lung do not “tether” the airways open as occurs during inspiration. Higher and Table 25-11, Congenital Heart Murmurs, pp. 1073–1075.
flow rates during inspiration produce turbulent flow, resulting in appreciable
sounds. Box 25-19. Cardiac Causes of Central Cyanosis in Infants and
Children
Upper respiratory infections are not serious in infants but can
produce loud inspiratory sounds that are often transmitted to the
Age of Onset Potential Cardiac Cause
chest.
Immediately at birth or Transposition of the great arteries
within a few days Pulmonary valve atresia
The characteristics of the breath sounds, such as vesicular and Severe pulmonary valve stenosis
bronchovesicular, and of the adventitious lung sounds, such as crackles, Possibly Ebstein malformation
wheezes, and rhonchi, are the same as those for adults, except that they may Additional conditions (often within days):
Total anomalous pulmonary venous return
be more difficult to distinguish in infants and often occur together. Hypoplastic left heart syndrome
Truncus arteriosus (sometimes)
Wheezes and rhonchi are common in infants. Wheezes, often audible without Single ventricle variants
the stethoscope, occur more frequently than in adults because of the smaller Weeks, months, or years All of the above plus:
size of the tracheobronchial tree. Rhonchi reflect obstruction of larger of life Pulmonary vascular disease with atrial, ventricular, or great
vessel shunting (right-to-left shunting)
airways, or bronchi. Crackles (rales) are discontinuous sounds (see p. 483),
near the end of inspiration; they are usually caused by lung disorders and are
far less likely to represent cardiac failure in infants than in adults. They tend A true strawberry pink is normal, whereas any hint of raspberry red suggests
to be harsher than in adults. desaturation and requires urgent evaluation. The distribution of cyanosis
should be evaluated. An oximetry reading will confirm desaturation.
Wheezes in infants occur commonly from asthma and less
In general, cardiac causes of central cyanosis involve right-to-left
commonly from bronchiolitis.
shunting and can be caused by a variety of congenital cardiac
Rhonchi in infants occur with upper respiratory infections. lesions.
Crackles can be heard with pneumonia and bronchiolitis.
Observe the infant for general signs of health. The infant’s nutritional status,
Heart responsiveness, irritability, and fatigue are all clues that may be useful in
evaluating cardiac disease. Note that noncardiac findings are often present in
infants with cardiac disease (Box 25-20).
The combination of tachypnea, tachycardia, and hepatomegaly in
infants suggests heart failure.

Box 25-20. Noncardiac Findings Commonly Present in Infants

with Cardiac Disease
Poor feeding Tachypnea Poor overall appearance
Failure to thrive Hepatomegaly Weakness
Irritability Clubbing Fatigue

Observe the respiratory rate and pattern to help distinguish the degree of
illness and cardiac versus pulmonary diseases. An increase in respiratory
effort is expected from pulmonary diseases, whereas in cardiac disease there
may be tachypnea without increased work of breathing (called “peaceful
tachypnea”) until heart failure becomes significant. FIGURE 25-29. Location of thrills in infants and children.

Palpation. Palpation of the chest wall will allow you to assess volume A patent ductus arteriosus (PDA) is associated with
changes within the heart. For example, a hyperdynamic precordium reflects a hyperdynamic precordium and bounding distal pulses.
big volume change.
Visible and palpable chest pulsations suggest a hyperdynamic
The point of maximal cardiac impulse, or PMI, is not always palpable in state from either increased metabolic rate or inefficient pumping
infants and is affected by respiratory patterns, a full stomach, and the infant’s as a result of an underlying cardiac defect.
positioning. It is usually an interspace higher than in adults during the first
few years of life because the heart lies more horizontally within the chest. Auscultation. You can evaluate the heart rhythm more easily in infants by
listening to the heart than by feeling the peripheral pulses; in older children
A “rolling” heave at the left sternal border suggests an increase assess the rhythm either way (see Box 25-18).
in right ventricular work, whereas the same kind of motion closer
to the apex suggests the same thing for the left ventricle. The most common abnormal dysrhythmia in infants is
supraventricular tachycardia (SVT). It can occur at any age and
Thrills are palpable when turbulence within the heart or great vessels is is sometimes found on examination. The child may look healthy,
transmitted to the surface. Knowledge of the structures of the precordium pale, or moderately ill. The heart rate is sustained and regular at
helps pinpoint the origin of the thrill. Thrills are easiest to feel with your around 220 beats per minute or more. SVT in older children is
palm or the base of your fingers rather than your fingertips. Thrills have a more likely to be truly paroxysmal, with episodes of varying
somewhat rough, vibrating quality. Figure 25-29 shows locations of thrills duration and frequency.
that occur in infants and children from various cardiac abnormalities.
Infants and children commonly have a normal sinus dysrhythmia, with the Distant heart tones suggest pericardial effusion.
heart rate increasing on inspiration and decreasing on expiration, sometimes
quite abruptly. This normal finding can be identified by its repetitive nature Heart Sounds. Heart sounds are very challenging to assess in infants because
and its correlation with respiration (Box 25-21). they are rapid and often obscured by respiratory or other sounds.
Nevertheless, attempt to evaluate the S1 and S2 heart sounds carefully and
Box 25-21. Characteristics of Normal Variants of Heart systematically. They are normally crisp. You can usually hear the second
Rhythms in Children sounds (S2) at the base separately, but they should fuse into a single sound in
deep expiration.
Characteristics Atrial Premature Normal Sinus Dysrhythmias
Contractions (APCs) or
Pathologic arrhythmias in children can be from structural cardiac
Ventricular Premature lesions but also from other causes such as drug ingestion,
Contractions (VPCs) metabolic abnormalities, endocrine disorders, serious infections,
Most common age Neonates (may occur at After infancy and postinfectious states, or conduction disturbances without
any time) Throughout childhood structural heart disease.
Correlation with respiration No Yes: Increases on inspiration,
decreases on expiration Try to detect a split S2 by examining the infant when the infant is completely
Effect of exercise on Eradicated by exercise Disappears quiet or asleep. This split is usually reassuring although there are exceptions
tachycardia May be more frequent as noted below.
post-exercise
Characteristic of rhythm Skipped or missed beat Gradually faster with inspiration In addition to trying to detect splitting of the S2, listen for the intensity of A2
Irregularly occurring Often suddenly slower on expiration
and P2. The aortic, or first component of the second sound at the base, is
Number of beats Usually single abnormal Several beats, usually in repetitive
beats cycles normally louder than the pulmonic, or second component (Fig. 25-30).
Severity Usually benign Benign (by definition)

Although ventricular premature contractions generally occur in

otherwise healthy infants, they can occur with underlying cardiac
disease, particularly cardiomyopathies and congenital heart
disorders. Electrolyte or metabolic disturbances are also
possible causes.

Many neonates and some older children have premature atrial or ventricular
beats that are often described as “skipped” beats. You can usually eradicate
them by increasing their intrinsic sinus rate through exercise such as crying in FIGURE 25-30. Healthy heart sounds in infants.
an infant or jumping in an older child, although they may also be more
frequent in the postexercise period. In a completely healthy child, they are
usually benign and rarely persist. A louder-than-normal pulmonic component, particularly when
louder than the aortic sound, suggests pulmonary hypertension
 or an atrial septal defect (ASD). Many (but not all) children with serious cardiac malformations have signs
and symptoms other than a heart murmur obtainable on careful history or
Persistent splitting of S2 may indicate a right ventricular volume
examination. Many have noncardiac signs and symptoms, including evidence
load such as atrial septal defect, or cardiac lesions associated of genetic defects that may offer helpful diagnostic clues.
with pulmonary hypertension.
Any of the noncardiac findings that frequently accompany cardiac
You may detect third heart sounds which are low-pitched, early diastolic disease in children markedly raises the possibility that a murmur
sounds best heard at the lower left sternal border, or apex; they reflect rapid is pathologic.
ventricular filling. These are frequently heard in children and are normal. A
fourth heart sound (S4), not often heard in children, is a low-frequency, late Most children, if not all, will have one or more functional, or benign, heart
diastolic sound, occurring just before the first heart sound. murmurs before reaching adulthood.37–39 It is important to identify functional
murmurs by their specific qualities rather than by their intensity. You will
A high-intensity third heart sound, or a gallop, is a sign of learn to recognize the common functional murmurs of infancy and childhood,
underlying pathology. which under most circumstances do not require evaluation. An important rule
A fourth heart sound represents decreased ventricular of thumb is that, by definition, benign murmurs in children have no
associated abnormal findings and are growing normally.
compliance, suggesting heart failure.
Some pathologic murmurs of congenital heart disease are
You may also detect an apparent gallop (widely split S2 that varies), in the present at birth. Others are not apparent until later, depending on
presence of a normal heart rate and rhythm. This is frequently found in their severity, drop in pulmonary vascular resistance following
normal children and does not represent pathology. birth, or changes associated with growth of the child. Table 25-
A true gallop rhythm (in contrast to a widely split S2 which gives 11, Congenital Heart Murmurs, on pp. 1073–1075, shows
an apparent gallop)—tachycardia plus a loud S3, S4, or both—is examples of pathologic murmurs of childhood.
pathologic and indicates heart failure (poor ventricular function). Box 25-22 characterizes two benign heart murmurs in infants according to
their locations and key characteristics.
Heart [Link] of the most challenging aspects of the cardiac examination
in children is the evaluation of heart murmurs. In addition to listening to a
squirming, perhaps uncooperative child, a major challenge is distinguishing Box 25-22. Two Common Benign Murmurs in Infants
common benign murmurs from unusual or pathologic ones.

Characterize heart murmurs in infants and children by noting their specific

location (e.g., left upper sternal border, not just left sternal border), timing,
intensity, and quality. If each murmur is delineated completely, the diagnosis
is usually made clinically; laboratory tools such as ECG, chest x-ray, and
echocardiography may be needed for confirmation and better
characterization.
 A pulmonary flow murmur in the newborn with other signs of
disease is more likely to be pathologic. Diseases may include
Williams syndrome, congenital rubella syndrome, and Alagille
syndrome. These conditions have pulmonary artery stenosis and
differ from the benign peripheral pulmonary stenosis.

When you detect a murmur in a child, note all of the qualities as described in
Chapter 16, Cardiovascular System, to help you distinguish pathologic
murmurs from benign murmurs. Heart murmurs that reflect underlying
structural heart disease are easier to evaluate if you have a good knowledge
of intrathoracic anatomy and the functional cardiac changes following birth
and if you understand the physiologic basis for heart murmurs. Understanding
these physiologic changes can help you distinguish pathologic murmurs from
benign heart murmurs in children (Box 25-23).
A newborn with a heart murmur and central cyanosis is likely to
Typical Age Name Characteristics Description and have congenital heart disease and requires urgent cardiac
Location evaluation.
Newborn Closing ductus Harsh, ejectile
(crescendo) systolic
murmur, as PDA closes Box 25-23. Physiologic Basis for Selected Pathologic Heart
becomes continuous Murmurs
Upper left sternal border
Newborn to 1 yr Peripheral Soft, ejectile, systolic Change in Pulmonary Vascular Resistance
pulmonary flow Upper left sternal border,
murmur radiating to lung fields and Heart murmurs that are dependent on a postnatal drop in pulmonary vascular resistance,
axillae allowing turbulent flow from the high-pressure systemic circuit to the lower-pressure
pulmonary circuit, are not audible until such a drop has occurred. Except in premature
infants, murmurs of a ventricular septal defect or PDA are sometimes not heard in the
first few days of life and usually become audible after a week to 10 days.

Obstructive Lesions
In some infants, you will detect a soft, ejectile murmur heard in the axilla and
Obstructive lesions, such as pulmonic and aortic stenosis, are caused by normal blood
back. This represents benign peripheral pulmonary stenosis, which is partly flow through two small valves. They are not dependent on a drop in pulmonary vascular
the result of inadequate pulmonary artery growth in utero (when there is little resistance. They are audible at birth.
pulmonary blood flow) and the sharp angle at which the pulmonary artery
Pressure Gradient Differences
curves backward. In the absence of any physical findings to suggest
additional underlying diseases, this peripheral pulmonary stenosis murmur Murmurs of atrioventricular valve regurgitation are audible at birth because of the high-
pressure gradient between the ventricle and its atrium.
(which is common) can be considered benign and usually disappears by 1
year. Changes Associated with Growth of Children
 Some murmurs do not follow the patterns above but become audible because of
alterations in normal blood flow that occur with growth. For example, even though it is an
obstructive defect, aortic stenosis may not be audible until considerable growth has
occurred and is frequently not heard until adulthood, although a congenitally abnormal
valve is responsible. Similarly, the pulmonary flow murmur of an atrial septal defect may
not be heard for a year or more because right ventricular compliance gradually increases
and the shunt becomes larger, eventually producing a murmur caused by too much
blood flow across a normal pulmonic valve.

Characteristics of specific pathologic heart murmurs in children

are described in Table 25-11, Congenital Heart Murmurs, pp.
1073–1075.

Peripheral Vascular System. The major branches of the aorta can be assessed by
evaluation of the peripheral pulses. All neonates should have an evaluation
of all pulses at the time of their newborn examination. In neonates and FIGURE 25-31. Palpating pulses in the lower extremity.
infants, the brachial artery pulse in the antecubital fossa is easier to feel
than the radial artery pulse at the wrist. Both temporal arteries should be A weak or thready, difficult-to-feel pulse may reflect myocardial
felt just in front of the ear. dysfunction and heart failure, particularly if associated with an
The absence or diminution of femoral pulses is indicative of unusual degree of tachycardia.
coarctation of the aorta. If you cannot detect femoral pulses, Although the pulses in the feet of neonates and infants are often
measure blood pressures of one of the lower and both upper faint, several conditions can cause full pulses, such as a patent
extremities. Normally, the blood pressure in the lower extremity ductus arteriosus or truncus arteriosus.
is slightly higher than in the upper extremities. If they are equal or
lower in the leg, coarctation is likely to be present. As discussed on p. 954, carefully measure the blood pressure of infants and
children (using an appropriate-sized infant blood pressure cuff) as part of the
Palpate the femoral pulses. They lie in the midline just below the inguinal cardiac examination.
crease, between the iliac crest and the symphysis pubis. Take your time to
search for femoral pulses; they are difficult to detect in chubby, squirming Breasts.
infants. Use the pads of your index and middle finger together to maximize The breasts of the newborn in both males and females are often enlarged
your chance of finding the pulse. If you first flex the infant’s thighs on the from maternal estrogen effect; this may last several months. The breasts may
abdomen, this may overcome the reflex flexion that occurs when you then also be engorged with a white liquid, sometimes colloquially called “witch’s
extend the legs. milk,” which may last 1 or 2 weeks.
In premature thelarche, breast development occurs, most often
Palpate the pulses in the lower extremities using your index or middle finger.
between 6 months and 2 years. Other signs of puberty or
The dorsalis pedis and posterior tibial pulses (Fig. 25-31) may be difficult to
feel unless there is an abnormality involving aortic run-off. Normal pulses hormonal abnormalities are not present.
should have a sharp rise and should be firm and well localized. Abdomen
Inspection. Inspect the abdomen with the infant lying supine (and, Auscultation. Auscultation of a quiet infant’s abdomen is easy. You may
optimally, asleep). The infant’s abdomen is protuberant as a result of poorly hear an orchestra of musical tinkling bowel sounds upon placement of your
developed abdominal musculature. You will easily notice abdominal wall stethoscope on the infant’s abdomen.
blood vessels and intestinal peristalsis.
An increase in pitch or frequency of bowel sounds is heard with
Inspect the newborn’s umbilical cord to detect abnormalities. Normally, gastroenteritis. Intestinal obstruction often produces a silent
there are two thick-walled umbilical arteries and one larger but thin-walled abdomen.
umbilical vein which is usually located at the 12 o’clock position.
Percussion and Palpation. You can percuss an infant’s abdomen as you
A single umbilical artery may be associated with congenital would an adult’s but you may note greater tympanitic sounds because of the
anomalies or be an isolated anomaly. infant’s propensity to swallow air. Percussion is useful for determining the
size of organs and abdominal masses.
The umbilicus in the newborn may have a long cutaneous portion (umbilicus
cutis) which is covered with skin, and an amniotic portion (umbilicus A silent, tympanic, distended, and tender abdomen suggests
amnioticus) which is covered by a firm gelatinous substance. The amniotic peritonitis.
portion dries up and falls off within 2 weeks, whereas the cutaneous portion
retracts to be flush with the abdominal wall. It is easy to palpate an infant’s abdomen because infants like being touched.
A useful technique to relax the infant is to hold the legs flexed at the knees
An umbilical granuloma at the base of the navel is the and hips with one hand and palpate the abdomen with the other.
development of pink granulation tissue formed during the healing
process. A pacifier may quiet the infant in this position.

Inspect the area around the umbilicus for redness or swelling. The normal When palpating the liver, start gently low in the abdomen, moving upward
healing process of the umbilical stump produces a sometimes foul-smelling, with your fingers. This technique helps to identify an extremely enlarged
moist exterior at the point of healing. However, the abdominal skin around liver that extends down into the pelvis. With a careful examination, you can
the umbilicus should be the same color as the baby’s abdomen. feel the liver edge in most infants, 1 to 3 cm below the right costal margin.
Infection of the umbilical stump (omphalitis) is characterized by Among newborns, causes of hepatomegaly include hepatitis,
periumbilical edema and erythema. storage diseases, vascular congestion, and late presentation of
biliary obstruction.
Umbilical hernias are detectable by a few weeks of age. Most disappear by
1 year, nearly all by 5 years. Umbilical hernias in infants are caused by a One technique for assessing liver size in infants is simultaneous percussion
defect in the abdominal wall and can be quite protuberant with increased and auscultation.40 Percuss and simultaneously auscultate, noting a change in
intra-abdominal pressure (e.g., during crying). sound as you percuss over the liver or beyond it (Box 25-24).

In some infants, you will notice a diastasis recti. This involves separation of
Box 25-24. Liver Size in Healthy Term Newborns
the two rectus abdominis muscles, causing a midline ridge most apparent
when the infant contracts the abdominal muscles. A benign condition in most By palpation and percussion41 Mean, 5.9 ± 0.7 cm
cases, it resolves during early childhood. Projection below right costal margin Mean, 2.5 ± 1.0 cm
The spleen, like the liver, is felt easily in most infants. It is soft with a sharp North America and varies worldwide, depending on cultural practices.
edge and it projects downward like a tongue from under the left costal While the AAP, CDC, and other experts state that the health benefits of
margin. The spleen is moveable and rarely extends more than 1 to 2 cm newborn male circumcision (reduced risks of HIV and other sexually
below the left costal margin. transmitted infections) outweigh the risks, the AAP states that the benefits are
not great enough to recommend universal newborn circumcision and
Splenomegaly can be due to infections, hemolytic anemias,
therefore recommends that the final decision should still be deferred to
infiltrative disorders, inflammatory or autoimmune diseases, and parents based on their religious, ethical, and cultural beliefs.42
portal hypertension.
Hypospadias refers to an abnormal location of the urethral orifice
Palpate the other abdominal structures. You will commonly note pulsations to some point along the ventral surface of the glans or shaft of
in the epigastrium caused by the aorta. This is felt on deep palpation to the the penis (see Table 25-13, Male Genitourinary System, p.
left of the midline. Rarely, you may be able to palpate the kidneys of infants 1077). The foreskin is incompletely formed ventrally.
by carefully placing the fingers of one hand in front of and those of the other
behind each kidney. The descending colon is a sausage-like mass in the left Inspect the shaft of the penis, noting any abnormalities on the ventral surface.
lower quadrant. Make sure the penis appears straight.
Abnormal abdominal masses in infants can be associated with A fixed, downward bowing of the penis is a chordee; this may
the kidney (e.g., hydronephrosis), bladder (e.g., urethral accompany a hypospadias. Micropenis is a normally structured
obstruction), bowel (e.g., stool from Hirschsprung disease, or penis with length <1.9 cm.
intussusception), and tumors.
Inspect the scrotum noting rugae, which should be present by 40 weeks’
Once you have identified the normal structures in the infant’s abdomen, use gestation. Scrotal edema may be present for several days following birth
palpation to identify abnormal masses. because of the effect of maternal estrogen.
In pyloric stenosis, deep palpation in the right upper quadrant or
Palpate the testes in the scrotal sacs, proceeding downward from the external
midline can reveal an “olive,” or a 2-cm firm pyloric mass. While inguinal ring to the scrotum. If you feel a testis up in the inguinal canal, gently
the infant is feeding you might see peristaltic waves pass across milk it downward into the scrotum. The newborn’s testes should be about 10
the abdomen. Infants present at about 4 to 6 weeks of age. mm in width and 15 mm in length and should lie in the scrotal sacs most of
Male Genitalia. the time.
Inspect the male genitalia with the infant supine noting the appearance of the The incidence of undescended testes (cryptorchidism) is about
penis, testes, and scrotum. 30% among premature infants, 3% among term neonates, and
1% by 1 year of age. In newborns with an undescended testicle,
The foreskin (prepuce) completely covers the glans penis. It is the scrotum often appears underdeveloped and tight; palpation
nonretractable at birth though you may be able to retract it enough to
reveals an absence of scrotal contents (see Table 25-13, Male
visualize the external urethral meatus.
Genitourinary System, p. 1077).
The foreskin gradually loosens over months to years and becomes Examine the testes for swelling within the scrotal sac and over the inguinal
retractable. The rate of circumcision had declined over several decades in ring. If you detect swelling in the scrotal sac try to differentiate it from the
testis. Note whether the size changes when the infant increases abdominal In the newborn female, the genitalia on inspection are prominent due to the
pressure by crying. See if your fingers can get above the mass, trapping it in effects of maternal estrogen (this decreases during the first year).
the scrotal sac. Apply gentle pressure to try to reduce the size of the mass and
note any tenderness. Note whether it transilluminates (Fig. 25-32). The labia majora and minora have a dull pink color in light-skinned infants
and may be hyperpigmented in dark-skinned infants. During the first few
weeks of life there is often a milky white vaginal discharge that may be
blood tinged and is a result of the effects of hormonal withdrawal; this is not
a cause for concern.
Ambiguous genitalia, involving masculinization of the female
external genitalia, is a rare condition caused by endocrine
disorders such as congenital adrenal hyperplasia.

Examine the different structures systematically, including the size of the

clitoris, the color and size of the labia majora, and any rashes, bruises, or
external lesions (Fig. 25-33).
Labial adhesions occur frequently, tend to be paper thin, and
often disappear without treatment. The adhesions attach the
labial minora to each other at the midline.
FIGURE 25-32. Transillumination of a hydrocele. (From Fletcher M. Physical
Diagnosis in Neonatology. Lippincott-Raven; 1998.) Next, separate the labia majora at their midpoint with the thumb of each hand,
or as shown in Figures 25-85 and 25-86 on page 1027. Inspect the urethral
Two common scrotal masses in newborns are hydroceles and orifice and the labia minora. Assess the hymen, which in newborns and
inguinal hernias; frequently both coexist, and both are more infants is a thickened, avascular structure with a central orifice, covering the
common on the right side. Hydroceles overlie the testes and the vaginal opening. You should note a vaginal opening, although the hymen will
spermatic cord, and can be communicating (i.e., reducible) or be thickened and redundant. Note any discharge.
noncommunicating (i.e., nonreducible). They can be An imperforate hymen may be noted at birth.
transilluminated (Fig. 25-32). Most resolve by 18 months.
Hernias are separate from the testes, are usually reducible, and
often do not transilluminate. They do not resolve. Sometimes a
thickened spermatic cord (called the silk sign) is noted.
Female Genitalia.
Become familiar with the anatomy of an infant’s female genitalia. Examine
the female genitalia with the infant supine.
 Inspection can reveal gross deformities such as dwarfism,
congenital abnormalities of extremities or digits, and amniotic
bands that constrict an extremity.

The newborn’s hands are clenched. Because of the palmar grasp reflex (see
the discussion on the nervous system, p. 990), you will need to help the infant
extend the fingers. Inspect the fingers carefully, noting any defects.
Skin tags, remnants of digits, polydactyly (extra fingers), or
syndactyly (webbed fingers) are congenital defects noted at
birth.
FIGURE 25-33. Highly estrogenized hymen of a newborn with thickening and
hypertrophy of hymenal tissue. Palpate along the clavicle noting any lumps, tenderness, or crepitus; these
may indicate a fracture which can occur during a difficult birth.
Rectum and Anus.
In general, a digital rectal examination is not performed on infants or Inspect the spine carefully especially for major defects. Note any subtle
children unless there is question of patency of the anus or an abdominal mass. abnormalities including pigmented spots, hairy patches, or deep pits.
In such cases, flex the infant’s hips and fold the legs to the head. Use your Major defects of the spine such as meningomyeloceles are often
lubricated and gloved pinky to perform the examination. detected by ultrasound before birth and if present within 1 cm or
A common cause of blood in the stool of infants is an anal so of the midline, may overlie external openings of sinus tracts
fissure which is a superficial break in the surface of the anus and that extend to the spinal canal. Do not probe any sinus tracts
observable with the naked eye. because of the risk of infection.

Musculoskeletal System. Palpate the spine in the lumbosacral region, noting any deformities of the
Significant changes in the musculoskeletal system occur during infancy. Much vertebrae.
of the examination of the infant focuses on detection of congenital Spina bifida occulta (a defect of the vertebral bodies) may be
abnormalities, particularly in the hands, spine, hips, legs, and feet. associated with defects of the spinal cord, which can cause
severe neurologic dysfunction.
Combine the musculoskeletal examination with the neurologic and
developmental examination. It is also worthwhile to remember the mnemonic Examine the newborn and infant’s hips carefully at each examination for
the assessment of the musculoskeletal system of IPROMS (“I promise. . .”) signs of dislocation.43,44 All babies should receive serial hip examinations
which includes inspection, palpation of bony structures and related joint and until they are walking. Two special maneuvers to detect hip instability are
soft tissue structures, assessment of range of motion, and special maneuvers often performed. One tests for the presence of a posteriorly dislocated hip
to test specific movements. (Ortolani test), and another tests for the ability to sublux or dislocate an
See discussion of approach to the musculoskeletal examination intact but unstable hip (Barlow test). The Ortolani and Barlow tests are
in Chapter 23, Musculoskeletal System, pp. 748–751. usually performed together in either sequence.
 Developmental dysplasia of the hip is important to detect as
early treatment has excellent outcomes.
A soft audible “click” heard with these maneuvers does not prove
a dislocated hip but should prompt a careful examination.

Ortolani Test. Make sure the baby is relaxed for these techniques. For the
Ortolani test, place the baby supine with the legs pointing toward you
(Fig. 25-34). Flex the legs to form right angles at the hips and knees, placing
your index fingers over the greater trochanter of each femur and your thumbs
over the lesser trochanters (Fig. 25-35). Abduct both hips simultaneously
until the lateral aspect of each knee touches the examining table (Fig. 25-36).
FIGURE 25-35. Ortolani test, starting position.

FIGURE 25-36. Ortolani test, ending position.

FIGURE 25-34. Ortolani test, overhead view.

Barlow Test. For the Barlow test, place your hands in the same position as
With a developmental dysplasia of the hip, you feel a “clunk” as for the Ortolani test. Pull the leg forward (Fig. 25-37) and adduct with
the femoral head, which lies posterior to the acetabulum, enters posterior force; that is, press in the opposite direction with your thumbs
moving down toward the table and outward, applying pressure posteriorly
the acetabulum. A palpable movement of the femoral head back
(Fig. 25-38). Feel for any movement of the head of the femur laterally.
into place constitutes a positive Ortolani sign.
Normally, there is no movement and the hips feel “stable.”
 specialist. If you feel the head of the femur slipping out onto the
posterior lip of the acetabulum, this constitutes a positive Barlow
sign. If you feel this dislocation movement, abduct the hip by
pressing with your index and middle fingers back inward and feel
for the movement of the femoral head as it returns to the hip
socket.
Children older than age 3 months may have a negative Ortolani
or Barlow sign and still have a dislocated hip due to tightening of
the hip muscles and ligaments.; in these children limited
abduction is concerning for developmental dysplasia of the hip.

Test for femoral shortening using the Galeazzi or Allis sign. Place the feet
(with knee flexed and sacrum flat on the table) together and note any
FIGURE 25-37. Barlow test, overhead view.
difference in knee heights.

Examine a newborn or infant’s legs and feet to detect developmental

abnormalities. Assess symmetry, bowing, and torsion of the legs. There
should be no discrepancy in leg length. It is common for normal infants to
have asymmetric thigh skin folds, but if you do detect asymmetry, make sure
you perform the instability tests because dislocated hips are commonly
associated with this finding.
Severe bowing of the knees can be normal, but it can also be
due to rickets or Blount disease. The most common cause of
bowing is tibial torsion (see below).

Most newborns are bowlegged, reflecting their curled-up intrauterine

position.

Some normal infants exhibit twisting or torsion of the tibia inwardly or

outwardly on its longitudinal axis. Parents may be concerned about a toeing
in or toeing out of the foot and an awkward gait, all of which are usually
FIGURE 25-38. Barlow test, direction of force. normal. Tibial torsion usually corrects itself during the second or third
year of life after months of weight bearing.43
A positive Barlow sign is not diagnostic of a dysplastic hip but
Pathologic tibial torsion occurs only in association with
indicates laxity and a potentially dislocatable hip; the baby needs
deformities of the feet or hips.
to be followed closely or obtain an ultrasound or refer to a
Examine the feet of newborns and infants. At birth, the feet may appear
deformed from retaining their intrauterine positioning, often turned inward
(Fig. 25-39). You should be able to correct the feet to the neutral and even to
an overcorrected position (Fig. 25-40). Scratch or stroke along the outer
edge to see if the foot assumes a normal position.

FIGURE 25-40. Assess alignment by turning to an overcorrected position.

In all of these normal variants the abnormal position can be easily

overcorrected past midline. They all tend to resolve within 1 or 2 years.
The most common severe congenital foot deformity is talipes
FIGURE 25-39. Assess alignment of the feet.
equinovarus or clubfoot.
See Table 25-14, Common Musculoskeletal Findings in Young
True deformities of the feet do not return to the neutral position Children, p. 1077.
even with manipulation. Nervous System.
The normal newborn’s foot has several benign features that may initially The examination of the nervous system in infants includes techniques that are
cause concern. The newborn’s foot appears flat because of a plantar fat pad. highly specific to this particular age group. Unlike many neurologic
There is often inversion of the foot, elevating the outer margin (see p. 989). abnormalities in adults that produce asymmetric localized findings,
Other babies will have adduction of the forefoot without inversion, called neurologic abnormalities in infants often present as developmental
metatarsus adductus which requires close follow-up. Still others will have abnormalities such as failure to do age-appropriate tasks. Therefore, the
adduction of the entire foot. Finally, most toddlers have some pronation neurologic and developmental examinations need to proceed together. A
during early stages of weightbearing with eversion of the foot. developmental abnormality should prompt you to pay particular attention to
the neurologic examination.
Signs of severe neurologic disease in infants include extreme
irritability, persistent asymmetry of posture, persistent extension
of extremities, constant turning of the head to one side, marked
 extension of the head, neck, and extremities (opisthotonus), may indicate intracranial disease although such disease is usually
severe flaccidity, limited response to pain, and sometimes accompanied by a number of other signs.
seizures.

The neurologic screening examination of all newborns should include

assessment of mental status, gross motor function, tone, cry, deep tendon
reflexes, and primitive reflexes. More detailed examination of cranial nerve
function and sensory function are indicated if you suspect any abnormalities
from the history or screening.45
Subtle neonatal behaviors such as fine tremors, irritability, and
poor self-regulation may indicate withdrawal from nicotine or
opioids.

The neurologic examination can reveal extensive disease but will not
pinpoint specific functional deficits or minute lesions.

Mental Status. Assess the mental status of newborns by observing the

newborn activities discussed in Box 25-7 on p. 947. Make sure you test the
newborn during alert periods. A detailed description of the assessment of
development follows.
FIGURE 25-41. Assessing motor tone.
Persistent irritability in the newborn may be a sign of neurologic
insult or may reflect a variety of metabolic, infectious, or other
Newborns with hypotonia often lie in a frog-leg position, with
constitutional abnormalities, or environmental conditions such as
arms flexed and hands near the ears. A hypotonic infant would
drug withdrawal.
almost slip through the examiner’s hands in Figure 25-41.
Motor Function and Tone. Assess the motor tone of newborns and Hypotonia can be caused by a variety of central nervous system
infants, first by carefully observing their position at rest and testing their abnormalities and disorders of the motor unit.
resistance to passive movement.
Sensory Function. You can test for sensory function of the newborn in
Further, assess tone as you move each major joint through its range of only a limited way. Test for pain sensation by flicking the infant’s palm or
motion, noting any spasticity or flaccidity. Hold the baby in your hands sole with your finger. Observe for withdrawal, arousal, and change in facial
(Fig. 25-41) to determine whether the tone is normal, increased, or expression. Do not use a pin to test for pain.
decreased. A baby with normal tone has normal response to vertical If changes in facial expression or cry follow a painful stimulus but
suspension, as in the figure, and won’t “slip through the hands” without the no withdrawal occurs, weakness or paralysis may be present.
examiner grasping the back of the infant. Either increased or decreased tone
Cranial Nerves. The cranial nerves of the newborn or infant can be tested. Congenital facial nerve palsy can result from birth trauma or
Box 25-25 provides useful strategies. developmental defects.
Abnormalities in the cranial nerves can suggest an intracranial Dysphagia, or difficulty in swallowing, can occasionally be due to
lesion such as hemorrhage or a congenital malformation (or injury to cranial nerve IX, X, and XII.
alternatively peripheral nervous system problems).
Deep Tendon Reflexes. The deep tendon reflexes are present in
Box 25-25. Strategies to Assess Cranial Nerves in newborns but may be difficult to elicit and may vary in their intensity
because the corticospinal pathways are immature. Their exaggerated
Newborns and Infants
presence or their absence has little diagnostic significance, unless this
response is different from results of previous testing or extreme responses
Cranial Nerve Strategy
are observed or they are very asymmetric.
I Olfactory Very difficult to test
II Visual acuity Have infant regard your face and look for
A progressive increase in deep tendon reflexes during the first
facial response and tracking. year of life may indicate central nervous system disease such as
II, III Response to light Darken room, raise infant to sitting position to cerebral palsy, especially if it is coupled with increased tone.
open eyes. Another common pattern of presentation is central hypotonia
Use light and test for optic blink reflex (blink in
response to light).
followed by progressively increased tone.
Use the otoscope’s light (without speculum)
to assess pupillary responses. Use the same techniques to elicit deep tendon reflexes as you would for an
III, IV, VI Extraocular Observe how well the infant tracks your adult. You can substitute your index or middle finger for the reflex hammer as
movements smiling face (or a bright light) and whether the shown in Figure 25-42.
eyes move together.
V Motor Test rooting reflex.
Test sucking reflex (watch infant suck breast,
bottle, or pacifier) and strength of suck.
VII Facial Observe infant crying and smiling; note
symmetry of face.
VIII Acoustic Test acoustic blink reflex (blinking of both
eyes in response to a loud noise).
Observe tracking in response to sound.
IX, X Swallow Observe coordination during swallowing.
Gag Test for gag reflex.
XI Spinal accessory Observe symmetry of shoulders.
XII Hypoglossal Observe coordination of sucking, swallowing,
and tongue thrusting.
Pinch nostrils; observe reflex opening of
mouth with tip of tongue to midline.
 may note rapid, rhythmic plantar flexion of the newborn’s foot (ankle clonus)
in response to this maneuver. Up to 10 beats are normal in newborns and
young infants; this is unsustained ankle clonus.

FIGURE 25-42. Assessing deep tendon reflexes with finger.

As in adults, asymmetric reflexes suggest a lesion of the

peripheral nerves or spinal segment or can be due to an
intracranial lesion. FIGURE 25-43. Assessing ankle reflexes.

The triceps, brachioradialis, and abdominal reflexes are difficult to elicit When the contractions are continuous (sustained ankle clonus),
before 6 months of age. The anal reflex or “anal wink” is present at birth
central nervous system disease should be suspected.
and important to elicit if a spinal cord lesion is suspected. This reflex is a
contraction of the external anal sphincter when the examiner touches the skin A newborn who is irritable, jittery and has tremors, hypertonicity,
near the anus. and hyperactive reflexes may have drug withdrawal from
maternal substance use during pregnancy. Neonatal abstinence
An absent anal reflex suggests loss of innervation of the external
syndrome results from the use of opioids by the mother while
sphincter muscle caused by a spinal cord abnormality such as a
congenital anomaly (e.g., spina bifida), tumor, or injury. pregnant. In addition to the signs listed above, the newborn may
also have autonomic signs, as well as poor feeding and seizures.
In newborns, a positive Babinski response to plantar stimulation
(dorsiflexion of big toe and fanning of other toes) can be elicited and may Primitive Reflexes. Evaluate the newborn’s and infant’s developing
persist for several months. central nervous system by assessing infantile automatisms, called primitive
reflexes. These develop during gestation, are generally demonstrable at birth,
In order to best elicit the ankle reflex of an infant, grasp the infant’s and disappear at defined ages. Abnormalities in these primitive reflexes
malleolus with one hand and abruptly dorsiflex the ankle (Fig. 25-43). You suggest neurologic disease and merit more intensive investigation.46
A neurologic or developmental abnormality is suspected if primitive Reflex) and legs. Abruptly lower
the entire body about 1
reflexes are: foot.
■ Absent at appropriate age The arms will abduct and
extend, hands will open,
■ Present longer than normal and legs will flex. The
infant may cry.
■ Asymmetric
■ Associated with posturing or twitching
Asymmetric With the infant supine, turn Birth to 2–3
Tonic Neck head to one side, holding months
The most important primitive reflexes are illustrated in Box 25-26. Reflex jaw over shoulder.
The arms/legs on side to
which head is turned will
Box 25-26. Primitive Reflexes extend while the opposite
arm/leg will flex. Repeat
Primitive Maneuver Ages on other side.
Reflex Trunk Support the infant prone Birth to 3–4
Incurvation with one hand and stroke months
Palmar Place your fingers into the Birth to 3–4
(Galant) one side of the back 1 cm
Grasp infant’s hands and press months
Reflex from midline, from
Reflex against the palmar
shoulder to buttocks.
surfaces.
The spine will curve
The infant will flex all
toward the stimulated
fingers to grasp your
side.
fingers.

Plantar Touch the sole at the base Birth to 6–8 Landau Suspend the infant prone Birth to 6 months
Grasp of the toes. months Reflex with one hand.
Reflex The toes will curl. The head will lift up, and
the spine will straighten.

Rooting Stroke the perioral skin at Birth to 3–4

Reflex the corners of the mouth. months Parachute Suspend the infant prone 8 months and
The mouth will open and Reflex and slowly lower the head does not
the infant will turn the head toward a surface. disappear
toward the stimulated side The arms and legs will
and suck. extend in a protective
fashion.

Moro Reflex Hold the infant supine, Birth to 4 months

(Startle supporting the head, back,
Positive Hold the infant around the Birth or 2 months
Support trunk and lower until the until 6 months Persistence beyond 4 months suggests neurologic disease (e.g.,
Reflex feet touch a flat surface.
The hips, knees, and cerebral palsy); persistence beyond 6 months strongly suggests
ankles will extend, the it.
infant will stand up,
partially bearing weight, Asymmetric response suggests fracture of clavicle or humerus or
sagging after 20–30
seconds.
brachial plexus injury.
Persistence beyond 3 months suggests asymmetric central
nervous system development and sometimes predicts the
development of cerebral palsy.
Absence suggests a transverse spinal cord lesion or injury.
Persistence may indicate delayed development.
Placing and Hold the infant upright as Birth (best after 4 Persistence may indicate delayed development.
Stepping in positive support reflex. days; variable
Reflexes Have one sole touch the age to Delay in appearance may predict future delays in voluntary motor
tabletop. disappear)
The hip and knee of that development.
foot will flex and the other
foot will step forward. Lack of reflex suggests hypotonia or flaccidity.
Alternate stepping will
occur. Fixed extension and adduction of legs (scissoring) suggests
spasticity from neurologic disease, such as cerebral palsy.
Absence of placing may indicate paralysis.
Newborns born by breech delivery may not have a placing reflex

Developmental Assessment. By observation and play with the infant,

you can both do a developmental screening examination and an assessment
Persistence of palmar grasp reflex beyond 4 to 6 months
for gross motor and (for older infants) fine motor achievement (Box 25-27).
suggests pyramidal tract dysfunction.
Infants who have developmental delay may have abnormalities on the
Persistence of clenched hand beyond 2 months suggests central neurologic examination because much of the examination is based on age-
nervous system damage, especially if fingers overlap the thumb. specific norms.
Persistence of plantar grasp reflex beyond 8 months suggests
pyramidal tract dysfunction. Box 25-27. Abnormalities Detected while Observing Play
Absence of rooting indicates severe generalized or central
Behavioral Social or Environmental
nervous system disease. Poor parent–child interactions Parental stress, depression
Sibling rivalry Risk for abuse or neglect
Inappropriate parental discipline Neurologic
“Difficult temperament”
Developmental Weakness The format of the clinical record is the same for both children and adults.
Gross motor delay Abnormal posture
Fine motor delay Spasticity
Although the sequence of the physical examination may vary, convert your
Language delay (expressive or receptive) Clumsiness clinical findings into the same order of the traditional written or electronic
Delay in social or emotional tasks Attentional problems, hyperactivity format.
Autistic features
Musculoskeletal abnormalities
Initially, you may use sentences to describe your findings; later you will use
Note: The child’s behavior during the visit may not represent typical behavior but your phrases. The style here contains phrases appropriate for most write-ups. As
observations may serve as a springboard for discussion with parents.
you read through this write-up, you will note some atypical findings. Try to
Specifically, look for weakness by observing sitting, standing, and test yourself. See if you can interpret these findings. You will also note the
transitions. Note station, or the posture of sitting or standing. Assess fine modifications necessary to accommodate reports from the parent.
motor development in older infants in a similar way, combining the
neurologic and developmental examination. Key milestones include the Since the structure and sequence of the write-up for the newborn or infant
development of the pincer grasp, ability to manipulate objects with the hands, history and physical examination mirrors the write-up for young children, use
and more precise tasks, such as building a tower of cubes or scribbling. Fine the example shown on page 993. The key elements of the history shown in
and gross motor development progresses in a proximal to distal direction. Box 25-4 on page 942 could be used as a guide for the write-up of the
history.
Many causes of developmental delay exist but often no cause is
identified. Etiologies include prenatal (genetic, central nervous
system, congenital hypothyroidism), perinatal (preterm, HEALTH PROMOTION AND COUNSELING:
asphyxia, infection, trauma), and postnatal (trauma, infection, EVIDENCE AND RECOMMENDATIONS
toxin, abuse).
The AAP and the group Bright Futures19 recommend health supervision visits
In addition, since some neurologic abnormalities produce deficits or slowing for infants below 1 year of age at the following ages: at birth, at 3 to 5 days,
in cognitive and social development, one can assess the infant’s cognitive by 1 month, and at 2, 4, 6, 9, and 12 months (Fig. 25-44). This is called the
and social–emotional developmental domains as you proceed with the Infant Periodicity Schedule. Health supervision visits provide opportunities
comprehensive neurologic and developmental examination. to answer questions for parents, assess the infant’s growth and development,
Developmental delay across more than one domain (e.g., motor perform a comprehensive physical examination, and provide anticipatory
plus cognitive) suggests more severe disease. guidance. Age-appropriate anticipatory guidance includes healthy habits and
behaviors, social competence of caregivers, parenting techniques, family
Refer to the developmental milestones in Box 25-5 on p. 944 and to the items relationships, and community interactions.
on a standardized developmental screening instrument to learn which age-
specific developmental tasks to evaluate. Regular visits provide an opportunity to plot a course for healthy and
successful development. Infants generally are well during these visits,
enhancing the quality of the experience. Parents are usually receptive to
RECORDING YOUR FINDINGS suggestions about health promotion which can have major, long-term
influences on the child and family. Strong interviewing skills are necessary
as you discuss strategies to optimize the health and well-being of their
infants. Adjust the content to the appropriate developmental level of the Developmental Promoting development (talk,
Assessment read, sing, music, play)
infant. As an exercise, review the critical components of a health supervision Family Relationships
Use a standardized
visit for a 6-month-old in Box 25-28. developmental Time for self; babysitters
instrument to measure Community Interaction
milestones Childcare, resources
Assess milestones by
history
Assess milestones by
examination

PRESCHOOL AND SCHOOL-AGED

CHILDREN–HEALTH HISTORY: GENERAL
APPROACH
Children are usually accompanied by a parent or caregiver (Fig. 25-45).
Even when alone in the examination room, they are often seeking health care
at the request of their parent (Fig. 25-46). Indeed, the parent is usually sitting
in the waiting room. When interviewing a child, you need to consider the
needs and perspectives of both the child and the caregivers.
FIGURE 25-44. Regular health supervision serves many purposes.

Box 25-28. Components of a Health Supervision Visit for a 6-

Month-Old
Discussions with Physical Examination Anticipatory Guidance
Parents Perform a careful Healthy Habits and Behaviors
Address parents’ examination, including Injury and illness prevention
concerns/questions growth parameters Use infant seat, watch for
Provide advice with percentiles for rolling, caution on walkers,
Obtain social history age poisons, tobacco exposure
Assess development, Screening Tests Nutrition
nutrition, sleep, Vision and hearing (by Breastfeeding or bottle, iron
elimination, safety, oral examination) supplementation with Vitamin D FIGURE 25-45. Pediatrician examining baby boy who is accompanied by his mother.
health, family Screen for social risk if needed, solids, no juice, (Used with permission from Shutterstock. By Lordn.)
relationships, factors prevent choking, overfeeding
stressors, parenting Immunizations Oral health
beliefs, community No bottle in bed, fluoride,
See schedule (AAP or
factors brushing teeth
CDC website)
Parent–Infant Interaction
 FIGURE 25-46. Examining a child’s throat. (Used with permission from Shutterstock. By
Business plus.)

Establishing Rapport FIGURE 25-47. Establishing rapport enables more effective evaluation.
Begin the interview by greeting and establishing rapport with each person
present (Fig. 25-47). Refer to the child by name rather than by “him” or Use your personal experiences with children to guide how you interact in a
“her.” Families come in many varieties—these include traditional families, health care setting. To establish rapport, meet children on their own level.
single parents, separated/divorced parents, blended, same-sex parents, Eye contact on their level, participating in playful engagement, and talking
kinship families, foster families, and adoptive families so clarify the role or about what interests them are good strategies. Ask children about their
relationship of all of the adults and children. “Now, are you Jimmy’s clothes, toys, favorite book or TV show, or their adult companion in an
grandmother?” “Please help me by telling me Jimmy’s relationship to enthusiastic but gentle style. Spending time at the beginning of the interview
everyone here.” Address the parents as “Mr. Smith” or “Ms. Smith” rather to calm and connect with an anxious child can put both the child and the
than by their first names or “Mom” or “Dad.” When the family structure is caregiver at ease.
not immediately clear, you may avoid embarrassment by asking directly
about other members. “Who else lives in the home?” “Who is Jimmy’s Working with Families
father?” “Do you live together?” Do not assume that just because parents are
separated, only one parent is actively involved in the child’s life. One challenge when several people are present is deciding to whom to direct
your questions. While eventually you need to get information from both the
child and the parent, it is useful to start with the child.

Asking simple open-ended questions like “Are you sick? . . . Tell me about
it,” followed by more specific questions, often provides much of the clinical
data. The parents can then verify the information, add details that give you the
larger context, and identify other issues you need to address. Sometimes
children are embarrassed to begin, but once the parent has started the
conversation, direct questions back to the child. Characterize symptom
attributes as for adults.

“Your mom tells me that you get stomachaches. Tell me about them.”
“Show me where you get the pain. What does it feel like?”
“Is it sharp like a pinprick, or does it ache?”
“Does it stay in the same spot, or does it move around?”
“What helps make it go away? What makes it worse?”
“What do you think causes it?”

The presence of family members allows you to observe how they interact
with the child. A child may be able to sit still or may get restless and start
fidgeting. Watch how the parents set, or fail to set, limits when needed.

Multiple Agendas
Each individual in the room, including the clinician, may have a different
idea about the nature of the problem and what needs to be done about it
(Fig. 25-48).

FIGURE 25-48. Pediatrician, parent, and patient sometimes have differing agendas.
(Used with permission from Shutterstock. A. By fizkes. B. By mangostock. C. By
fizkes.)

Discover as many of these perspectives and agendas as possible. Family

members who are not present (e.g., the absent parent or grandparent) may
also have concerns. Ask about those concerns, too. “If Suzie’s father were Hidden Agendas
here today, what questions or concerns would he have?” “Have you, Mrs.
Jones, discussed this with your mother or anyone else?” “What does she As with adults, the chief complaint may not relate to the real reason the
think?” parent has brought the child to see you (Fig. 25-49). The complaint may be a
bridge to concerns that may not seem like a legitimate reason to go to the
For example, Mrs. Gonzalez brings MaryAnn in for abdominal pain because clinician. Create a trusting atmosphere that allows parents to be open about
she is worried that MaryAnn may have an ulcer and also poor eating habits. all their concerns by asking facilitating questions such as:
MaryAnn is not worried about the belly pain but is uneasy about the changes
in her body and about getting fat. Mr. Gonzalez thinks that MaryAnn’s
schoolwork is not getting enough attention. You, as the clinician, need to
balance these concerns with what you see as a healthy 12-year-old girl in
early puberty with some mild functional abdominal pain and concern for
possible emerging obesity.

Your goals need to include uncovering the concerns of each person and
helping the family to be realistic about the range of “normal.”

Family as a Resource
In general, family members provide most of the care and are your natural
allies in promoting the child’s health. Being open to a wide range of FIGURE 25-49. Engaging parents can reveal hidden agendas.
parenting behaviors helps to make this alliance. Raising a child reflects
cultural, socioeconomic, and family practices. It is important to respect the
tremendous variation in these practices. A good strategy is to view the “Do you have any other concerns about Randy?”
parents as experts in the care of their child and yourself as their “Was there anything else that you wanted to tell/ask me today?”
consultant. This demonstrates respect for the parents’ care and minimizes
their likelihood of discounting or ignoring your advice. Parents face many
challenges raising children, so practitioners need to be supportive, not SURVEILLANCE OF DEVELOPMENT: EARLY
judgmental. Comments like, “Why didn’t you bring him in sooner?” or CHILDHOOD: 1 TO 4 YEARS
“What did you do that for?” do not improve your rapport with the parent.

Statements acknowledging the hard work of parenting and praising successes Physical Development
are always appreciated. “Mr. Chang, you are doing such a wonderful job After infancy, the rate of physical growth slows by approximately half. After
with Brian. Being a parent takes so much work and Brian’s behavior here
2 years, toddlers gain about 2 to 3 kg and grow 5 cm per year. Physical
today clearly shows your efforts. We might have some suggestions for you changes are impressive characterized by leaner but a more muscular bulk.
at the end of the visit.” Or to the child, “Brian you are so lucky to have
such a wonderful dad.”
Gross and fine motor skills also develop quickly. Almost all children walk is more likely to reflect global neurologic disorders such as
by 15 months, run well by 2 years, and pedal a tricycle and jump by 4 years. cognitive disability that can have many etiologies.
Fine motor skills develop through neurologic maturation and play (Fig. 25-
50). The 18-month-old who scribbles becomes a 2-year-old who draws lines Social and Emotional Development.
and then a 3-year-old who copies a circle; 4-year-olds can draw a simple Toddlers develop rapidly from beginning to pretend play, to mostly parallel
person with a couple of body parts and can start to copy simple capital play, to imitating adult actions and really pretending and imagining. New
letters. intellectual pursuits are surpassed only by an emerging drive for
independence (Fig. 25-51). Because toddlers are impulsive and have poor
self-regulation, temper tantrums are common. Self-regulation is an important
developmental task with a wide range of normal (Box 25-29).

FIGURE 25-50. Fine motor skills develop along with cognition.

Cognitive and Language Development

Toddlers move from sensorimotor learning (through touching and looking) to
symbolic thinking, solving simple problems, remembering songs, and
engaging in imitative play. Language develops with extraordinary speed. An
18-month-old with 10 to 20 words becomes a 2-year-old with two to three FIGURE 25-51. Individual personalities emerge as the intellect grows.
word sentences, and a 3-year-old who converses well. By 4 years,
preschoolers form complex sentences. They remain preoperational, however
—that is, without sustained logical thought processes. You can ask children Box 25-29. Developmental Milestones: 1 to 5 Years
older than 3 years to draw a picture or copy objects and then discuss their
pictures to test simultaneously for fine motor coordination, cognition, and
language.
Distinguish between isolated delays in one aspect of
development (e.g., coordination or language) and more
generalized delays that occur in several components. The latter
 Box 25-30. Developmental Tasks during Middle Childhood

Task Characteristic Healthcare Needs

Physical Enhanced strength and Screening for strengths, assessing

coordination problems
Competence in various Involving parents
tasks and activities Support for disabilities
Anticipatory guidance: safety,
exercise, nutrition, sleep
Cognitive “Concrete operational”: Emphasis on short-term
focus on the present consequences
Achievement of knowledge Support; screening for skills and
and skills, self-efficacy school performance
Social Achieving good “fit” with Assessment, support, advice about
family, friends, school interactions including peer
relationships
Sustained self-esteem Support, emphasis on strengths
Evolving self-identity Understanding, advice, support

Physical Development
Children grow steadily but more slowly. Strength and coordination improve
dramatically with more participation in activities (Fig. 25-52). This is also
when children with physical disabilities or chronic illnesses become more
aware of their limitations.

Cognitive and Language Development

Children become “concrete operational ”—capable of limited logic and
more complex learning. They remain rooted in the present with little ability
to understand consequences or abstractions. School, family, and environment
greatly influence learning (Fig. 25-53). A major developmental task is self-
SURVEILLANCE OF DEVELOPMENT: efficacy, or the child’s belief in their ability to thrive in different situations.
MIDDLE CHILDHOOD, 5 TO 10 YEARS Language becomes increasingly complex.

Middle childhood is an active period of growth and development (Box 25-

30). Goal-directed exploration increased physical and cognitive abilities,
and achievements by trial and error mark this stage.
 environment contribute enormously to the child’s self-image. Moral
development remains simple and concrete with a clear sense of “right and
wrong.”

FIGURE 25-52. Physical abilities rapidly progress in early childhood.

Among school-aged children, the best test for development is their school
FIGURE 25-53. A child’s cognitive development is shaped by family relationships.
performance. You can obtain school records or psychological testing results,
obviating the need for the clinician to formally test an older child’s
development. Delayed or disordered development in early childhood can
lead to early school failure as well as social, behavioral, and emotional PHYSICAL EXAMINATION: GENERAL
problems. APPROACH
Social and Emotional Development An important aspect of examining children is that parents are usually
watching and taking part in the interaction, providing you the opportunity to
Children become progressively more independent, initiating activities and observe the parent–child interaction. Note whether the child displays age-
enjoying accomplishments. Achievements are critical for self-esteem and appropriate behaviors.
developing a “fit” within major social structures—family, school, and peer
activity groups. Guilt and poor self-esteem also may emerge. Family and
Assess the “goodness of fit” between parents and child. Although some solidly in their parent’s lap throughout much of the examination and that the
abnormal interactions may result from the unnatural setting of the examination parent remains close when the child is on the examination table.
room, others may be a consequence of interactional problems. Careful
observation of the child’s interactions with parents and the child’s Engage children in age-appropriate conversation. Ask simple questions about
unstructured play in the examination room can reveal abnormalities in their illness or toys. Compliment their appearance or behavior, tell a story, or
physical, cognitive, and social development or issues with parent–child play a simple game (Fig. 25-54). If a child is shy, turn your attention to the
relationship, and also provide opportunities for gentle education and parent to allow the child to warm up gradually. Also, sometimes the parent is
anticipatory guidance. anxious. Helping the parent relax or asking them to help by reading to the
child or playing with the child can help relax everyone in the examination
Normal toddlers are occasionally alarmed at the examiner. Some will be room.
uncooperative but most eventually warm up to you. If this behavior continues
or is not developmentally appropriate, there may be an underlying With certain exceptions, physical examination does not require use of the
behavioral or developmental abnormality. Older, school-aged children have examining table; it can be done with the child in a parent’s lap. The key is to
more self-control and prior experience with clinicians and are generally engage the child’s cooperation. For young children who resist undressing,
cooperative with the examination. expose only the body part being examined. When examining siblings, begin
with the oldest child who is more likely to cooperate and set a good
Assessing Younger Children example. Approach the child pleasantly. Explain each step as you perform it.
Continue conversing with the family to provide distraction.
One challenge in examining children in this age group is avoiding a physical
struggle, a crying child, or a distraught parent. Accomplishing this
successfully is one aspect of the “art of medicine” in the practice of
pediatrics.

Gain the child’s confidence and allay the child’s fears from the start of the
encounter. Your approach will vary with the circumstances of the visit. As an
example, you can start a visit with a preschooler by having a cleaned toy to
play with or giving the child a book as a gift. A health supervision visit
allows greater rapport than a visit when the child is ill.

The child should remain dressed during the interview to minimize the child’s
apprehension. It also allows you to interact more naturally and observe the
child playing, interacting with the parents, and undressing and dressing.

Toddlers who are of 9 to 15 months may have stranger anxiety, a fear of

strangers that is developmentally normal. It signals the toddler’s growing
awareness that the stranger is new. You should not approach these toddlers
quickly, and you might want to avoid direct eye contact initially with the
toddler. Play can help the child warm up to you. Make sure they remain
 FIGURE 25-55. Familiarizing the child with the equipment and procedures can reduce
anxiety in children.

Assessing Older Children

Examining children after they reach school age usually poses few difficulties.
Although some have unpleasant memories of previous clinical encounters,
most children respond well when the examiner is attuned to their
developmental level.
FIGURE 25-54. Engaging children in play is sometimes part of the assessment.
Many children at this age are modest (Fig. 25-56). Providing gowns and
leaving underwear in place as long as possible are wise approaches.
Plan the examination to start with the least distressing procedures and end Consider leaving the room while they change with their parents’ help. Some
with the most distressing ones, usually involving the throat and ears. Begin children may prefer opposite-sex siblings to leave, but most prefer a parent
with parts that can be done with the child sitting such as examining the eyes of either sex to remain in the room. Parents of children younger than 11
or palpating the neck. Lying down may make a child feel vulnerable, so years should stay with them. Adhere to your setting’s chaperone policy.
change positions with care. Once a child is supine, begin with the abdomen,
saving throat and ears or genitalia for last. You may need a parent’s help to
restrain the child for examination of the ears or throat; however, use of
formal restraints is inappropriate. Patience, distraction, play, flexibility in
the order of the examination, and a caring but firm and gentle approach,
are all key to successfully examining the young child (Fig. 25-55).
 First examine the child’s toy or teddy bear, or even the parent, then the child (Fig. A).
Let the child do some of the examination (e.g., move the stethoscope). Then go back and
“get the places we missed” (Fig. B).
Ask the toddler who keeps pushing you away to “hold your hand.” Then have the toddler
“help you” with the examination.
Avoid asking permission to examine a body part because you will do the examination
anyway. Instead, ask the child which ear or which part of the body he or she would like
you to examine first.
Make a game out of the examination! For example, “Let’s see how big your tongue is!” or
“Is Elmo in your ear? Let’s see!”
Some toddlers believe that if they can’t see you, then you aren’t there. Perform the
examination while the child stands on the parent’s lap, facing the parent.
Hand the child an age-appropriate book and engage the child in reading.
If 2-year-olds are holding something in each hand (such as tongue depressors), it is
more difficult for them to fight or resist.
If unable to console the child, give the child a short break.

FIGURE 25-56. Clinicians need to be aware of older children’s developing modesty.

TECHNIQUES OF EXAMINATION
The order of the examination now begins to follow that used for adults
(Box 25-31). Examine painful areas last and forewarn children about areas
you are going to examine. If a child resists part of the examination, you can
return to it at the end.

Used with permission from Shutterstock. A. By SeventyFour. B. By Ocskay Bence.

Box 25-31. Tips for Examining Young Children (1- to 4-Year-
Olds) Useful Toys and Aids

“Blow out” the otoscope light.

Useful Strategies for Examination “Beep” the stethoscope on your nose.
Make tongue-depressor puppets.
Have the parent help you facilitate the examination (e.g., removing clothing, holding child Use the child’s own toys for play.
on lap). Try to be at the child’s eye level. Jingle your keys to test for hearing.
Use a reassuring voice throughout the examination. Shine the otoscope through the tip of your finger (or the child’s finger) to show it doesn’t
Let the child see and touch the examination tools you will be using. hurt, “lighting it up,” and then examine the child’s ears with it.
Use age-appropriate toys and books.
 Use a fun toy attached to the stethoscope to make it less scary.
Note: Make sure to clean toys and your stethoscope in between patients.
Somatic Growth
Reassure parents that resistance to examination is developmentally Figures 25-57 and 25-58 demonstrate somatic growth patterns in children.
appropriate. Some embarrassed parents scold the child, compounding the
problem. Involve parents in the examination. Learn which techniques and
approaches work best and are most comfortable for you.

FIGURE 25-57. Growth patterns of various systems.

 attachment are not very accurate. After age 2 years children should grow at
least 5 cm per year. During puberty, growth velocity increases.
Short stature, defined as height <5th percentile, can be a normal
variant or caused by endocrine or other diseases. Normal
variants include familial short stature and constitutional delay.
Chronic diseases include growth hormone deficiency, other
endocrine diseases, gastrointestinal disease, renal or metabolic
disease, and genetic syndromes.
Weight.
Children who can stand should be weighed in a gown (or in clothing without
shoes) on a stand-up scale. Use the same scales across successive visits to
optimize comparability.
Etiologies for insufficient caloric intake causing poor growth
include psychosocial, gastrointestinal, and endocrine disorders.
These conditions often cause poor growth in both height and
weight.
Head Circumference.
In general, head circumference is measured until the child reaches 24 months.
Afterward, head circumference measurement may be helpful if you suspect a
genetic or a central nervous system disorder.
Body Mass Index for Age.
Age- and sex-specific charts are now available to assess BMI in children
FIGURE 25-58. Velocity curves for length and height for boys and girls based on (Box 25-32). BMI in children is associated with body fat, related to
intervals of 1 year. (Reprinted from Lowrey GH. Growth and Development of Children. subsequent health risks for obesity.
8th ed. Year Book Medical; 1986. Copyright © 1986 Elsevier. With permission.)

Box 25-32. Interpreting BMI in Children

Height.
For children older than 2 years measure standing height, optimally using Group BMI-for-Age
wall-mounted stadiometers. Have the child stand with heels, back, and head Underweight <5th percentile
against a wall or the back of the stadiometer. If using a wall with a marked
Healthy weight 5th–85th percentile
ruler, make sure to place a flat board or surface against the top of the child’s
head and at right angles to the ruler. Stand-up weight scales with a height Overweight 85th–95th percentile
Obese ≥95th percentile
 Most children with exogenous obesity are also tall for their age. elevated blood pressure in children is probably an improperly
Children with endocrine causes of obesity tend to be short. performed examination, often due to an incorrect cuff size.
Childhood obesity is a major epidemic: 32% of U.S. children have A proper cuff size is essential for accurate determinations of blood
a BMI greater than the 85th percentile, and 17% have a BMI in pressure in children. Select the blood pressure cuff as you would for adults.
the 95th percentile or greater.30 The bladder length of the cuff should encircle 80% to 100% of the
circumference of the child’s arm. The cuff’s width-to-arm circumference
BMI measurements are helpful for early detection of obesity in children
ratio should be 0.45 to 0.55 (Fig. 25-59). A narrower cuff falsely elevates
older than 2 years. BMI growth charts for children take into account
the blood pressure reading, whereas a wider cuff lowers it and may
differences by sex and age. Obesity is now a major childhood epidemic and
interfere with proper placement of the stethoscope diaphragm over the artery.
it often begins before age 6 to 8 years. Consequences of childhood obesity
include hypertension, diabetes, metabolic syndrome, and poor self-esteem.
Childhood obesity often leads to adult obesity and shortened lifespan. It is
helpful to give parents their child’s BMI results (or show them the graph)
together with information about the impact of healthy eating and physical
activity.
Long-term morbidity from childhood obesity spans many organ
systems, including cardiovascular, endocrine, renal,
musculoskeletal, gastrointestinal, and psychological. Prevention,
early detection, and aggressive management are needed.

Vital Signs
Blood Pressure.
Hypertension during childhood is more common than previously thought and
it is important to recognize, confirm, and appropriately manage it. FIGURE 25-59. Blood pressure monitoring in childhood can be challenging.

Children have elevated blood pressure during exercise, crying, and anxiety. With children, as with adults, the first Korotkoff sound indicates systolic
The procedure for measuring blood pressure was explained and
pressure and the point at which the Korotkoff sounds disappear constitutes
demonstrated in p. 954. Most children are cooperative with blood pressure
the diastolic pressure. At times, especially among young children with
measurement. If the blood pressure is initially elevated, you can perform
increased body fat, the Korotkoff sounds are not easily heard. Keep trying in
blood pressure readings again at the end of the examination. Leave the cuff
a quiet room. If needed, you can use palpation to determine the systolic blood
on the arm (deflated) and repeat the reading later. Elevated readings must
pressure, remembering that the systolic pressure obtained is approximately
always be confirmed by subsequent measurements.
10 mm Hg lower by palpation than by auscultation.
A very common cause of apparent hypertension is anxiety or
In children, as in adults, blood pressure readings from the thigh
“white-coat hypertension.” The most frequent “cause” of an
are approximately 10 mm Hg higher than those from the upper
 arm. If they are the same or lower, coarctation of the aorta however, have essential or primary hypertension. In all cases it is important
should be suspected. to repeat measurements to reduce the possibility that the elevation reflects
anxiety. Sometimes, repeating measurements in school is a way to obtain
Transient hypertension in children can be caused by some readings in a more relaxed environment. Hypertension and obesity often
common childhood medications, including those to treat asthma coexist in children. It is important not to falsely label a child or adolescent
(e.g., prednisone) and ADHD (e.g., methylphenidate). as having hypertension because of the stigma of labeling, potential limitations
to activities, and possible side effects of treatment.
In 2017, the AAP Subcommittee on screening and management of high blood
pressure in children defined normal, elevated, and high blood pressure as Pulse Rate.
follows, with measurements on at least three separate occasions (Box 25- Average heart rates and normal ranges are shown in Box 25-34. Measure the
33).29 heart rate over a 60-second interval.
The epidemic of childhood obesity has also resulted in a rising
prevalence of childhood hypertension.29 Box 25-34. Average Heart Rate of Children at Rest30

Age (Years) Average Rate (Median) Range (1st to 99th percentile)

Box 25-33. Updated Definitions of BP Categories and Stages29
1–2 110–120 88–155
For Children Age 1 to <13 years For Children Age ≥13 2–6 100–110 65–140
years
6–10 75–90 52–130
Normal BP <90th percentile <120/<80 mm Hg
Elevated BP ≥90th percentile to <95th percentile or 120/80 120/<80 to 129/<80 mm Sinus bradycardia is a heart rate <100 beats per minute in
mm Hg to <95th percentile (whichever is Hg infants and toddlers and <60 beats per minute in children >3
lower)
years.
Stage 1 HTN ≥95th percentile to <95th percentile + 12 mm 130/80 to 139/89 mm Hg
Hg, or 130/80 to 139/89 mm Hg (whichever is Respiratory Rate.
lower)
The rate of respirations per minute ranges from 20 to 40 during early
Stage 2 HTN ≥95th percentile + 12 mm Hg, or ≥140/90 mm ≥140/90 mm Hg childhood and 15 to 25 during late childhood, reaching adult levels at around
Hg (whichever is lower)
15 years of age.30
Causes of sustained hypertension29 in childhood include primary
hypertension (with no underlying etiology) and secondary For young children, observe the movements of the chest wall for two 30-
hypertension (which has an underlying etiology). Causes of second intervals or over 1 minute, preferably before stimulating them. Direct
secondary hypertension include obesity, renal, endocrine, and auscultation of the chest or placing the stethoscope in front of the mouth is
also useful for counting respirations, but the measurement may be falsely
neurologic disease, vascular causes, drugs or medications, and
elevated if the child becomes agitated. For older children use the same
psychological causes.
technique as that used for adults.
Children who have hypertension should be evaluated extensively to
The commonly accepted standard for tachypnea in children older than age 1
determine the cause. For infants and young children, a specific cause can
year is a respiratory rate >40 breaths per minute.
often be found. An increasing proportion of older children and adolescents,
 The best single physical finding for ruling out pneumonia is an The two most important components of the eye examination for young
absence of tachypnea. children are to determine whether the gaze is conjugate or symmetric and to
test visual acuity in each eye.
Temperature.
In children, auditory canal temperature recordings are preferable because Conjugate Gaze.
they can be obtained quickly with essentially no discomfort. Use the methods described in Chapter 7 for adults to assess conjugate gaze,
or the position and alignment of the eyes, and the function of the extraocular
Children younger than 3 years, who appear very ill with a fever, muscles. The corneal light reflex test and the cover–uncover test are
should be evaluated for sepsis, urinary tract infection, particularly useful in young children (Figs. 25-60 and 25-61).
pneumonia, or other serious infection.

Skin
After a child’s first year of life, the techniques of examination are the same as
those for the adult.
See Chapter 10, Skin, Hair, and Nails. Also see Table 25-4,
Common Skin Lesions during Childhood, p. 1065.

Head
In examining the head and neck, tailor your examination to the child’s stage of
growth and development.
FIGURE 25-60. Corneal light reflex test.
Even before touching the child, carefully observe the shape of the head, its
symmetry, and the presence of abnormal facies. Abnormal facies may not be
apparent until later in childhood; therefore, carefully examine the face as
well as the head of all children.
See Table 25-6, Diagnostic Facies in Infancy and Childhood, pp.
1067–1068, which shows several diagnostic facies in childhood
that reflect chromosomal abnormalities, endocrine defects,
chronic illness, and other disorders.
Fetal alcohol syndrome can cause abnormal facies (p. 1067),
microcephaly, and developmental delay.

Eyes
FIGURE 25-61. Cover–uncover test.
 Anisometropia (eyes with significantly different refractive errors) Age Acuity
can result in amblyopia, or reduced vision in an otherwise normal 3 months Eyes converge, baby reaches
eye. Amblyopia can lead to a “lazy eye,” with permanently 12 months ∼20/200
reduced visual acuity if not corrected early. Younger than 4 years 20/40
Strabismus (see Table 25-7, Abnormalities of the Eyes, Ears, 4 years and older 20/30
and Mouth, p. 1069) in children requires treatment by an
Any difference in visual acuity between the eyes (e.g., 20/20 on
ophthalmologist because it can also lead to amblyopia. The
the left and 20/30 on the right) is abnormal by age 5 years
common forms of strabismus in children involve horizontal
(Figs. 25-62 and 25-63).
deviation: nasal (“eso”) or temporal (“exo”). A latent strabismus
(“phoria”) occurs when you disrupt fixation, whereas manifest
strabismus (“tropia”) is present without interruption.

Perform the cover–uncover test as a game by having the young child watch
your nose or tell you if you are smiling or not while you cover one of the
child’s eyes. When you uncover the eye, watch for any deviation of that eye.
Repeat for the other eye. Latent strabismus is indicated by movement of
either eye when uncovered.
Visual Acuity.
It may not be possible to measure the visual acuity of children younger than 3
years who cannot identify pictures on an eye chart. For these children, the
simplest examination is to assess for fixation preference by alternately
covering one eye; the child with normal vision will not object, but a child
with poor vision in one eye will object to having the good eye covered.
Importantly, if you or the parent have any doubts about visual acuity, it is
wise to refer to an optometrist or ophthalmologist because this aspect of the
physical examination is insensitive (Box 25-35). In all tests of visual acuity,
it is important that both eyes show the same result because of the risk for
amblyopia. FIGURE 25-62. Testing visual acuity with a simple chart.

Reduced visual acuity is more likely among children who were

born prematurely and among those with other neurologic or
developmental disorders.

Box 25-35. Visual Acuity

 midline while bringing an object such as a toy into the field of vision from
behind the child. The overall method is the same as that for adults, except
that you will have to make this into a game for your patient.

Ears
Examining the ear canal and tympanic membrane can be difficult in young
children who are sensitive and fearful because they cannot observe the
procedure. With a little practice though, you can master this technique.
Unfortunately, many young children need to be briefly restrained during
this examination, which is why you may want to leave it for the end.

Ask the parent for a preference regarding the positioning of the child for the
examination. There are two common positions: the child lying down and
restrained, and if the child is not too fearful, you may examine the ears with
the child sitting on a parent’s lap.

If the child is held supine, have the parent hold the arms either extended
(Figs. 25-64 and 25-65) or close to the sides to limit motion. Hold the head
FIGURE 25-63. Test each eye and note the difference in acuity. and pull the pinna (auricle) upward with one hand while you hold the
otoscope with your other hand.
Some children develop abnormalities in near vision, which can
lead to reading difficulties, headaches, and school problems, as
well as double vision.

Visual acuity in children 4 years and older can usually be formally tested
using an eye chart with one of a variety of optotypes (characters or
symbols).47 A child who does not know letters or numbers reliably can be
tested using pictures, symbols, or the “E” chart. Using the “E” chart, most
children will cooperate by telling you in which direction the “E” is pointing.
The most common visual disorder of childhood is myopia, which
can be easily detected using this examination technique.
Visual Fields.
While it is often challenging, the visual fields can be examined in infants and
young children with the child sitting on the parent’s lap. One eye should be
tested at a time with the other eye covered. Hold the child’s head in the
 With otitis externa (but not otitis media), movement of the pinna
elicits pain.

If the child is on the parent’s lap, the child’s legs should be between the
parent’s legs. The parent could help by placing one arm around the child’s
body and using the second arm to steady the head (with the parent’s hand on
the child’s forehead).
Otoscopic Examination.
Make a game out of the otoscopic examination, such as finding an imaginary
object in the child’s ear or talking playfully to allay fears (Box 25-36). It may
help to place the otoscopic speculum gently into the external auditory canal
of one ear and then withdraw it so that the child gets used to the procedure
before the actual examination. It is also helpful to show the child that the
speculum does not hurt by letting the child touch it and shine a light through
your finger.
FIGURE 25-64. Gently holding the child’s arms reduces reactions to the otoscope.

Box 25-36. Tips for Conducting the Otoscopic Examination

Use the best angle of the otoscope.

Use the largest possible speculum.
A larger speculum allows you to better visualize the tympanic membrane and is
less painful since it is not inserted as far as a smaller speculum.
A small speculum may not provide a seal for pneumatic otoscopy.
If using a pneumatic otoscope, do not apply too much pressure or the child may cry.
Insert the speculum ¼–½ in into the canal.
First find the landmarks.
Careful—sometimes the ear canal resembles the tympanic membrane.
Note whether the tympanic membrane is abnormal.
Remove cerumen if it is blocking your view, using one of the following:
Flushing of ears
Special plastic curettes
Moistened microtipped cotton swab if not totally occluded
Special instruments that can also be purchased.

Gently move and pull on the pinna before or during your otoscopic
FIGURE 25-65. Hand positions for standard otoscope approach.
examination. Carefully inspect the area behind the pinna, over the mastoid
bone. Many offices now use a tympanometer, which measures the compliance
of the tympanic membrane and helps to diagnose a middle ear effusion.
 With acute mastoiditis, the auricle may protrude forward and
outward, and the area over the mastoid bone is red, swollen,
and tender.

Many students have difficulty visualizing a child’s tympanic membrane. In

young children, the external auditory canal is directed upward and backward
from the outside, and the auricle must be pulled upward, outward, and
backward to afford the best view. Press the child’s head with one hand, and
with that same hand pull up on the auricle. Position the otoscope with your
other hand.

There are two ways to hold the otoscope:

FIGURE 25-67. Auricle pulled up, handle pointed down, assessing left ear.
The first is the method generally used in adults, with the otoscope handle
pointing upward or laterally while you pull up on the auricle. While holding
the otoscope with the handle pointing down, pull up on the auricle. Steady Acute otitis media is a common condition of childhood. A
your hand against the child’s head and pull up on the auricle with that hand, symptomatic child typically has a red, bulging tympanic
while you hold the otoscope with the other hand (see Figs. 25-64 and 25-65). membrane with a dull or absent light reflex and diminished
movement on pneumatic otoscopy. Purulent material may also be
The second method, with the handle of the otoscope pointing down toward seen behind the tympanic membrane. See Table 25-7,
the child’s feet, is preferred by many pediatricians because of the angle of the Abnormalities of the Eyes, Ears, and Mouth, p. 1069. The most
auditory canal in children (Figs. 25-66 and 25-67). useful symptom in making the diagnosis is ear pain, if combined
with the above signs.48–50
Pneumatic Otoscopy.
You can use a pneumatic otoscope to improve the accuracy of diagnosis of
otitis media in children (Fig. 25-68). This allows you to assess the mobility
of the tympanic membrane as you increase and decrease the pressure in the
external auditory canal by squeezing the rubber bulb of the pneumatic
otoscope.
Sometimes acute otitis media causes a ruptured tympanic
membrane, leading to pus in the auditory canal. In these cases,
you will generally not visualize the tympanic membrane.

First, check the pneumatic otoscope for leaks by placing your finger over the
FIGURE 25-66. Gently pulling up on the auricle gives a better otoscope view with many tip of the speculum and squeezing the bulb. Note the pressure on the bulb.
children.
Then insert the speculum, obtaining a proper seal; this is critical because
failure to obtain a seal can produce a false-positive finding (lack of Significantly, temporary hearing loss for several months can
movement of the tympanic membrane). Of note, this process requires a accompany otitis media with effusion.
patient who is not moving.
Movement of the tympanic membrane is absent in middle ear
When air is introduced into the normal ear canal, the tympanic membrane and effusion (otitis media with effusion).
its light reflex move inward. When air is removed, the tympanic membrane
moves outward. This rapid, subtle to-and-fro movement of the tympanic If the tympanic membrane fails to move perceptibly as you introduce positive
membrane has been likened to the luffing of a sail. or negative pressure, the child is likely to have a middle ear effusion (or the
technique was poor).

A child with acute otitis media may flinch because of pain due to the air
pressure.
Hearing Testing.
You can grossly test for hearing in very young children by using the
whispered voice test. Stand behind the child (so that the child cannot read
your lips), cover one of the child’s ear canals, and rub the tragus, using a
circular motion. Whisper letters, numbers, or a word and have the child
repeat it, and then test the other ear. This technique can have similar
sensitivity and specificity compared to formal testing,51 but this technique is
highly variable depending on the examiner.
Younger children who fail these screening maneuvers or who
have speech delay should have audiometric testing. These
children may have hearing deficits or central auditory processing
disorders.
Up to 15% of school-aged children have at least mild hearing
loss, emphasizing the importance of screening for hearing prior
to school age.51
The types of hearing loss seen in children are conductive,
sensorineural, and mixed conductive/sensorineural hearing loss.
Causes of conductive hearing loss include congenital
abnormalities, ossicular abnormalities, cerumen impaction,
trauma, otitis media, and tympanic membrane perforation.
FIGURE 25-68. Pneumatic otoscope.
Formal hearing testing is necessary for accurate detection of hearing deficits
in young children, and nowadays children as young as 6 months old may
undergo behavioral hearing tests. Once the child is old enough to cooperate,
use a formal hearing test method (Box 25-37).
Causes of sensorineural hearing loss include genetic, hereditary
congenital infections, ototopic drugs, trauma, and some
infections such as meningitis.

Box 25-37. Hearing Ranges on Formal Acoustic

Screening Tests
Normal hearing 0–20 dB
Mild hearing loss 21–40 dB
Moderate hearing loss 41–60 dB
Severe hearing loss 61–90 dB FIGURE 25-69. Standardized testing equipment provides more precise metrics.
Profound hearing loss >90 dB

The AAP recommends that all children older than 4 years have a full-scale
acoustic screening test using standardized equipment (Figs. 25-69 and 25-
70).19 Even though a normal hearing screen at birth is reassuring, some
hearing loss can be acquired as children age and hearing loss can
dramatically affect a child’s language and development. If you do use an
acoustic screening test, be sure to test the entire acoustic range, including the
speaking range (500 to 8,000 Hz). Box 25-37 shows one classification of
hearing ranges.

FIGURE 25-70. Children often enjoy a full-scale acoustic screening test.

Nose and Sinuses

Inspect the anterior portion of the nose by using a large speculum on your Children with (1) purulent rhinorrhea for more than 10 days, (2)
otoscope. Inspect the nasal mucous membranes, noting their color and worsening course, or (3) severe symptoms, high fever, and
condition. Look for nasal septal deviation and the presence of polyps purulent rhinorrhea >3 days may have sinusitis. These children
(Fig. 25-71). also have headache and sore throat, and you might note
Pale, boggy nasal mucous membranes are found in children with tenderness over the sinuses on percussion or palpation.54
allergic rhinitis.
Purulent rhinitis is common in viral infections. Box 25-38. Age of Pneumatization of Sinuses in Children

Sinus Age of Pneumatization

Sinuses develop at varying ages (Box 25-38).52 The sinuses of older children
can be palpated or percussed as in adults, looking for tenderness.53 Ethmoid Birth
Transillumination of the paranasal sinuses of younger children has poor Maxillary Birth to several years
sensitivity and specificity for diagnosing sinusitis or fluid in the sinuses. Sphenoid 5–6 years
Frontal 7–8 years (continues until adolescence)

Mouth and Pharynx

For anxious or young children, it is wise to leave the examination of the
mouth and pharynx until near the end because it may require parental
restraint. It is often practical to examine the ears, and then the mouth. The
young, cooperative child may be more comfortable sitting in the parent’s lap.
Healthy children are more likely to cooperate with this examination than sick
children, especially if the sick child sees the tongue depressor or has had
previous experience with throat cultures.

Figure 25-72 demonstrates how to get children to open their mouths. The
child who can say “ahhh” will usually offer a sufficient (albeit brief) view of
the posterior pharynx so that a tongue depressor is unnecessary (Box 25-39).

FIGURE 25-71. Nasal inspection of children.

Foul-smelling, purulent, unilateral discharge from the nose may

be due to a foreign body. Young preschool children tend to stick
objects into body orifices.
Nasal polyps are gray/yellow-colored growths inside the nares.
 gag reflex, which should permit a brief look at the posterior pharynx and
tonsils. Careful planning and parental help are needed.
Teeth.
Examine the teeth for the timing and sequence of eruption, number, character,
condition, and position. Abnormalities of the enamel may reflect local or
general disease.
Dental caries are the most common health problem in children.
They are particularly prevalent in populations living in
impoverished areas and can cause both short-term and long-
term problems.55 Caries are highly preventable and can be
FIGURE 25-72. Children generally imitate well enough to allow you to inspect the back treated with dental visits.
of their mouths.
Carefully inspect the upper teeth as shown in Figure 25-73. This is a common
location for early childhood caries. The technique shown in Figure 25-73 is
Box 25-39. How to Get Children to Open Their Mouths (a.k.a., called “lift the lip,” and it can help visualize dental caries.
“Would You Please Say ‘Ahhh’?”)
Visualize the inside of the upper teeth by having the child look up at the
Turn it into a game. ceiling with the mouth wide open.
“Now let’s see what’s in your mouth.”
“Can you stick out your whole tongue?”
“I bet you can’t open your mouth really wide!”
“Let me see the inside of your teeth.”
“Can you pant like a dog on a hot day?”
Don’t show a tongue depressor unless really necessary.
Demonstrate first on an older sibling (or even the parent).
Offer enthusiastic praise for opening their mouths a little and encourage them to open
even wider.

Pharynx.
If you need to use a tongue depressor, push down and pull slightly forward
toward yourself while the child says “ahhh,” being careful not to place the
depressor too far posteriorly, eliciting a gag reflex. Sometimes, young and
anxious children will need to be restrained and will clamp their teeth and
purse their lips. In these cases, carefully slip the tongue depressor between
the teeth and the cheek in the vertical plane to the back of the gum line. Then
turn the tongue depressor horizontally toward the tongue and push down.
These techniques will either allow you to push down on the tongue or elicit a
 (white stain) is an example of extrinsic stain. Extrinsic stains can
be polished off; intrinsic stains cannot (see Table 25-9,
Abnormalities of the Teeth, Pharynx, and Neck, p. 1071).

Box 25-40. Tooth Types and Age of Eruption

Approximate Age of Eruption47

Tooth Type Primary (months) Permanent (years)

Central incisor 5–8 6–8

Lateral incisor 5–11 7–9
Cuspids 24–30 11–12
First bicuspids — 10–12
Second bicuspids — 10–12
First molars 16–20 6–7
Second molars 24–30 11–13
Third molars — 17–22

FIGURE 25-73. Lift the lip to check for dental caries. Delayed tooth eruption can be due to a variety of conditions such
as genetic disorders involving an altered craniofacial complex,
or systemic diseases.
Dental caries are caused by bacterial activity. Caries are more
likely among young children who have prolonged bottle-feeding Look for abnormalities of the position of the teeth. These include
(“nursing-bottle caries”). malocclusion, maxillary protrusion (overbite), and mandibular protrusion
See Table 25-9, Abnormalities of the Teeth, Pharynx, and Neck, (underbite). You can demonstrate the latter two by asking the child to bite
p. 1071, for different stages of caries. down hard while either you or the child parts the lips. Normally, the lower
teeth are contained within the arch formed by the upper teeth.
Box 25-40 displays the common pattern of tooth eruption. In general, lower
Malocclusion and misalignment of teeth can be from thumb
teeth erupt a bit earlier than upper teeth.
sucking, excess pacifier use, a hereditary condition, or
Staining of the teeth may be intrinsic or extrinsic. Intrinsic stains premature loss of primary teeth.
may be from tetracycline use before 8 years (yellow, gray, or
Tongue.
brown stain). Other examples of intrinsic stains that we see are
the “green stain” in teeth of children with liver disease, and Carefully inspect the tongue, including the underside (Fig. 25-74). Most
fluorosis (white stain) caused by the excess of ingested fluoride children will happily stick their tongue out at you and move it from side to
side.
during early childhood. Iron preparation (black stain) and fluoride
 Streptococcal pharyngitis typically produces white or yellow
exudates on the tonsils or posterior pharynx, a beefy-red uvula,
and palatal petechiae; see Table 25-9, Abnormalities of the
Teeth, Pharynx, and Neck, p. 1071.57

Tonsils in children usually have deep crypts on their surfaces, which often
have white concretions or food particles protruding from their depths. This
does not indicate disease.
A peritonsillar abscess is suggested by erythema and
asymmetric protrusion of one tonsil, pain, difficulty opening the
mouth (trismus), and lateral displacement of the uvula.
FIGURE 25-74. Inspect all parts of the tongue.
Look for clues of a submucosal cleft palate such as notching of the posterior
A geographic tongue is a benign but chronic condition in which a margin of the hard palate or a bifid uvula. Because the mucosa is intact, the
portion of the tongue has a rough, unusual appearance (looking underlying defect is easily missed, but needs referral to otolaryngology.
like a map). The abnormal-appearing portion can vary over time Extremely rarely, you may encounter a child who has a sore throat and has
and is thought to be a benign inflammatory process. Some difficulty swallowing saliva and who is sitting up stiffly in a “tripod”
children with geographic tongue also have fissured tongue, which position because of throat obstruction. Do not open this child’s mouth
is usually benign, and notable for small fissures.56 because he may have acute epiglottitis, or obstruction from another cause,
Common abnormalities include coated tongue in viral infections, and examination of the throat may induce gagging and laryngeal obstruction.
and strawberry tongue, from strep (see below) or scarlet fever. Acute epiglottitis is now rare in the United States because of
immunization against Haemophilus influenzae type B.
Some young children have a tight frenulum. Have the child touch the tongue to
the roof of the mouth to diagnose this condition which often does not require Bacterial tracheitis can cause airway obstruction.
treatment unless it interferes with eating or speech.
Note the quality of the child’s voice. Certain abnormalities can change the
Children who are severely “tongue-tied” might have a speech pitch and quality of the voice (Box 25-41).
impediment.
Tonsillitis can be caused by bacteria, such as Streptococcus or
Tonsils. Staphylococcus, or viruses. The “hot potato” voice is
Note the size, position, symmetry, and appearance of the tonsils. The peak accompanied by enlarged tonsils with exudates.
growth of tonsillar tissue is between 2 and 10 years (see Fig. 25-57, p.
1004). The size of the tonsils varies considerably in children and is often
Box 25-41. Voice Changes—Clues to Underlying Abnormalities
categorized by the percent of the width of the posterior oropharynx (e.g.,
reduce the opening by <25% of opening, by 50%, etc.). The tonsils in
Voice Change Possible Abnormality
children often appear more obstructive than they really are.
Hypernasal speech Submucosal cleft palate
Nasal voice plus snoring Adenoidal hypertrophy Check for neck mobility. It is important to ensure that the neck of all children
is supple and easily mobile in all directions. This is particularly important
Hoarseness plus cough Viral infection (croup)
when the patient is holding the head in an asymmetric manner and when
“Hot potato speech” Tonsillitis central nervous system disease such as meningitis is suspected.
The epidemic of childhood obesity has resulted in many children In young children, it may be difficult to differentiate low posterior
who snore and have obstructive sleep apnea. cervical lymph nodes from supraclavicular lymph nodes (which
are always abnormal and raise suspicion for an abdominal
You may note an abnormal breath odor which may help lead to a specific malignancy).
diagnosis.
Halitosis (bad breath) in a child can be caused by upper In children, the presence of nuchal rigidity is a more reliable indicator of
respiratory, pharyngeal, or mouth infection, foreign body in the meningeal irritation than Brudzinski sign or Kernig sign. To detect nuchal
nose, sinusitis, dental disease, and gastroesophageal reflux. rigidity in older children, ask the child to sit with legs extended on the
examining table. Normally, children should be able to sit upright and touch
Neck. their chins to their chests. Younger children can be persuaded to flex their
Beyond infancy, the techniques for examining the neck are the same as for necks by having them follow a small toy or light beam. You also can test for
adults. Lymphadenopathy is unusual during infancy but very common during nuchal rigidity with the child lying on the examining table, as shown in
childhood. The child’s lymphatic system reaches its zenith of growth at 12 Figure 25-75. Nearly all children with nuchal rigidity will be extremely sick,
years, and cervical or tonsillar lymph nodes reach their peak size between 8 irritable, and difficult to examine. In many countries the incidence of
and 16 years (see Fig. 25-57). bacterial meningitis has plummeted because of vaccinations.
Lymphadenopathy is usually from viral or bacterial infections
(see Table 25-9, Abnormalities of the Teeth, Pharynx, and Neck,
p. 1071).

The vast majority of enlarged lymph nodes in children are due to infections
(mostly viral, but sometimes bacterial) and not due to malignant disease,
even though the latter is a concern for many parents. It is important to
differentiate normal lymph nodes from abnormal ones or from congenital
cysts of the neck.
Malignancy is more likely if the node is >2 cm, is hard, or is
fixed to the skin or underlying tissues (i.e., not mobile) and is
accompanied by serious systemic signs such as weight loss.

Figure 25-27 on p. 993 demonstrates the typical anatomical locations of

lymph nodes and congenital cysts of the neck.
 See Table 25-15, Power of Prevention: Vaccine-Preventable
Diseases, pp. 1078–1079.

Thorax and Lungs

As children age, the lung examination becomes similar to that for adults.
Cooperation is critical.

Auscultation is usually easiest when a child barely notices (as when in a

parent’s lap). Let a toddler who seems fearful of the stethoscope play with it
before it touches the child’s chest.
With upper airway obstruction such as croup, inspiration is
prolonged and accompanied by other signs such as stridor,
cough, or rhonchi.

Assess the relative proportion of time spent on inspiration versus expiration.

The normal ratio is about 1:2. Prolonged inspirations or expirations are a
clue to disease location. Degree of prolongation and effort or “work of
breathing” are related to disease severity.
With lower airway obstruction such as asthma, expiration is
prolonged and often accompanied by wheezing (as well as
coughing).

Young children asked to “take deep breaths” often hold their breath, further
FIGURE 25-75. Inspect the neck for nuchal rigidity. complicating auscultation. It is easier to let preschoolers breathe normally.
Demonstrate to older children how to take nice, quiet, deep breaths. Make it
a game. To accomplish a forced expiratory maneuver, ask the child to blow
Nuchal rigidity is marked resistance to movement of the head in
out candles on an imaginary birthday cake or use pinwheels (Fig. 25-76).
any direction. It suggests meningeal irritation due to meningitis,
bleeding, tumor, or other causes. These children are extremely
irritable and difficult to console and may have “paradoxical
irritability”—increased irritability when being held.
When meningeal irritation is present, the child may assume the
tripod position and is unable to assume a full upright position to
perform the chin-to-chest maneuver.
 accompanied by inspiratory rhonchi caused by upper respiratory
congestion.58 Asthma flares often occur with viral infections.

Children in respiratory distress may assume a “tripod position” in which

they lean forward to optimize airway patency (Fig. 25-77). This same
position can also be caused by pharyngeal obstruction (see p. 1047).

FIGURE 25-76. Getting a child to perform a forced expiration.

Pneumonia in young children is generally manifested by fever,

tachypnea, dyspnea, and increased work of breathing.
Upper respiratory infections due to viruses in young children
present with the same signs as in adults; children generally
appear well without lower respiratory signs.

Older children will usually be cooperative for the respiratory examination

and can even go through the maneuvers of assessing fremitus or listening to
“E to A” changes (see p. 1019). As children grow, the evaluation by
observation discussed on the previous page, such as assessing the work of FIGURE 25-77. A child in respiratory distress.
breathing, nasal flaring, and grunting, becomes less helpful in assessing for
respiratory pathology. Palpation, percussion, and auscultation achieve
Children exhibiting these signs of respiratory distress must be
greater importance in a careful examination of the thorax and lungs.
managed emergently. Possible causes include upper airway
Childhood asthma is an extremely common condition throughout obstruction (such as epiglottitis or bacterial tracheitis), bacterial
the world. Children with acute asthma present with varying or viral lower respiratory infections, and foreign-body obstruction.
severity and often have increased work of breathing. Expiratory
wheezing and a prolonged expiratory phase, caused by Heart
reversible bronchospasm, may be heard without the stethoscope
and are apparent on auscultation. Wheezes are often
The examination of the heart and vascular systems in infants and children is Examine the child while he/she is on their parent’s lap, and have the parent turn
them to face you
similar to that in adults. However, a child’s fearfulness or inability to Give the child something to hold in each hand making it more challenging for the
cooperate may make the examination difficult while the desire to play will child to push you away
make the examination easier and more productive (Fig. 25-78). Use your Have the child watch a video on a smartphone or tablet (with the volume on low)
Use endless chatter to hold the child’s attention, pausing briefly to listen (they may
knowledge of the developmental stage of each child, and some helpful forget you are listening)
techniques (Box 25-42). Older children (5–10 years)
Explain what you plan to do
Remind the child that the stethoscope might be cold
Say “shhh” very gently with a smile, asking the child to be quiet
Ask the child to just breathe normally

Benign Murmurs.
Preschool and school-aged children often have benign murmurs (Box 25-43).
The most common (Still’s murmur) is a grade I–II/VI, musical, vibratory,
early and midsystolic murmur with multiple overtones located over the mid
or lower left sternal border; it may also be heard over the carotid arteries.
Carotid artery compression will usually cause the precordial murmur to
disappear. This murmur may be extremely variable and may be accentuated
when cardiac output is increased, as occurs with fever or exercise. The
murmur will diminish as the child goes from supine to sitting to standing,
conversely it will often sound louder as the child lies down if you started the
examination while the child was sitting.38
See Box 25-43, Location and Characteristics of Benign Heart
Murmurs in Children, p. 1022.
FIGURE 25-78. Young children are easiest to examine when held by a parent. You can
even sneak your stethoscope around to the anterior chest.
Box 25-43. Location and Characteristics of Benign Heart
General abnormalities detected on examination may suggest Murmurs in Children
increased likelihood of congenital cardiac disease as exemplified
by Down syndrome or Turner syndrome.

Box 25-42. Techniques to Enhance Your Cardiac Examination

in Young Children

Young children (2–4 years)

Examine the child’s arm or parent’s arm first with your stethoscope
Have the child touch your stethoscope and play with it a bit
 affect venous return, such as lying supine, changing head position, or jugular
venous compression. It has the same quality as breath sounds and is therefore
frequently overlooked.38

Typical Age Name Characteristics Description and Location

Preschool or Still’s murmur Grade I–II/VI, musical, vibratory

early school age Multiple overtones
Early and midsystolic
Mid/lower left sternal border
Frequently also a carotid bruit

Preschool or Venous hum Soft, hollow, continuous

FIGURE 25-79. Listening for venous hum.
early school age Louder in diastole
Just above or below the
clavicle
Can be eliminated by Among young children, murmurs without the recognizable
maneuvers features of the common benign murmurs may signify underlying
Preschool and Carotid bruit Early and midsystolic heart disease and should be evaluated thoroughly by a pediatric
later Usually louder on left cardiologist.
Eliminated by carotid
compression Pathologic murmurs that signify cardiac disease can first appear
Preschool and Pulmonary flow Grade 2–3 systolic crescendo– after infancy and during childhood. Examples include aortic
school age murmur decrescendo stenosis and mitral valve disease.
Loudest at pulmonary
auscultation area
Harsh, nonvibratory The murmur heard in the carotid area or just above the clavicles is known as
Intensity increases when in the a carotid bruit. It is early and midsystolic with a slightly harsh quality. It is
supine position
usually louder on the left and may be heard alone or in combination with the
Still’s murmur. It may be completely eradicated by carotid artery
In preschool or school-aged children, you may detect a venous hum. This is a
compression (Fig. 25-80).
soft, hollow, continuous sound, louder in diastole, heard just above or below
the clavicle (Fig. 25-79). It can be completely eliminated by maneuvers that
A pulmonary flow murmur is typically located in the left upper sternal An exaggerated “pot-belly appearance” may indicate
border. It is a grade I–II/VI, soft systolic crescendo–decrescendo murmur. malabsorption from celiac disease, cystic fibrosis, or
The second heart sound is normal (i.e., not unusually loud). Like the Still’s constipation; in developing countries it can be a sign of
murmur, it also is louder when the child lies down. It is quieter when the kwashiorkor or intestinal parasites.
patient sits or stands or holds his/her breath.
Most children are ticklish when you first place your hand on their abdomens
for palpation. This reaction tends to disappear, particularly if you distract
the child with conversation and place your whole hand flush on the
abdominal surface for a few moments without probing. For children who are
particularly sensitive and who tighten their abdominal muscles you can start
by placing the child’s hand under yours. Eventually, you will be able to
remove the child’s hand and palpate the abdomen freely. Palpate the liver
edge and measure its span as you would in an adult using percussion
techniques. Expected liver spans by percussion are shown in Box 25-44.
A common condition of childhood that can occasionally cause a
protuberant abdomen is constipation. The abdomen is often
tympanitic on percussion, and stool is sometimes felt on
palpation.

Try flexing the knees and hips to relax the child’s abdominal wall, as shown
in Figure 25-81. Palpate lightly in all areas, then deeply, leaving the site of
FIGURE 25-80. Carotid artery compression while listening to murmur. potential pathology to the end.
Chronic or recurrent abdominal pain is relatively common in
Blood Pressure in Extremities. children. Some functional disorders causing abdominal pain
Measure the blood pressure in both arms and one leg one time to check for include irritable bowel syndrome, functional dyspepsia, and
possible coarctation of the aorta. Thereafter, only the right arm blood childhood functional abdominal pain syndrome. Other causes in
pressure needs to be measured after a coarctation has been ruled out. children include gastritis or ulcer, gastroesophageal reflux,
In coarctation of the aorta the blood pressure is lower in the legs constipation, and inflammatory bowel disease.
than in the arms.

Abdomen
Toddlers and young children commonly have protuberant abdomens, most
apparent when they are upright. The examination can follow the same order
as for adults except that you may need to distract the child during the
examination.
 2 3.5 3.6
3 4.0 4.0
4 4.4 4.3
5 4.8 4.5
6 5.1 4.8
8 5.6 5.1
10 6.1 5.4

If hepatomegaly is accompanied by splenomegaly, portal

hypertension, storage diseases, chronic infections, and
malignancy should be considered.
Various diseases can cause splenomegaly, including infections,
hematologic disorders such as hemolytic anemias, infiltrative
disorders, and inflammatory or autoimmune diseases, as well as
congestion from portal hypertension.

FIGURE 25-81. Position child as shown to palpate abdomen. The spleen, like the liver, may be palpable in some children. It too is soft
with a sharp edge, and it projects downward like a tongue from under the left
Many children present with abdominal pain from acute costal margin. The spleen is moveable and rarely extends more than 1 to 2
cm below the costal margin.
gastroenteritis. Despite pain, their physical examination is
relatively normal except for increased bowel sounds on Palpate the other abdominal structures. You will commonly note pulsations
auscultation and mild tenderness on palpation. in the epigastrium caused by the aorta. This is felt most easily to the left of
The childhood obesity epidemic has resulted in many children the midline, on deep palpation.
who have extremely obese abdomens. This makes the An abdominal mass felt on palpation may represent stool from
examination more challenging but the steps for examining the constipation, a distended bladder, or a serious condition such as
abdomen are the same. a tumor.
Hepatomegaly in young children is unusual. It can be caused by
Palpating for abdominal tenderness in an older child is the same as for the
cystic fibrosis, parasites, fatty liver, hepatitis, and tumors.
adult; however, the causes of abdominal pain are often different,
encompassing a wide spectrum of acute and chronic diseases. Localization of
Box 25-44. Expected Liver Span of Children by Percussion tenderness may help you pinpoint the abdominal structures most likely to be
causing the abdominal pain.
Mean Estimated Liver Span (cm)
Age in Years Males Females In a child with an acute abdomen, as in acute appendicitis, check
for involuntary rigidity, rebound tenderness, a Rovsing sign, or a
 positive psoas or obturator sign (see pp. 647–648).59 The cremasteric reflex can be elicited by gently stroking upward or
Gastroenteritis, constipation, and gastrointestinal obstruction are downward along the medial aspect of the thigh. The testis on the side being
other possible etiologies of acute abdominal pain. stroked will move upward.

Male Genitalia. Examine the inguinal canal as you would for adults noting any swelling that
An appropriate chaperone such as a parent should be present during the may reflect an inguinal hernia. If desired, have the boy increase abdominal
genital examination. Inspect the penis. The size in prepubertal children has pressure by pretending to blow a balloon or fill up his cheeks by pursing his
little significance unless it is abnormally large or small. In boys who are lips and blowing; note whether a bulge in the inguinal canal increases with
obese, the fat pad over the symphysis pubis may obscure the penis. Valsalva.
In precocious puberty, the penis and testes are enlarged with Inguinal hernias in older boys present as they do in adult men
signs of pubertal changes. Other pubertal changes also occur. It with swelling in the inguinal canal, particularly following a Valsalva
is due to excess androgens and can be caused by multiple maneuver.
conditions including adrenal or pituitary tumors.
Female Genitalia
Examination by palpation of the scrotum and testes of a young boy may cause
the testis to retract upward into the inguinal canal (cremasteric reflex) and An appropriate chaperone such as a parent should be present during the
thereby appear to be undescended. Examine the child when he is relaxed examination. The genital examination can be anxiety provoking for the older
because anxiety stimulates the cremasteric reflex. Have the boy lie down, child and for parents. Nevertheless, it is important to perform it to detect
and with warm hands, palpate the lower abdomen, working your way abnormalities and to reassure parents in the case of normal examination
downward toward the scrotum along the inguinal canal. This will minimize findings. Depending on the child’s developmental stage, explain what parts
retraction of the testes into the canal. If you can detect the testis in the of the body you will check and that this is part of the routine examination.
scrotum it is descended, even if it spends much time in the inguinal canal. A The appearance of pubic hair before age 7 years should be
retractile testis can be brought into the scrotum and remains there, while an considered precocious adrenarche and requires evaluation to
undescended testis may be able to be brought into the scrotum but readily determine the cause.
pops up into the inguinal canal.
Cryptorchidism may be noted at this age. It requires surgical After infancy, the labia majora and minora flatten out and the hymenal
correction. It should be differentiated from a retractile testis. membrane becomes thin, translucent, and vascular, with the edges easily
identified.
A painless scrotal mass in a young boy is usually due to a
Rashes on the external genitals can be from physical irritation,
hydrocele or a nonincarcerated inguinal hernia. Other rare
causes include a varicocele or tumor. sweating, and candidal or bacterial infections including
streptococcal infection.
A painful testicle requires urgent consultation and treatment.
The genital examination is the same for all ages of children, from late infancy
Possible causes of a painful testicle include infection such as until adolescence. Use a calm, gentle approach including a developmentally
epididymitis or orchitis, torsion of the testicle, or torsion of the appropriate explanation as you do the examination. A bright light source is
appendix testis. essential. Most children can be examined in the supine, frog-leg position.
If the child seems reluctant, it may be helpful to have the parent sit on the Vulvovaginal pruritis and erythema can be caused by external
examination table with the child; alternatively, the examination may be irritants, bubble baths, masturbatory activity, pinworms, or other
performed while the child sits in the parent’s lap. Do not use stirrups as these infections such as Candida or sexually transmitted infections.
may frighten the child. Figure 25-82 demonstrates a 5-year-old girl sitting on
her parent’s lap with the parent holding her knees outstretched. Next, visualize the structures by separating the labia with your fingers, as
shown in Figure 25-83. You can also grasp the labia between your thumb and
Examine the genitalia in an efficient and systematic manner. Inspect the index finger of each hand, separating the labia majora with gentle traction
external genitalia for pubic hair, the size of the clitoris, the color and size of laterally and toward the examiner in order to the inner structures as shown in
the labia majora, and the presence of rashes, bruises, or other lesions. Figure 25-84. Labial adhesions, or fusion of the labia minora, may be noted
in prepubertal children. They are normal findings. They may be a normal
variant.

FIGURE 25-83. Separate labia to assess genital structures.

FIGURE 25-82. Positioning the mother behind her child has a calming effect.
 abuse as a child; while many of these do not involve severe
physical trauma, some do.60

FIGURE 25-84. Using thumb and forefinger to examine inner structures.

A vaginal discharge in early childhood can be from perineal

irritation (e.g., bubble baths or soaps), foreign body, nonspecific FIGURE 25-85. Position for more advanced technique to visualize hymen.
vulvovaginitis, Candida, pinworms, or a sexually transmitted
infection from sexual abuse.
Precocious puberty can induce menses in a young girl.
Purulent, profuse, malodorous, and blood-tinged discharge
should be evaluated for the presence of infection, foreign body,
or trauma.

The finding of vaginal bleeding is worrisome and warrants further

evaluation.

Note the condition of the labia minora, urethra, hymen, and proximal vagina.
If you are unable to visualize the edges of the hymen, ask the child to take a FIGURE 25-86. Using thumbs to separate labia to open the hymen.
deep breath to relax the abdominal muscles.
Avoid touching the hymenal edges because the hymen is exquisitely sensitive
Another useful technique (to be performed only by an experienced pediatric without the protective effects of hormones. Examine for discharge, labial
examiner, such as during an examination for possible sexual abuse) is to adhesions, lesions, estrogenization (indicating onset of puberty), hymenal
position her in the knee–chest position, as shown in Figures 25-85 and 25- variations (such as imperforate or septate hymen, which are rare), and
86. These maneuvers will often open the hymen. Experienced examiners can hygiene. A thin, white discharge (leukorrhea) can be present. A speculum
also use saline drops to make the edges of the hymen less sticky. examination of the vagina and cervix is contraindicated in a prepubertal child
Sexual abuse is unfortunately far too common throughout the unless there is suspicion of severe trauma or foreign body; it should be
world. Up to one fifth of women report some history of sexual performed by an expert.
 Abrasions or signs of trauma of the external genitalia can be
from benign causes such as masturbation, irritants, or accidental
trauma, but should also raise the possibility of sexual abuse. See
Table 25-12, Physical Signs of Sexual Abuse, p. 1076.

The normal hymen in infants and young girls can have various configurations,
as shown in Box 25-45. The physical examination may reveal mounds,
notches, and tags on the hymen which may all be normal variants. The size of
the vaginal orifice can vary with age and with examination technique.
Therefore, there is no correlation between the size of the vaginal orifice and 2-year-old girl with an annular hymen, visible 9-year-old girl with redundant labial tissue
with labial traction. Annular means that the suggesting estrogen effect. Greater traction
whether or not the patient has been sexually assaulted. hymen surrounds the orifice circumferentially. or a knee–chest position would reveal a
normal orifice. If unable to locate an orifice,
consider the possibility of an imperforate
Box 25-45. Normal Configurations of the Hymen in Prepubertal hymen.
and Adolescent Females

6-year-old girl with a septate hymen causing 7-year-old girl with a crescent-shaped
two orifices. Traction is needed to visualize hymen. Crescentic hymens do not encircle
the two openings. the vaginal orifice but rather border the lower
part of the vaginal orifice and extend to the
posterior and lateral margins of the hymenal
ring. 12-year-old girl with annular hymen and hormonal influence of puberty, causing thickened,
pink tissue.

Source of photos: Reece R, Ludwig S, eds. Child Abuse: Medical Diagnosis and
Management. 2nd ed. Lippincott Williams & Wilkins; 2001.

The physical examination may reveal signs that suggest sexual abuse, and the
examination is particularly important if there are suspicious clues in the
history.
 As demonstrated in Table 25-12, Physical Signs of Sexual Reflex anal dilatation suggests the possibility of sexual abuse
Abuse, p. 1076, physical signs strongly suggestive of sexual involving the rectum and requires more complete examination by
abuse include lacerations, ecchymoses and newly healed scars an expert.
of the hymen, lack of hymenal tissue from 3 to 9 o’clock while the
patient is in the supine position, and healed hymenal Musculoskeletal System
transections. Other signs such as purulent discharge and
In older children, abnormalities of the upper extremities are rare in the
herpetic lesions are concerning as well.
absence of injury.
Even with known abuse, the majority of examinations will be unremarkable; Toddlers may acquire nursemaid’s elbow or subluxation of the
a normal genital examination does not rule out sexual abuse. radial head from a tugging injury. They will hold their arms slightly
flexed at the elbows.
If the hymenal edges are smooth and without interruption in the inferior
half, the hymen is probably normal (but does not rule out abuse since the The normal young child has increased lumbar concavity and decreased
hymen, like most other tissues, can heal over 7 to 10 days). Certain physical thoracic convexity compared with the adult, and often has a protuberant
findings, however, suggest the possibility of sexual abuse and require more abdomen.
complete evaluation by an expert in the field.
Observe the child standing and walking barefoot. Ask the child to touch the
Rectum and Anus toes, rise from sitting, run a short distance, and pick up objects. You will
detect most abnormalities by watching carefully from both front and behind.
The rectal examination is not routine but should be done whenever intra-
abdominal, pelvic, or perirectal disease is suspected. The examination of the The cause of acute limp in childhood is usually trauma or injury,
young child can be performed with the child in either the side-lying or although many etiologies are possible including infection of the
lithotomy position. For many young children, the lithotomy position is less bone, joint, or muscle and also malignancy. In an obese child,
threatening and easier to perform. Have the child lie on the back with the consider slipped capital femoral epiphysis.
knees and hips flexed and the legs abducted. Drape the child from the waist
down. Provide frequent reassurance during the examination and ask the child During early infancy, there is a common and normal progression from
to breathe in and out through the mouth to relax. Spread the buttocks and bowleggedness (Fig. 25-87) that begins to disappear at about 18 months of
observe the anus. You can use your lubricated gloved index finger, even in age, often followed by transition toward knock-knees.
small children. Palpate the abdomen with your other hand, both to distract the
child and to note the abdominal structures between your hands. The prostate The knock-knee pattern (Fig. 25-88) is usually maximal by age 3 years and
gland is not palpable in young boys. gradually corrects by age 7 years.

Anal skin tags are present in inflammatory bowel disease but are
more often an incidental finding when located in the midline.
Tenderness noted on rectal examination of a child usually
indicates an infectious or inflammatory cause, such as an
abscess or appendicitis.
 Severe bowing of the legs (genu varum) may still be physiologic
bowing that will spontaneously resolve. Extreme bowing or
unilateral bowing may be from pathologic causes such as rickets
or tibia vara (Blount disease).

The presence of tibial torsion can be assessed in several ways43; one method
is shown in Figure 25-89. Have the toddler lie prone on the examination
table, with the knees flexed to 90 degrees. Note the thigh–foot axis. Usually
there is 0 to 10 degrees of internal or external rotation noted by a foot
pointing off in a direction. A negative thigh-foot angle indicates tibial
torsion. Check the position of the malleoli—they should be symmetric.

FIGURE 25-87. Bowleggedness is normal in early childhood.

FIGURE 25-89. Checking for tibial torsion.

The most common lower extremity pathology in childhood is

injury from accidents. Fractures are somewhat common in young
children due to incompletely developed bones and growth plates
FIGURE 25-88. Knock-knee is not unusual in childhood.
and frequent injuries during play. Joint injuries, sprains, and
strains are common in young children.
 A chronic limp in childhood could be caused by Blount disease,
hip disorders such as avascular necrosis of the hip, leg-length
discrepancy, spinal disorder, or rarely a malignancy.

Medial femoral torsion (or femoral anteversion) is an inward twisting of the

femur resulting in toeing in by the child after age 3 to 4 years; this tends to
resolve by 8 to 10 years of age although many adults have some toeing in as
well.

Inspect any child who can stand for scoliosis using techniques described on
page 1055.

Determine any leg shortening that may accompany hip disease by comparing
the distance from the anterior superior spine of the ilium to the medial
malleolus on each side. Make sure the hips are level. Straighten the child by
pulling gently on the legs, and then compare the levels of the medial malleoli
with each other. Put a small ink dot over the prominent malleoli and touch
them together for a direct measure.

Have the child stand straight and place your hands horizontally over the iliac
crests from behind. Small discrepancies can be noted. If such a discrepancy
is noted and you suspect leg-length discrepancy, with one iliac crest higher
than the other, place a book under the shorter leg—if this equalizes the iliac
crests then a leg-length discrepancy is likely.

Test for severe hip disease with its associated weakness of the gluteus
medius muscle. Observe from behind as the child shifts weight from one leg FIGURE 25-90. Negative Trendelenburg sign.
to the other (Figs. 25-90 and 25-91). A pelvis that remains level when
weight is shifted from one foot to the other is a negative Trendelenburg
sign.61 With an abnormal positive sign in severe hip disease, the pelvis tilts
toward the unaffected hip (the hip muscle does not hold the hip level
resulting in a drop in the nonweight-bearing leg) during weightbearing on the
affected side (positive Trendelenburg sign).
 perhaps clenched fists as toddlers and young children.

Use a validated developmental screen for preschool children. Children

usually enjoy this component, and you can too. Many neurologic conditions in
children are accompanied by developmental abnormalities. You can ask
children older than 3 years to draw a picture or copy objects and then
discuss their pictures to test simultaneously for fine motor coordination,
cognition, and language.
Problems with social interaction, verbal and nonverbal
communication, restricted interests, and repetitive behaviors
could be signs of autism.
Distinguish between isolated delays in one aspect of
development (e.g., coordination or language) and more
generalized delays several components. The latter is more likely
to reflect global neurologic disorders such as cognitive disability
that can have many etiologies.
Sensation.
The sensory examination can be performed by using a cotton ball or tickling
the child. This is best performed with the child’s eyes closed. Do not use pin
pricks.
Gait, Strength, and Coordination.
Observe the child’s gait while the child is walking and, optimally, running.
Note any asymmetries, weakness, undue tripping, or clumsiness.
FIGURE 25-91. Positive Trendelenburg sign.
Follow developmental milestones to test for appropriate maneuvers such as
heel-to-toe walking (Fig. 25-92), hopping, and jumping. Use a toy to test for
Nervous System coordination and strength of the upper extremities.
Beyond infancy, the neurologic examination includes the components In children with uncoordinated gait, be sure to distinguish
evaluated in adults. Combine the neurologic and developmental assessment; orthopedic causes such as positional deformities of the hip,
turn this into a game with the child to assess optimal development and knee, or foot from neurologic abnormalities such as cerebral
neurologic performance. palsy, ataxia, or neuromuscular conditions.
Children with spastic diplegias will often have hypotonia as
infants and then excessive tone with spasticity, scissoring, and If you are concerned about the child’s strength, have the child lie on the floor
and then stand up, and closely observe the stages. Most normal children will
first sit up, then flex the knees, and extend the arms to the side to push off Children love to feel their legs bounce when you test their patellar reflexes.
from the floor and stand up. Have the child keep the eyes closed during some of this examination because
tensing will disrupt the results.
Hand preference is often demonstrated by age 2 years, although many
preschool children use one hand or another preferentially for different tasks. Children with meningitis, encephalitis, or cerebral abscess can
If a younger child has clear hand preference, check for weakness in the have abnormalities of cranial nerves, although they also have
nonpreferred upper extremity. altered consciousness and other signs.
Cerebellar Function.
The cerebellar examination can be tested using finger-to-nose and rapid
alternating movements of the hands or fingers (Figs. 25-93 and 25-94).
Children older than 5 years should be able to tell right from left so you can
assign them right–left discrimination tasks as is done in the adult patient.

FIGURE 25-93. Finger-to-nose test—first have child touch your finger.

FIGURE 25-92. Heel-to-toe walking is a coordination milestone.

In certain forms of muscular dystrophy with weakness of the

pelvic girdle muscles, children will rise to standing by rolling over
prone and pushing off the floor with the arms while the legs
remain extended (Gower sign).
Deep Tendon Reflexes.
Deep tendon reflexes can be tested as in adults. First, demonstrate the use of
the reflex hammer on the child’s hand, assuring the child that it will not hurt.
 V Motor Play a game with a soft cotton ball to
test sensation.
Have the child clench the teeth and
chew or swallow some food.
VII Facial Have the child “make faces” or imitate
you as you make faces (including
moving your eyebrows) and observe
symmetry and facial movements.
VIII Acoustic Perform auditory testing after age
4 years.
Whisper a word or command behind the
child’s back and have the child repeat it.
IX, X Swallow and gag Have the child stick the “whole tongue
FIGURE 25-94. Then have the child touch her or his nose. out” or “say ‘ah’.” Observe movement of
the uvula and soft palate.
Test the gag reflex.
Some children with attention deficit disorder with hyperactivity XI Spinal accessory Have the child push your hand away with
(ADHD) will have difficulty cooperating with your neurologic and his head. Have the child shrug his
shoulders while you push down with
developmental examination because of problems focusing. These your hands to “see how strong you are.”
children often have high-energy levels, fidgetiness, and a history
XII Hypoglossal Ask the child to “stick out your tongue all
of difficulty in school or structured situations. Other conditions the way.”
such as anxiety may have similar manifestations, so a complete
history and physical examination is warranted. Localizing neurologic signs are rare in children but can be caused
by trauma, brain tumor, intracranial bleed, or infection. Children
Cranial Nerves. with increased intracranial pressure can develop cranial nerve
The cranial nerves can be assessed quite well using developmentally abnormalities as well as papilledema and altered mental status.
appropriate strategies, as shown in Box 25-46.
Children with mild cerebral palsy may have both slightly
increased tone and hyperreflexia.
Box 25-46. Strategies to Assess Cranial Nerves in
Young Children Although facial nerve palsy can be congenital, it is often caused
by infection or trauma.
Cranial Nerve Strategy
I Olfactory Testable in older children.
II Visual acuity Use Snellen chart after age 3 years.
RECORDING YOUR FINDINGS
Test visual fields as for an adult. A parent
may need to hold the child’s head. The format of the clinical record is the same for both children and adults.
III, IV, VI Extraocular Have the child track a light or an object
Although the sequence of the physical examination may vary, convert your
movements (a toy is preferable). A parent may need clinical findings into the same order of the traditional written or electronic
to hold the child’s head. format.
Initially, you may use sentences to describe your findings; later you will use enormous quantities of juice and soda. His father has tried
phrases. The style here contains phrases appropriate for most write-ups. As everything to get him to eat healthy food, to no avail.
you read through this write-up, you will note some atypical findings. Try to The family has been under substantial stress during the past
test yourself. See if you can interpret these findings. You will also note the year because Eli’s father has been unemployed. Although Eli now
modifications necessary to accommodate reports from the small child’s has Medicaid insurance, the parents are uninsured.
parent, rather than from the child. Eli sleeps through the night.
Medications. One multivitamin daily.
Recording the Pediatric Examination
Past History

4/19/2020 Pregnancy. Uneventful. Dad reduced tobacco intake to a half-pack

Eli is an active, 26-month-old boy accompanied by his father, a day and drank alcohol at times. He denies use of other drugs or
Matthew Nolan, who is concerned about his development and any infections.
behavior. Newborn Period. Born vaginally at 40 weeks; left the hospital in 2
days. Birth weight 2.5 kg (5 lb, 8 oz). Dad does not know why Eli
Source and Reliability: Father.
was small at birth.
Chief Complaint: Slow development and difficult behavior.
Illnesses. Only minor illnesses; no hospitalizations.
History of Present Illness: Eli appears to be developing more
Accidents. Required sutures last year for a facial laceration
slowly than his older sister did. He uses only single words and
simple phrases, rarely combines words, and appears frustrated secondary to a fall on the road. He did not lose consciousness and
with not being able to communicate. People understand less than had no sequelae.
one-quarter of his speech. Physical development seems normal to Preventive Care. Eli has had regular preventive check-ups. At the
the mother: he can throw a ball, kick, scribble, and dress himself last appointment 6 months ago, his regular physician said that Eli
well. He has had no head trauma, chronic illnesses, seizures, or was a bit behind on some developmental milestones and suggested
regression in his milestones. a childcare center that she knew was excellent, as well as
Eli’s dad is also concerned about his behavior. Eli is extremely increased parental attention to reading, speaking, playing, and
stubborn, frequently has tantrums, gets angry easily (especially stimulation. Immunizations are up to date. His lead level was
with his older sister), throws objects, bites, and physically strikes elevated mildly last year and Dad reports that he had “low blood.”
others when he doesn’t get his way. His behavior seems worse His physician recommended iron supplements and foods high in
around his father who reports that he is “fine” at his childcare iron, but Eli really won’t eat these foods.
center. He moves from one activity to another with an inability to sit Family History
still to read or play a game. Of note, he is sometimes affectionate
and cuddly. He does make eye contact and plays normally with Strong family history of diabetes (two grandparents, none with
toys. He has no unusual movements. diabetes as children) and hypertension. No family history of
Eli is an extremely picky eater who eats a large quantity of junk childhood developmental, psychiatric, or chronic illnesses.
food and little else. He will not eat fruits or vegetables and drinks Developmental History: Sat up at 6 months, crawled at 9 months,
and walked at 13 months. First words (“mama” and “car”) said at
approximately 1 year. Respiratory. Frequent cough and whistle in chest. Dad cannot
Personal and Social History: Parents are married and live with the identify trigger; it tends to go away. He can run around all day
two children in a rented apartment. Dad has not had a steady job without seeming to get tired.
for 1 year but has worked intermittently in a gym. Mom works as a Cardiovascular. No known heart disease. He had a murmur when
waitress part-time while Eli is in childcare. younger, but it went away.
Mom had depression during Eli’s first year and attended some Gastrointestinal. Appetite and eating habits described above.
counseling sessions but stopped because she could not pay for Regular bowel movements. He is in the process of toilet training
them or medications. She gets support from her mother who lives and wears pull-ups at night, but not at childcare.
30 minutes away, and many friends, some of whom babysit
occasionally. Urinary. Good stream. No prior urinary tract infections.
Despite substantial family stress, Dad describes a loving and Genital. Normal.
intact family. They try to eat dinner together daily, limit television, Musculoskeletal. He is “all boy” and never gets tired. Minor bumps
read to both children (although Eli won’t sit still), and go to the and bruises occasionally.
nearby park regularly to play.
Neurologic. Walks and runs well; seems coordinated for age. No
Environmental Exposures. Both parents smoke, although generally stiffness, seizures, or fainting. Dad says his memory seems great,
outside the house. but his attention span is poor.
Safety. Dad reports this as a major concern: he can barely leave Psychiatric. Generally, seems happy. Cries easily; bounces back
Eli out of his sight without him getting into something. He fears he and forth from trying to be independent to needing cuddling and
will run under a car; the family is thinking of fencing in their small comforting.
yard. Eli sits in his car seat most of the time; smoke detectors
work in the home. Dad’s guns are locked; medications are in a Physical Examination
cabinet in the parents’ bedroom. General Appearance: Eli is an active and energetic toddler. He
plays with the reflex hammer, pretending it is a truck. He appears
Review of Systems
closely bonded with his father, looking at him occasionally for
General. No major illnesses. comfort. He seems concerned that Eli will break something. His
Skin. Dry and itchy. Last year he was prescribed hydrocortisone clothes are clean.
for it. Vital Signs. Ht 90 cm (90th percentile). Wt 16 kg (>95th
Head, Eyes, Ears, Nose, and Throat (HEENT). Head: No trauma. percentile). BMI 19.8 (>95th percentile). Head circumference 50
Eyes: Vision fine. Ears: Multiple infections in the past year. cm (75th percentile). BP 108/58. Heart rate 90 beats per minute
Frequently ignores parents’ requests; they can’t tell if this is and regular. Respiratory rate 30/min; varies with activity.
purposeful or if he can’t hear well. Nose: Often runny; Dad Temperature (ear) 37.5°C. Obviously no pain.
wonders about allergies. Mouth: No dentist visit yet. Brushes teeth Skin. Normal except for bruises on the anterior aspects of his legs,
sometimes (a frequent source of dispute). and patchy, dry skin over external surface of elbows.
Neck. No lumps. Glands in neck seem large.
HEENT. Head: Normocephalic; no lesions. Eyes: Difficult to motor—Imitates vertical line. Language—Does not combine words;
examine because he won’t sit still. Symmetric with normal single words only, three to four noted during examination.
extraocular movements. Pupils 4 to 5 mm, and symmetrically Personal–social—Washes face, brushes teeth, and puts on shirt.
reactive to light. Discs difficult to visualize; no hemorrhages noted. Overall—Normal, except for language, which appears delayed.
Ears: Normal pinna; no external abnormalities. Normal external Cranial Nerves: Intact, although several difficult to elicit.
canals and tympanic membranes (TMs). Nose: Normal nares; Cerebellar: Normal gait; good balance. Deep tendon reflexes
septum midline. Mouth: Several darkened teeth (inside surface of (DTRs): Normal and symmetric throughout with downgoing toes.
upper incisors). One clear cavity on upper right incisor. Tongue Sensory: Deferred.
normal. Cobblestoning of posterior pharynx; no exudates. Tonsils
large but adequate gap (1.5 cm) between them. No allergic
shiners.
Neck. Supple, midline trachea, no thyroid palpable.
Lymph Nodes. Easily palpable (1.5 to 2 cm), firm, mobile anterior
cervical lymph nodes bilaterally. Small (0.5 cm) nodes in inguinal
canal bilaterally. All lymph nodes mobile and nontender.
Lungs. Good expansion. No tachypnea or dyspnea. Congestion
audible but seems to be upper airway (louder near mouth,
symmetric). No rhonchi, rales, or wheezes. Clear to auscultation.
Cardiovascular. PMI in 4th or 5th interspace and midsternal line. HEALTH PROMOTION AND COUNSELING:
Normal S1 and S2. No murmurs or abnormal heart sounds. Normal
femoral pulses; dorsalis pedis pulses palpable bilaterally. Capillary
EVIDENCE AND RECOMMENDATIONS
refill brisk.
Breasts. Normal, with some fat under both. Children 1 to 4 Years
Abdomen. Protuberant but soft; no masses or tenderness. Liver The AAP and Bright Futures periodicity schedules for children include
span 2 cm below right costal margin (RCM) and not tender. Spleen health supervision visits at 12, 15, 18, and 24 months followed by annual
and kidneys not palpable. Bowel sounds present. visits when the child is 3 and 4 years old.30,34 An additional visit at 30
months is also recommended to assess the child’s development.
Genitalia. Tanner I circumcised penis; no pubic hair, lesions, or
discharge. Testes descended, difficult to palpate because of active During these health supervision visits clinicians address concerns and
cremasteric reflex. Normal scrotum both sides. questions from parents, evaluate the child’s growth and development,
Musculoskeletal. Normal range of motion of upper and lower perform a comprehensive physical examination, and provide anticipatory
extremities and all joints. Spine straight. Gait normal. guidance about healthy habits and behaviors, social competence of
caregivers, family relationships, and community interactions. This is a
Neurologic. Mental Status: Happy, cooperative, active child.
Developmental: Gross motor—Jumps and throws objects. Fine
critical age for preventing childhood obesity as many children begin their Nutrition and exercise
Obesity assessment; healthy meals and snacks
trajectory toward obesity after the age of 2 years. Oral health
Brushing teeth; dentist
It is also important to assess the child’s development. Standardized Parent–Child Interaction
developmental screening instruments are recommended to measure the Reading and fun times, child-directed play, limiting screen time
different dimensions of a child’s development (see p. 944) because Family Relationships
clinicians often fail to identify problems in the general history and Activities, babysitters
Community Interaction
examination.62 Similarly, it is important to differentiate normal (but
Childcare, resources
potentially challenging) childhood behavior from abnormal behavioral or
mental health problems.
Children 5 to 10 Years
Box 25-47 demonstrates the major components of a health supervision visit
for a 3-year-old, stressing health promotion. You do not have to wait for a The AAP and Bright Futures periodicity schedules for children recommend
health supervision visit to address many of these health promotion issues; annual health supervision visits during this period.18
they can be addressed during other types of visits, even when the child is
mildly ill. As for earlier ages, these visits present opportunities to assess the child’s
physical, mental, and developmental health and the parent–child relationship
and the child’s relationships with peers and school performance (Fig. 25-
Box 25-47. Components of a Health Supervision Visit for a 3- 95).
Year-Old
Once again, health promotion should be incorporated into all interactions
Discussions with Parents with children and families. Older children enjoy talking directly with the
Parental concerns 18 examiner. In addition to discussing health, safety, development, and
Providing advice anticipatory guidance with parents, include the child in these conversations
Childcare, school, social
Major topic areas: development, nutrition, safety, oral health, family relationships,
using age-appropriate language and concepts. Discuss the child’s experience
community and perceptions of school, interactions with peers, and other cognitive and
Developmental Assessment social activities.
Assessment of milestones: gross and fine motor, personal–social, language, and
cognitive; use a validated developmental screener.
Physical Examination
Careful examination, including growth parameters with percentiles for age.
Screening Tests
Vision (formal testing starting at age 3 years), hearing (formal testing starting at age 4
years), hematocrit and lead (if high risk), screen for social risk factors
Immunizations
See updated AAP schedule
Anticipatory Guidance
Healthy Habits and Behaviors
Injury and illness prevention
Car seats, poisons, tobacco exposure, supervision
 FIGURE 25-95. As children develop, mental health and peer relationships become FIGURE 25-96. Connecting with children with chronic conditions can positively affect
increasingly important. health outcomes.

Focus on healthy habits such as good nutrition, exercise, reading, stimulating For all children, health promotion involves assessing and promoting the
activities, healthy sleep hygiene, screen time, and safety. About 20% of family’s overall health.
children have some type of chronic physical, developmental, or mental
condition.63 These children should be seen more frequently for monitoring, The specific components of the health supervision visit for older children are
disease management, and preventive care (Fig. 25-96). Some behaviors that the same as the components for younger children. Emphasize school
become established at this age can lead to or exacerbate chronic conditions performance and experiences as well as appropriate and safe sports and
such as obesity or eating disorders. Health promotion is critical to optimize activities and healthy peer relationships.
healthy habits and minimize unhealthy ones. Helping families and children
with chronic diseases deal most effectively with these disorders is a key part
of health promotion. ADOLESCENTS: HEALTH HISTORY
The key to successfully examining adolescents is a comfortable, confidential
environment. This makes the examination more relaxed and informative.

Consider the teen’s cognitive and social development when deciding issues
of privacy, parental involvement, and confidentiality (Fig. 25-97).

Adolescents usually respond positively to anyone demonstrating a genuine

interest in them. Show such interest early and then sustain the connection for
effective communication. Adolescents are more likely to open up when the
interview focuses on them rather than on their problems.
 realistic level. This is particularly true regarding “early bloomers,” who
look older than their age. The reverse can also be true, especially in teens
with delayed puberty or chronic illness.

Issues of confidentiality are important in adolescence. Explain to both

parents and adolescents that the best health care allows adolescents some
degree of independence and confidentiality. It helps if the clinician starts
asking the parent to leave the room for part of the interview when the child is
age 11 to 12 years. This prepares both parents and teens for future visits
when the patient spends time alone with the clinician.

Before the parent leaves, obtain relevant clinical history from him or her,
such as certain elements of past history, and clarify the parent’s agenda for
the visit. Adolescents need to know that you will hold in confidence what
FIGURE 25-97. Trust-building is vital with the adolescent patient.
they discuss with you.

In contrast to most other interviews, start with specific questions to build However, never make confidentiality unlimited. Always state explicitly that
trust and rapport and get the conversation going. You may have to do more you may need to act on information that makes you concerned about safety: “I
talking than usual at the beginning. Chat informally about friends, school, will not tell your parents what we talk about unless you give me
hobbies, and family. Using silence in an attempt to get adolescents to talk or permission, or I am concerned about your safety. For example, if you were
asking about feelings directly is usually not a good idea. to talk to me about hurting yourself or someone else and I thought that you
really were at risk to follow through, I would need to discuss it with others
It is particularly important to use summarization and transitional statements in order to help you.” Familiarize yourself with your relevant laws
and to explain what you are going to do during the physical examination. The regarding confidentiality, reproductive care, and rights of adolescents.
physical examination can also be an opportunity to engage young persons.
Once you have established rapport, return to more open-ended questions. An important goal is to help adolescents bring their concerns or questions to
At that point, make sure to ask what concerns or questions the adolescent may their parents. Encourage adolescents to discuss sensitive issues with their
have. parents and offer to be present or help. Although young people may believe
that their parents would “reject them if they only knew,” you may be able to
Because adolescents are often reluctant to ask their most important questions promote more open dialogue. Occasionally, you will encounter a parent who
(which are sometimes about sensitive topics), ask if the adolescent has is very rigid and punitive. It is important to carefully assess the parents’
anything else to discuss. A useful phrase to use is “tell me what other perspective prior to further discussion, and to obtain the explicit consent of
questions you have.” Another technique is to use the phrase: “other kids the young person.
your age often have questions about . . .”
HEEADSSS Assessment
Adolescents’ behavior is related to their developmental stage and not
necessarily to chronologic age or physical maturation. Their appearance may Obtaining an adequate psychosocial history from an adolescent offers you the
fool you into assuming that they are functioning on a more future-oriented and ability to contextualize their lives. Since most adolescents have minimal
clinical problems, most of their medical issues stem from risky behaviors. Source: Republished with permission of SLACK Incorporated from Smith GL, McGuinness
The HEADSS assessment is a good guide.64 Recently the HEADSS TM. J Psychosoc Nurs Ment Health Serv. 2017;55(5):24–27; permission conveyed through
assessment was expanded to HEEADSSS (or HE2ADS3) to include questions Copyright Clearance Center, Inc.
about eating and safety.65 The acronym stands for Home environment,
Education and employment, Eating, peer-related Activities, Drugs, Sexuality,
Suicide/depression, and Safety from injury and violence.64–66 It is analogous SURVEILLANCE OF DEVELOPMENT: 11 TO
to the “review of systems” and is a valuable tool for assessing the physical, 20 YEARS
emotional, and social well-being of adolescents (Box 25-48).66 The
information you gather can then be used to provide appropriate support for Adolescence can be divided into three stages: early, middle, and late.
your patient. Interview and examination techniques vary widely depending on the
adolescent’s physical, cognitive, and social–emotional levels of
development.
Box 25-48. HEEADSSS Assessment

Category Sample Question Topics Physical Development

Home environment Who lives with you? How long have you lived there? Own Adolescence is the period of transition from childhood to adulthood. The
room? What are relationships like at home? Recent moves physical transformation generally occurs over a period of years, beginning at
or running away?
an average age of 10 years in girls and 11 years in boys. On average, girls
Education and employment School/grade performance—any recent changes?
Suspension, termination, dropping out? Favorite/least
end pubertal development with a growth spurt by age 14 years and boys by
favorite class? Safety at school? age 16 years. The age of onset and duration of puberty vary widely, although
Eating Likes and dislikes about one’s body? Any recent changes in
the stages follow the same sequence in all adolescents. Early adolescents are
your weight or appetite? Any worries about weight? Worries preoccupied with these physical changes.
about having food to eat?
Activities With peers and family? Church, clubs, sports activities? Cognitive Development
Video games? History of arrests, acting out, crime?
Drugs and alcohol Use of tobacco, vaping, alcohol, or drugs by peers, by teen, Although less obvious, cognitive changes during adolescence are as dramatic
by family members? as changes in physique. Most adolescents progress from concrete to formal
Sexuality Orientation? Dated anyone? Kissed anyone? Degree and operational thinking, acquiring an ability to reason logically and abstractly
types of sexual experience and acts? Number of partners? and to consider future implications of current actions (Fig. 25-98).
Sexually transmitted infections, contraception,
pregnancy/abortion?
Although the interview and examination resemble those of adults, keep in
Suicide, depression, and self- Have you thought about hurting yourself or someone else? mind the wide variability in cognitive development of adolescents and their
harm Have you lost interest in things that you used to really
enjoy? often erratic and still limited ability to see beyond simple solutions. Moral
thinking becomes sophisticated with lots of time spent debating issues.
Safety from injury and violence History of accidents, physical or sexual abuse, or bullying?
Concerns about online activities? Violence in home, school, Recent evidence shows that brain development (especially in the right
or neighborhood? Access to firearms? Seatbelt use? prefrontal cortex) probably continues well into the twenties.
Ridden with someone who was drunk or high? Any violence
in school? Where you live? Ever been picked on or bullied?
Ever felt the need to protect yourself?
 helpful health care approaches. Note that there can be a wide variability of
ages at which adolescents go through these stages.

Box 25-49. Developmental Tasks of Adolescence

Task Characteristic Health Care Approaches

Early Adolescence (10- to 14-year-olds)

Physical Puberty (F: 10–14; M: 11–16) Confidentiality; privacy
Cognitive Concrete operational Emphasis on short-term
Social identity Am I normal? Peers increasingly Reassurance and positive attitude
important
Independence Ambivalence (family, self, peers) Support for growing autonomy

Middle Adolescence (15- to 16-year-olds)

Physical Females more comfortable, males Support if patient varies from
often awkward normal
Cognitive Transition; many ideas, often highly Problem solving; decision making,
emotional thinker increased responsibility
Social identity Who am I? Much introspection; Nonjudgmental acceptance
global issues, sexuality
Independence Limit testing; experimental Consistency; limit setting
behaviors; dating
FIGURE 25-98. Rapid physical changes during adolescence provide wonderful
opportunities for new activities. Late Adolescence (17- to 20-year-olds)
Physical Adult appearance Minimal unless chronic illness

Social and Emotional Development Cognitive Formal operational (for many but Approach as an adult
not all)
Adolescence is a tumultuous time, marked by the transition from family- Social identity Role with respect to others; Encouragement of identity to allow
dominated influences to increasing autonomy and peer influence (Fig. 25-99). sexuality; future growth; safety and healthy decision-
making
The struggle for identity, independence, and eventually intimacy can lead to Independence Separation from family; toward real Support, anticipatory guidance
independence
stress, health-related problems, and high-risk behavior. This struggle also
provides an important opportunity for health promotion.

Box 25-49 demonstrates common developmental tasks or achievements of

adolescence, typical characteristics you might note during the history, and
 LGBTQ youth reported that their clinician knew that they were LGBTQ.69,70
When initiating this conversation, it is important that the clinician emphasize
and practice confidentiality to allow for a more open discussion. It is not the
role of the clinician to inform parents or guardians about a teenager’s sexual
or gender identity, as doing so could expose the youth to harm.71

It is important to understand that being LGBTQ is not abnormal and is not

inherently a risk factor for high-risk behaviors or adverse health outcomes.
Many LGBTQ youth experience discrimination and are negatively impacted
by the presence of stigma from homophobia, transphobia, and heterosexism.
This can damage the emerging self-image of an LGBTQ youth and result in
psychological distress and an increase in high-risk behaviors. Ostracism,
bullying, and parental rejection remain common and can lead to physical and
emotional abuse and the possibility of homelessness. This is often associated
with health disparities and may result in poor health outcomes in the areas of
mental health and suicide risk, substance abuse, and STIs.67 Clinicians
FIGURE 25-99. In adolescence, peers often become more influential than family. should be aware of these disparities and appropriately screen for signs of
bullying, depression and suicide risk, as well as help adolescents identify
their protective factors and strengths and build upon their existing talents.18
Gender and Sexual Identity Formation
Studies show that with the necessary support and guidance, LGBTQ youth
among Adolescents are quite resilient and are able to develop as adults with sexual and gender
Discussing sexuality and gender may be difficult for adolescents and young identities that are associated with little or no significant increase in high-risk
adults, and many struggle with their sexual attractions and identity formation. behaviors compared with peers.72
Clinicians must create a welcoming, supportive, confidential and
nonjudgmental environment for adolescents to talk about their emerging
sexual identity and concerns about their sexual activities or feelings. In 2017, PHYSICAL EXAMINATION: GENERAL
the CDC’s national Youth Risk Behavior Survey found that of 118,803 high APPROACH
school students, 2.4% of youth identified as gay/lesbian, 8% as bisexual, and
4.2% were not sure of their sexual orientation. It also found that 1.8% of The sequence and content of the physical examination of the adolescent are
youth identified as transgender.67 Similarly, in 2016, the Minnesota Student similar to those in the adult. Keep in mind, however, issues unique to
Survey of 80,929 students in 9th and 11th grades found that 2.7% of students adolescents such as puberty, growth, development, family and peer
labeled their gender identity as transgender or gender nonconforming.68 relationships, sexuality, healthy decision making, and high-risk behaviors.
Research shows lesbian, gay, bisexual, transgender, and queer (LGBTQ) As in middle childhood, modesty is important. The patient should remain
youth value the opportunity to discuss their gender and sexuality with their dressed until the examination begins (Fig. 25-100). Leave the room while the
clinician, but they often delay disclosing their sexuality until the clinician has patient puts on a gown. Not all adolescents are willing to don a gown, so
built a trusting relationship with the patient. One study found that only 35% of partially uncovering as the examination proceeds to preserve the patient’s
modesty is important. Most adolescents older than 13 years prefer to be Vital Signs
examined without a parent in the room, but this depends on the patient’s
developmental level, familiarity with the examiner, relationship with the Ongoing evaluations of blood pressure are important for adolescents.63 The
parent, and culture. Ask younger adolescents and their parent their average heart rate from age 10 to 14 years is 85 beats per minute, with a
preferences. In fact, it is safest to have a chaperone in the room regardless of range of 55 to 115 beats per minute considered normal. Average heart rate
patient gender when examining a patient’s breasts or genitalia. It is best to for those 15 years and older is 60 to 100 beats per minute. Percentiles for
discuss the issue of chaperones with patients/parents and record the shared blood pressure are shown on p. 951.
decision in the clinical chart; some U.S. states and many organizations.73 Causes of sustained hypertension for this age group include
primary hypertension, renal parenchymal disease, and drug
use.

Skin
Examine the adolescent’s skin carefully. Many adolescents will have
concerns about various skin lesions, such as acne, dimples, blemishes, warts,
and moles. Pay particular attention to the face and back in examining
adolescents for acne. Stretch marks have become more common with the
epidemic of obesity.
Adolescent acne, a common skin condition, tends to resolve
eventually, but often benefits from proper treatment. It tends to
FIGURE 25-100. Some adolescents will request to remain in their clothes.
begin during middle to late puberty.

Many adolescents spend considerable time in the sun and at tanning salons.
TECHNIQUES OF EXAMINATION You may detect this during a comprehensive health history or by noticing
signs of tanning during the physical examination. This is a good opportunity
to counsel adolescents about the dangers of excessive ultraviolet exposure,
Somatic Growth: Height and Weight
the need for sunscreen, and the risks of tanning salons.
Adolescents should wear gowns to be weighed or have them remove their
See Table 25-3, “Warts, Lesions That Resemble Warts, and
shoes and heavy clothing. This is particularly important for adolescents being
Other Raised Lesions,” on p. 1064. Moles or benign nevi may
evaluated for underweight problems. Ideally, serial weights (and heights)
appear during adolescence.
should use the same scale.
Both obesity and eating disorders (anorexia and bulimia) are Counsel older adolescents to begin performing a regular self-examination of
major public health problems requiring regular assessments of the skin, as shown on p. 1046.
weight, monitoring for complications, and promoting healthy
choices and self-concept. Head, Eyes, Ears, Nose, Mouth, and Neck
The examination of these body parts is generally the same as for adults. The Preadolescent: elevation of nipple only
methods used to examine the eye, including testing for visual acuity, are the Stage 2
same as those for adults. Refractive errors become common, and it is
important to test visual acuity monocularly at regular intervals, such as
during the annual health supervision visit.

The ease and techniques of examining the ears and testing the hearing
approach the methods used for adults. There are no ear, mouth, throat, or
neck abnormalities or variations of normal unique to this age group.
An adolescent with persistent fever, sore throat, swollen tonsils,
and cervical lymphadenopathy may have streptococcal
pharyngitis or infectious mononucleosis. Breast bud stage: elevation of breast and nipple as a small mound; enlargement of areolar
diameter
Stage 3
Thorax and Lungs
The technique for examining the lungs of adolescents is the same as the
technique for adults.

Breasts
Physical changes in a girl’s breasts are one of the first signs of puberty. As in
most developmental changes, there is a systematic progression. Generally,
over a 4-year period, the breasts progress through five stages, called Tanner
stages or Tanner sex maturity rating stages, as shown in Box 25-50. Breast
buds in the preadolescent stage enlarge, changing the contour of the breasts Further enlargement of elevation of breast and areola, with no separation of their contours
and areola. The areola also darkens in color. These stages are accompanied Stage 4
by the development of pubic hair and other secondary sexual characteristics,
as shown on p. 1025. Menarche usually occurs when a girl is in breast stage
3 or 4. By then, she has passed her peak growth spurt (see Box 25-50).
Breast buds (pea-size firm masses inferior to the nipple) are
common among both girls and boys entering puberty or during
early puberty. They are benign.

Box 25-50. Sexual Maturity Ratings in Girls: Breasts

Projection of areola and nipple to form a secondary mound above the level of breast
Stage 1 Stage 5
 embarrassing. It often resolves in a few years.
Masses or nodules in the breasts of adolescent girls should be
examined carefully. They are usually benign fibroadenomas or
cysts; less likely, etiologies include abscesses or lipomas. Breast
carcinoma is extremely rare in adolescence and nearly always
occurs in families with a strong history of the disease.78

Breasts in boys consist of a small nipple and areola. During puberty, about
one-third of boys develop a breast bud 2 cm or more in diameter, usually in
Mature stage: projection of nipple only; areola has receded to general contour of the breast
(although in some normal individuals the areola continues to form a secondary mound) one breast. Boys who are obese may develop substantial breast tissue.
Source: Photos republished with permission of American Academy of Pediatrics from
Bourdony CJ et al. Assessment of Sexual Maturity Stages in Girls. Elk Grove Village: American Heart
Academy of Pediatrics, 1995; permission conveyed through Copyright Clearance Center, Inc.
The technique and sequence of examination are the same as those for adults.
For years, the normal range for onset of breast development and pubic hair Murmurs are a continued cardiovascular issue for evaluation.
was 8 to 13 years (average, 11 years), with earlier onset considered
abnormal.7–76 Some studies suggest that the lower age cutoff should be as The benign pulmonary flow murmur is a grade I–II/VI soft, non-harsh
low as age 7 years for white girls and 6 years for African American and murmur with the timing characteristics of an ejection murmur, beginning after
Hispanic girls. Breast development varies by age, race, and ethnicity.74,76 the first sound and ending before the second sound, but without the marked
Breasts develop at different rates in approximately 10% of girls, with crescendo–decrescendo quality of an organic ejection murmur (Box 25-51).
resultant asymmetry of size or Tanner stage. Reassurance that this generally If you hear this murmur, evaluate whether the pulmonary closure sound is of
resolves is helpful to the patient. normal intensity and whether splitting of the second heart sound is eliminated
during expiration. An adolescent with a benign pulmonary ejection murmur
Breast asymmetry is common in adolescents, particularly when will have normal intensity and normally split S2.
adolescents are between Tanner stages 2 and 4. This is nearly
always a benign condition. A pulmonary flow murmur accompanied by a fixed split second
heart sound suggests right-heart volume load such as an atrial
Guidelines for the usefulness of clinical breast examinations by a clinician septal defect.
are changing, and the American Cancer Society no longer recommends
clinical breast examinations for women of any age to screen for breast The pulmonary flow murmur may also be heard in the presence of volume
cancer.77 However, professional organizations consistently recommend overload from any cause such as chronic anemia and following exercise. It
providing female patients with instructions for self-examination (see p. may persist into adulthood.
1046). It is useful to begin this process with adolescent females. In the event
of a clinical breast examination, a chaperone (parent or nurse) should assist Box 25-51. Location and Characteristics of Benign Heart
male or all clinicians.
Murmurs in Adolescents
Many adolescent boys develop gynecomastia (enlarged breasts)
on one or both sides. Although usually slight, it can be
 Spenomegaly in an adolescent who has had sore throat and
fever, may be a sign of infectious mononucleosis.

Male Genitalia
The genital examination of the adolescent boy proceeds like the examination
of the adult male. Be aware of the embarrassment many boys experience
during this aspect of the examination. Important anatomical changes in the
male genitalia accompany puberty and help to define its progress. The first
reliable sign of puberty (Fig. 25-101), starting between ages 9 and 13.5 years
is an increase in the size of the testes. Next, pubic hair appears, along with
progressive enlargement of the penis. The complete change from
preadolescent to adult anatomy requires about 3 years, with a range of 1.8 to
5 years.
Delayed puberty is suspected in boys who have no signs of
pubertal development by 14 years of age.
Typical Age Name Characteristics Description and
Location
An axiom of development is that pubertal changes follow a well-established
Older child, Pulmonary flow Grade I–II/VI soft, sequence. The age range for start and completion is wide, but the sequence
adolescence and later murmur nonharsh
Ejection in timing for each boy is the same (see Fig. 25-101). This progression is helpful when
Upper left sternal border counseling anxious adolescents about current and future maturation and the
Normal P2
wide range of normal for puberty.

Abdomen
Techniques of abdominal examination are the same as for adults. The size of
the liver approaches the adult size as the teen progresses through puberty and
is related to the adolescent’s overall height. Although data are lacking about
the usefulness of different techniques to assess liver size, it is likely that
evidence from adult studies apply, particularly for older adolescents. Palpate
the liver. If it is nonpalpable, hepatomegaly is highly unlikely. If you can
palpate the lower edge, use light percussion to assess liver span.
Hepatomegaly in teens may be from infections such as hepatitis
or infectious mononucleosis, inflammatory bowel disease, or
tumors.
 In addition to constitutional delay, less common causes of
delayed puberty in boys include primary or secondary
hypogonadism as well as congenital GnRH deficiency.79

Box 25-52. Sexual Maturity Rating in Boys

FIGURE 25-101. Pubertal changes in male adolescents.

When examining the adolescent male, assign a sexual maturity rating. The
five stages of sexual development, first described by Tanner, are outlined and
illustrated in Box 25-52. These involve changes in the penis, testes, and
scrotum. In about 80% of men, pubic hair spreads farther up the abdomen in a
triangular pattern pointing toward the umbilicus; this phase is not completed
until the 20s.
The most common cause of delayed puberty in males is
constitutional delay, frequently a familial condition involving
delayed bone and physical maturation, but normal hormonal
levels.
Although nocturnal or daytime ejaculation tends to begin around
Sexual Maturity Rating 3, a finding on either history or physical
examination of penile discharge may indicate a sexually
transmitted infection. Observe the penis for sores and discharge as you would in an adult male.
In uncircumcised males, the foreskin should be easily retractable by benign, but may occasionally be associated with polycystic ovary
adolescence. This is also an opportunity to discuss normal hygiene. Discuss syndrome, insulin resistance, and metabolic syndrome.
testicular examination in older boys by age 18 years.
Assign a sexual maturity rating to every female, irrespective of chronologic
Female Genitalia age. The assessment of sexual maturity in girls is based on both growth of
pubic hair and the development of breasts.75 The sexual maturity rating of
The external examination of adolescent female genitalia proceeds in the same pubic hair growth is shown in Box 25-53. Counsel girls about this sequence
manner as for school-aged children. If clinically necessary to perform a and their current stage.
pelvic examination, the technique is the same as for an adult female. Of note,
indications for performing pelvic examinations in adolescents have become See p. 979 for breast development assessment.
much more stringent. When performing a pelvic examination, a full Delayed puberty (no breasts or pubic hair development by age
explanation of the steps of the examination, demonstration of the instruments, 12 years) is usually caused by inadequate gonadotropin
and a gentle, reassuring approach are necessary because the adolescent is secretion from the anterior pituitary due to defective
usually quite anxious. A chaperone (parent or nurse) must be present. hypothalamic GnRH production. A common cause is anorexia
Vaginal discharge in a young adolescent should be treated as in nervosa.
the adult. Causes include physiologic leukorrhea, sexually
transmitted infections from consensual sexual activity or sexual Box 25-53. Sexual Maturity Ratings in Girls: Pubic Hair
abuse, bacterial vaginosis, foreign body, and external irritants.
Stage 1
An adolescent’s first pelvic examination should be performed by an Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the
experienced health care provider. Routine pelvic examination is not abdomen
recommended for adolescents. Stage 2 Stage 3

A girl’s initial signs of puberty are hymenal thickening and redundancy

secondary to estrogen, widening of the hips, and beginning of a height spurt,
although these changes are difficult to detect.

The first easily detectable sign of puberty is usually the appearance of breast
buds although pubic hair sometimes appears earlier. The average age of the
appearance of pubic hair has decreased in recent years, and current
consensus is that the appearance of pubic hair as early as 7 years can be
normal, particularly in dark-skinned girls who develop secondary sexual
characteristics at an earlier age.
Pubertal development prior to the normal age range may signify
precocious puberty which has a variety of endocrine and central Darker, coarser, curlier hair, spreading
Sparse growth of long, slightly pigmented, sparsely over the pubic symphysis
nervous system causes. Premature adrenarche is usually
downy hair, straight or only slightly curled,
chiefly along the labia development in an extremely thin adolescent girl are anorexia
Stage 4 Stage 5 nervosa and chronic disease.

Coarse and curly hair as in adults; area Hair adult in quantity and quality, spreads on
covered greater than in stage 3 but not as the medial surfaces of the thighs but not up
great as in the adult and not yet including the over the abdomen
thighs
Source: Photos republished with permission of American Academy of Pediatrics from
Bourdony CJ et al. Assessment of Sexual Maturity Stages in Girls. Elk Grove Village: American
Academy of Pediatrics, 1995; permission conveyed through Copyright Clearance Center, Inc.
FIGURE 25-102. Pubertal changes in female adolescents.
Amenorrhea in adolescence can be primary (no menarche by
age 16 years) or secondary (cessation of menses in an Obesity in females can be associated with early onset of
adolescent who had previously menstruated). While primary puberty.
amenorrhea is usually due to anatomic or genetic causes,
secondary amenorrhea can be due to a variety of etiologies such Rectum and Anus
as stress, excessive exercise, and eating disorders.
The examination of the rectum and anus is the same as for adults. Routine
Although there is a wide variation in the age of onset and completion of rectal examination is not recommended for adolescents unless there is a
puberty in girls, the stages occur in a predictable sequence, as shown in particular concern.
Figure 25-102.
Delayed puberty in an adolescent female below the third Musculoskeletal System
percentile in height may be from Turner syndrome or chronic Evaluations for scoliosis and screening for participation in sports (pp.
disease. The two most common causes of delayed sexual 1057–1059) remain common components of examination in adolescents.
Other segments of the musculoskeletal examination are the same as for adults.
Assessing for Scoliosis.
First, examine the patient standing assessing symmetry of shoulders, scapula,
and hips. Then have the child bend forward with the knees straight and head
hanging straight down between extended arms (Adams forward bend test).
Next, evaluate any asymmetry in positioning.
Scoliosis in a young child is unusual and abnormal; mild scoliosis
in an older child occurs in 2% to 4% of adolescents. Scoliosis
appears as an asymmetrical rise in the thoracic region (as shown
in Fig. 25-103) or lumbar region, or both.
If you detect scoliosis use a scoliometer to test for the degree of scoliosis.
Ask the adolescent to bend forward again as previously described. Place the
scoliometer over the spine at a point of maximum prominence making sure
that the spine is parallel to the floor at that point, as shown in Figure 25-103.
If needed, move the scoliometer up and down the spine to find the point of
maximal prominence. An angle greater than 7 degrees on the scoliometer is a
reason for concern and often used as a threshold for referral to a specialist.
Of note, the sensitivity and specificity of both the Adams forward bend test
and scoliometer vary greatly according to the skill and experience of the
examiner.

FIGURE 25-103. Measure and record scoliosis with a scoliometer.

Several types of scoliosis may present during childhood.

Idiopathic scoliosis (75% of cases), seen mostly in girls, is
usually detected in early adolescence. As seen in the adolescent
girl in Figure 25-103, the right hemithorax is generally more
prominent. Other causes include neuromuscular and congenital.

You can also use a plumb line, a string with a weight attached, to assess
symmetry of the back (Fig. 25-104). Place the top of the plumb line at C7 and
have the child stand straight. The plumb line should extend to the gluteal
crease (not shown).
 medical history focusing on cardiovascular risk factors, prior surgeries,
prior injuries, other medical problems, and a family history.

In fact, a complete history is the most sensitive and specific part of the
evaluation for detection of risk factors or abnormalities that would preclude
participation in sports. The preparticipation physical evaluation is often one
of the few times a healthy adolescent will see a clinical professional, so it is
important to include some screening questions and anticipatory guidance (see
the discussion in Health Promotion and Counseling, pp. 1060–1061). Finally,
perform a general physical examination, with special attention to the heart
and lungs and a vision and hearing screening. Include a focused, thorough
musculoskeletal examination, looking for weakness, limited range of motion,
and evidence of previous injury.
Important risk factors for sudden cardiovascular death during
sports include episodes of dizziness or palpitations, prior
syncope (particularly if associated with exercise), or family
history of sudden death or cardiomyopathy in young or middle-
aged relatives.

During the preparticipation sports physical examination, assess carefully for

cardiac murmurs and wheezing in the lungs. Also, if the adolescent has had
FIGURE 25-104. Measuring scoliosis with a plumb line.
head injuries or a concussion,80 perform a careful, focused neurologic
examination.81,82
Scoliosis is more common among children and adolescents with
neurologic or musculoskeletal abnormalities. A 2-minute preparticipation screening musculoskeletal examination shown in
Box 25-54 has been recommended by some experts.81,82
Apparent scoliosis, including an abnormal plumb line test, can be
caused by a leg-length discrepancy (see p. 1031).
Box 25-54. Screening Musculoskeletal Examination for Sports
The remainder of the musculoskeletal examination is similar to that for
adults, except for the sports preparticipation screening examination Position and Instruction to Patient
described below. Step 1: Stand straight, facing forward. Note Step 2: Move neck in all directions. Note for
for any asymmetry or swelling of joints. any loss of range of motion.
Sports Preparticipation Physical Evaluation.
Millions of children and adolescents participate in organized sports and
often require “medical clearance.” Start the evaluation with a thorough
Step 3: Shrug shoulders against resistance. Step 4: Hold arms out to the side against
Note for any weakness of shoulder, neck, resistance, and actively raise arms over
or trapezius muscles. the head. Note for any loss of strength of
deltoid muscle.
Step 7: Hold arms down, bend elbows 90 Step 8: Make a fist, clench, and then spread
degrees, and pronate and supinate fingers. Note for protruding knuckle,
forearms. Note for any reduced range of reduced range of motion of fingers from
motion from prior injury to forearm, elbow, prior sprain or fracture.
or wrist.

Step 5: Hold arms out to side with elbows Step 6: Hold arms out, completely bend, and
bent 90 degrees; raise and lower arms. straighten elbows (should be able to
Note for any loss of external rotation and easily touch the shoulder). Note for any
injury of glenohumeral joint. reduced range of motion of elbow.
Step 9: Squat and duck-walk for four steps Step 10: Stand straight with arms at sides,
forward. Note for inability to fully flex facing back. Check whether shoulders,
knees and difficulty standing up from prior scapula, and hips are even. Note for
knee or ankle injury. asymmetry from scoliosis, leg-length
discrepancy, or weakness from prior Nervous System
injury.
The neurologic examination of the adolescent and the adult is the same.
Assess the adolescent’s developmental achievement according to age-
specific milestones, as described on pp. 936–939.

RECORDING YOUR FINDINGS

The format of the clinical record is the same for both children and adults.
Although the sequence of the physical examination may vary, convert your
clinical findings into the same order of the traditional written or electronic
format.

Initially, you may use sentences to describe your findings; later you will use
phrases. The style here contains phrases appropriate for most write-ups. As
you read through this write-up, you will note some atypical findings. Try to
test yourself. See if you can interpret these findings. You will also note the
Step 11: Bend forward with knees straight Step 12: Stand on heels and rise to the toes. modifications necessary to accommodate reports from the small child’s
and touch toes. Note any asymmetry from Note any wasting of calf muscles from parent, rather than from the child.
scoliosis and twisting of back from low prior ankle or Achilles tendon injury.
back pain.
The write-up of the note for the history and physical examination of the
adolescent mirrors that of the adult or younger child (p. 993). Remember to
include the key elements of the HEEADSSS evaluation in the history section
of the write-up.

HEALTH PROMOTION AND COUNSELING:

EVIDENCE AND RECOMMENDATIONS
The AAP recommends annual health supervision visits for adolescents.18 Be
sure to include health promotion during all health encounters with youth.
Adolescents with chronic problems or high-risk behaviors may require
additional visits for health promotion and anticipatory guidance. FIGURE 25-105. Inquire about and encourage adolescents to participate in healthy
activities.
Most chronic diseases of adults have their antecedents in childhood or
adolescence. For example, obesity, cardiovascular disease, addiction (to Because some health promotion topics involve confidential issues such as
drugs, tobacco, or alcohol), and depression are all influenced by childhood mental health, addiction, sexual behavior, and eating disorders, speak to
and teen experiences and by behaviors established during adolescence. For adolescents (particularly older youth) privately during part of a visit that
example, most obese adults were obese as adolescents or had abnormal involves health supervision. Self-completed screening questionnaires can be
indicators such as elevated BMI scores. As a second example, almost all completed before the visit to facilitate comprehensive assessment of youth
adults who are addicted to tobacco began their tobacco habits before 18 risk behaviors. This approach saves time so that you can better address the
years. Therefore, a major component of health promotion for adolescents specific risk behaviors the adolescent endorses during the visit. The AAP’s
includes discussions about health behaviors or habits (Fig. 25-105). Bright Futures has guidelines for preventive services for adolescents
Effective health promotion can help patients develop healthy habits and (Box 25-55).18
lifestyles and avoid several chronic health problems.
Box 25-55. Components of a Health Supervision Visit for
Adolescents Ages 11 to 18 Years

Discussions with Parents Immunizations

Address parent concerns See schedule from the AAP
Provide advice about supervision, Anticipatory Guidance—Teen
encouraging progressively responsible Promote Healthy Habits and Behaviors:
decision making Injury and illness prevention
Ask about school, activities, social Seat belts, drunk driving, helmets,
interactions sun, weapons
Assess youth’s behaviors and habits,
Nutrition
mental health
Healthy meals/snacks, obesity
Discussions with Adolescent
prevention
 Social and Emotional: mental health, Oral health: dentist, brushing SVT in infants is usually sustained, requiring clinical therapy for conversion to a normal
friends, family, gender identity Physical activity and screen time rate and rhythm. In older children, it is more likely to be truly paroxysmal, with episodes of
Physical Development: puberty, self- Sexuality: varying duration and frequency.
concept Confidentiality, sexual behaviors,
Behaviors and Habits: nutrition, exercise, safer sex, contraception if needed Hypertension in Childhood—A Typical Example
TV or computer screen time, drugs, High-Risk Behaviors:
alcohol, tobacco, e-cigarettes, sleep
Prevention strategies
Relationships and Sexuality: dating,
Parent–teen interaction, peer
sexual activity, sexual orientation, forced
interactions
sex
Communication, rules
Family Functioning: relations with parents
Social Achievement:
and siblings
School Performance: activities, Activities, school, future
strengths, goals Community interaction
Resources, involvement
Physical Examination
Anticipatory Guidance—Parent
Perform a careful examination; note
growth parameters, sexual maturity Positive interactions, support, safety, limit
ratings setting, family values, modeling
behaviors, increased responsibility
Screening Tests
Vision and hearing, blood pressure;
consider hematocrit (in females); assess
emotional health and risk factors (using a
validated instrument)
Hypertension can start in childhood.30 Although elevated blood pressure in young children
is more likely to have a renal, cardiac, or endocrine cause, older children and adolescents
with hypertension are most likely to have primary or essential hypertension.
Table 25-1. Abnormalities in Heart Rhythm and Blood
This child developed hypertension, and it “tracked” into adulthood. Children tend to remain
Pressure in the same percentile for blood pressure as they grow. This tracking of blood pressure
continues into adulthood, supporting the concept that adult essential hypertension often
begins during childhood.
Supraventricular Tachycardia
The consequences of untreated hypertension can be severe and include cardiac, renal,
and visual sequelae.

Table 25-2. Common Skin Rashes and Skin Findings

in Newborns and Infants

Paroxysmal supraventricular tachycardia (PSVT) is the most common dysrhythmia in

children. Some infants with SVT look well or may be somewhat pale with tachypnea but
have a heart rate of ≥220 beats per minute. Others are ill and in cardiovascular collapse.
P waves have different morphology or are not seen.
 Seborrhea
The salmon red, scaly eruption often involves the face, neck, axilla, diaper area, and behind
Erythema Toxicum the ears.
These common yellow or white pustules are surrounded by a red base.

Atopic Dermatitis (Eczema)

Neonatal Acne
Erythema, scaling, dry skin, and intense itching characterize this condition.
Red pustules and papules are most prominent over the cheeks and nose of some normal
newborns.
 This bright red rash involves the intertriginous folds, with small “satellite lesions” along the
edges.

Contact Diaper Dermatitis

This irritant rash is secondary to diarrhea or irritation and is noted along contact areas
(here, the area touching the diaper).

Neurofibromatosis
Characteristic features include more than 5 café-au-lait spots and axillary freckling. Later
findings include neurofibromas and Lisch nodules (not shown).
Impetigo
This infection is due to bacteria and can appear bullous or crusty and yellowed with some
pus.

Source of photos: Erythema Toxicum—White AJ. The Washington Manual of Pediatrics,

2nd ed. Wolters Kluwer; 2017, Fig. 15-1; Seborrhea—Salimpour RR et al. Photographic
Atlas of Pediatric Disorders and Diagnosis. Wolters Kluwer; 2014, Fig. 5-8a; Atopic
Dermatitis—Lippincott’s Nursing Advisor 2011. Wolters Kluwer; 2011, Fig. 48-1; and
Goodheart HP, Gonzalez M. Goodheart’s Photoguide of Common Skin Disorders, 2nd ed.
Wolters Kluwer; 2003, Fig. 2-11.

Table 25-3. Warts, Lesions That Resemble Warts, and

Candidal Diaper Dermatitis
Other Raised Lesions
Verruca Vulgaris
Dry, rough warts on hands Molluscum Contagiosum
Dome-shaped, fleshy lesions with central umbilication.

Verruca Plana
Small, flat warts

Adolescent Acne
Plantar Warts Acne in adolescents involves open comedones (blackheads) and closed comedones
(whiteheads) shown at the left, and inflamed pustules (right).
Tender warts on feet
Source of photos: Molluscum Contagiosum—Fleisher GR et al. Atlas of Pediatric
Emergency Medicine. Lippincott Williams & Wilkins; 2004, Fig. 6-25.
 This pruritic, allergic sensitivity reaction changes shape quickly.
Table 25-4. Common Skin Lesions during Childhood

Insect Bites
Intensely pruritic, red, distinct papules characterize these lesions.

Scabies
Intensely itchy papules and vesicles, sometimes burrows, most often on extremities.
Tinea Capitis
Scaling, crusting, and hair loss are seen in the scalp, along with a painful plaque (kerion)
and occipital lymph node (arrow).

Tinea Corporis
This annular lesion has central clearing and papules along the border.

Urticaria (Hives)
 Although not present at birth, cephalohematomas appear within the first 24 hours from
subperiosteal hemorrhage involving the outer table of one of the cranial bones. The
swelling, shown at the arrow, does not extend across a suture though it is occasionally
bilateral following a difficult birth. The swelling is initially soft, then develops a raised bony
margin within a few days from calcium deposits at the edge of the periosteum. It tends to
resolve within several weeks.

Pityriasis Rosea
Oval lesions on trunk, in older children, often in a Christmas tree pattern, sometimes a
herald patch (a large patch that appears first).

Source of Bites, Tinea Capitis, and Tinea Corporis photos—Goodheart HP, Gonzalez ME.
Goodheart’s Photoguide to Common Pediatric and Adult Skin Disorders. 4th ed. Wolters
Kluwer; 2016, Figs. 9-11, 18-8, and 29-2; Urticaria—Chung EK et al. Visual Diagnosis and
Treatment in Pediatrics. 3rd ed. Wolters Kluwer; 2015, Fig. 64-1; Scabies—Courtesy of
Ronald W. Cotliar, MD; Pityriasis Rosea—Fleisher GR et al. Atlas of Pediatric Emergency
Medicine. Lippincott Williams & Wilkins; 2004, Fig. 6-23b.

Table 25-5. Abnormalities of the Head

Hydrocephalus
In hydrocephaly, the anterior fontanelle is bulging, and the eyes may be deviated downward
revealing the upper sclerae and creating the setting sun sign, as shown on the left.

Cephalohematoma
 Table 25-6. Diagnostic Facies in Infancy and
Childhood
Fetal Alcohol Syndrome

Babies born to women with chronic alcoholism are at increased risk for growth deficiency,
microcephaly, and intellectual disability. Facial characteristics include short palpebral
Craniosynostosis fissures, a wide and flattened philtrum (the vertical groove in the midline of the upper lip),
and thin lips.
Craniosynostosis is a condition of premature closure of one or more sutures of the skull. Congenital Syphilis
This results in an abnormal growth and shape of the skull because growth will occur
across sutures that are not affected but not across sutures that are affected.
The figures demonstrate different skull shapes associated with the various types of
craniosynostosis. The prematurely closed suture line is noted by the absence of a suture
line in each figure. Scaphocephaly and frontal plagiocephaly are the most common forms
of craniosynostosis. The blue shading shows areas of maximal flattening. The red arrows
show the direction of continued growth across the sutures, which is normal.

Source of photos: Cephalohematoma—Chung EK et al. Visual Diagnosis and Treatment in

Pediatrics. 3rd ed. Wolters Kluwer; 2015, Fig. 2-6; Hydrocephalus—Fleisher GR et al.
Atlas of Pediatric Emergency Medicine. Lippincott Williams & Wilkins; 2004, Fig. 14.4.
 The child with congenital hypothyroidism has coarse facial features, a low-set hair line,
sparse eyebrows, and an enlarged tongue. Associated features include a hoarse cry,
umbilical hernia, dry and cold extremities, myxedema, mottled skin, and intellectual
disability. Since most infants with congenital hypothyroidism have no physical stigmata, the
United States and many other nations screen all newborns for congenital hypothyroidism.
Facial Nerve Palsy

In utero infection by Treponema pallidum usually occurs after the 16th week of gestation
and affects virtually all fetal organs. If it is not treated, the mortality rate is quite high. Signs
of illness appear in survivors within the first month of life. Facial stigmata often include
bulging of the frontal bones and nasal bridge depression (saddle nose), both from
periostitis; rhinitis from weeping nasal mucosal lesions (snuffles); and a circumoral rash.
Mucocutaneous inflammation and fissuring of the mouth and lips (rhagades), not shown
here, may also occur as stigmata of congenital syphilis, as may craniotabes tibial periostitis
(saber shins) and dental dysplasia (Hutchinson teeth—see p. 437).
Congenital Hypothyroidism Peripheral (lower motor neuron) paralysis of the facial nerve may be from (1) an injury to
the nerve from pressure during labor and birth, (2) inflammation of the middle ear branch of
the nerve during episodes of acute or chronic otitis media, or (3) unknown causes (Bell
palsy). The nasolabial fold on the affected left side is flattened, and the eye does not close.
This is accentuated during crying, as shown here. Full recovery occurs in most children.
Down Syndrome
 The child suffering from perennial allergic rhinitis has an open mouth (cannot breathe
through the nose) and edema and discoloration of the lower orbitopalpebral grooves
(“allergic shiners”). Such a child is often seen to push the nose upward and backward with
a hand (“allergic salute”) and to grimace (wrinkle the nose and mouth) to relieve nasal
itching and obstruction.
The child with Down syndrome (trisomy 21) usually has a small, rounded head, a flattened Nonaccidental Trauma
nasal bridge, oblique palpebral fissures, prominent epicanthal folds, small, low-set, shell-
like ears, and a relatively large tongue. Associated features include generalized hypotonia,
transverse palmar creases, shortening and incurving of the fifth fingers (clinodactyly),
Brushfield spots (see p. 1069), and mild to moderate cognitive impairment.
Perennial Allergic Rhinitis
 Thyrotoxicosis (Graves disease) occurs in approximately 2 per 1,000 children younger than
10 years. Affected children exhibit tachycardia, hypermetabolism, and accelerated linear
growth. Facial characteristics shown in this 6-year-old girl are “staring” eyes (not true
exophthalmos, which is rare in children) and an enlarged thyroid gland (goiter).

Table 25-7. Abnormalities of the Eyes, Ears, and

Mouth

The child who has been physically abused may have old and fresh bruises on the head and
face. Other stigmata include bruises in areas (axilla and groin) not usually subject to injury
rather than the bony prominences; x-ray evidence of fractures of the skull, ribs, and long
bones in various stages of healing; and skin lesions that are morphologically similar to
implements used to inflict trauma (hand, belt buckle, strap, rope, coat hanger, or lighted
cigarette).
Hyperthyroidism
Brushfield Spots
These abnormal speckling spots on the iris suggest Down syndrome.
 Oral Candidiasis (“Thrush”)
This infection is common in infants. The white plaques do not rub off.

Strabismus
Strabismus, or misalignment of the eyes, can lead to visual impairment. Esotropia, shown
here, is an inward deviation.

Otitis Media Herpetic Stomatitis

Otitis media is one of the most common conditions in young children. The spectrum of Tender ulcerations on the oral mucosa are surrounded by erythema.
otitis media is shown here. A: Typical acute otitis media with a red, distorted, bulging
tympanic membrane in a highly symptomatic child. B: Acute otitis media with bullae Source of photos: Otitis Media—Courtesy of Alejandro Hoberman, Children’s Hospital of
formation and fluid visible behind the tympanic membrane. C: Otitis media with effusion, Pittsburgh, University of Pittsburgh; Thrush—Salimpour RR et al. Photographic Atlas of
showing a yellowish fluid behind a retracted and thickened tympanic membrane. Often you Pediatric Disorders and Diagnosis. Wolters Kluwer; 2014, UNImage13C; Herpetic
can no longer visualize the normal landmarks such as the light reflex and handle of the Stomatitis—Fleisher GR et al. Atlas of Pediatric Emergency Medicine. Lippincott Williams
malleus. & Wilkins; 2004, Fig. 11-7b.

Table 25-8. Abnormal Infant Cries (If Persistent)

Type Possible Abnormality

Shrill or high-pitched Increased intracranial pressure. Also, in a newborn born to a

 mother with an addiction to narcotics.

Hoarse Hypocalcemic tetany, congenital hypothyroidism, or unilateral

vocal cord weakness.

Continuous inspiratory Upper airway obstruction from various lesions (e.g., a polyp or
and expiratory stridor hemangioma), a relatively small larynx (infantile laryngeal
stridor), a delay in the development of the cartilage in the
tracheal rings (tracheomalacia), or bilateral vocal cord
paralysis.

Absence of cry Severe illness, or glottis web.

Severe early childhood caries

Table 25-9. Abnormalities of the Teeth, Pharynx, and
Neck Dental Caries
Dental caries is a major global health and pediatric problem. White spots on the teeth often
reflect early caries. The photographs to the left show different characteristics of caries.

Dental Caries (Early Childhood Caries, or ECC) Staining of the Teeth

Various causes can lead to staining of the teeth of children, including intrinsic stains such
as tetracycline (left) or extrinsic stains such as poor oral hygiene (carious lesions shown in
previous figures). Extrinsic stains can be removed.
 Lymphadenopathy
Enlarged and tender cervical lymph nodes are common in children. The most likely causes
are viral and bacterial infections. Lymph node enlargement can be bilateral, as shown in the
figure to the left.

Source of photos: Dental Caries—From Sherman S et al. Atlas of Clinical Emergency

Medicine. Wolters Kluwer; 2016, Fig. 5-6; Staining of the Teeth—Used with permission
from Shutterstock. By Maliutina Anna.

Streptococcal Pharyngitis (“Strep Throat”)

This common childhood infection has a classic presentation of erythema of the posterior
pharynx and palatal petechiae. A foul-smelling exudate is also commonly noted. Table 25-10. Cyanosis in Children
It is important to recognize cyanosis. The best location to examine is the mucous
membranes. Cyanosis is a “raspberry” color, whereas normal mucous membranes should
have a “strawberry” color. Try to identify the cyanosis in these photographs before reading
the captions.
 Bluish Lips, Giving Appearance of Cyanosis
Normal pigment deposition in the vermilion border of the lips gives them a bluish hue, but
the mucous membranes are pink.

Generalized Cyanosis
This baby has total anomalous pulmonary venous return and an oxygen saturation level of
80%.
Perioral Cyanosis classic patterns. This table shows a limited selection of the more common murmurs,
This baby has mild cyanosis above the lips, but the mucous membranes remain pink. starting with murmurs that appear in the newborn period.

Congenital Defect and Characteristics of the Associated Findings

Mechanism Murmur

Pulmonary Valve Stenosis

Usually a normal valve Location. Upper left sternal Usually a prominent ejection
annulus with fusion of some border click in early systole
or most of the valve leaflets, Radiation. In mild degrees of Pulmonary component of the
restricting flow across the stenosis, the murmur may second sound at the base
valve be heard over the course of (P2 ) becomes delayed and
the pulmonary arteries in the softer, disappearing as
lung fields obstruction increases.
Intensity. Increases in Inspiration may increase
intensity and duration as the murmur; expiration may
degree of obstruction increase click.
increases Growth is usually normal.
Quality. Ejection, peaking Newborns with severe
later in systole as the stenosis may be cyanotic
obstruction increases from right-to-left atrial
shunting and rapidly develop
heart failure as the ductus
arteriosus closes.
Acrocyanosis
This commonly appears on the feet and hands of babies shortly after birth. This infant is a Aortic Valve Stenosis
32-week-old newborn. Acrocyanosis does not reflect cardiac disease.
Usually a bicuspid valve with Location. Midsternum, upper May be an associated
progressive obstruction, but right sternal border ejection click
Source of photos (except Generalized Cyanosis): Fletcher M. Physical Diagnosis in
may occur as a result of a Radiation. To the carotid The aortic closure sound
Neonatology. Lippincott-Raven; 1998.
dysplastic valve or damage arteries and suprasternal may be increased in
from rheumatic fever or notch; may also be a thrill intensity. There may be a
degenerative disease diastolic murmur of aortic
Intensity. Varies, louder with
Table 25-11. Congenital Heart Murmurs increasingly severe valve regurgitation (not
obstruction shown in the diagram).
Newborns with severe
Quality. An ejection, often
Some heart murmurs reflect underlying heart disease. If you understand their physiologic stenosis may have weak or
harsh, systolic murmur
causes, you will more readily be able to identify and distinguish them from innocent heart absent pulses and severe
murmurs. Obstructive lesions result when blood flows through under-sized valves or heart failure. May not be
narrowed vessels. Because this problem does not depend on the drop in pulmonary audible until adulthood even
vascular resistance following birth, these murmurs are audible at birth. Defects with left- though the valve is
to-right shunts, on the other hand, depend on the drop in pulmonary vascular resistance congenitally abnormal
that occurs shortly after birth. High-pressured shunts such as ventricular septal defect,
Tetralogy of Fallot
patent ductus arteriosus, and persistent truncus arteriosus may not be heard until 1 week
or more after birth; the murmur gets louder as peripheral vascular resistance drops. Low-
Complex defect with General. Variable cyanosis, Normal pulses
pressured left-to-right shunts, such as atrial septal defects, may not be heard until age 1
ventricular septal defect, increasing with activity The pulmonary closure
year or more. Many children with congenital cardiac defects have combinations of defects
infundibular and usually sound is usually not heard.
or variations of abnormalities, so findings on cardiac examination may not follow these
valvular right ventricular Location. Mid-to-upper left May have abrupt poor weight gain, poor
outflow obstruction, sternal border. If pulmonary hypercyanotic spells with feeding.
malrotation of the aorta, and atresia, the continuous sudden increase in cyanosis, Associated defects are
right-to-left shunting at murmur of ductus arteriosus air hunger, altered level of frequent.
ventricular septal level flow at upper left sternal awareness
With Pulmonic Stenosis border or in the back. Failure to gain weight with Patent Ductus Arteriosus
Radiation. Little, to upper left persistent and increasingly
sternal border, occasionally severe cyanosis Continuous flow from aorta Location. Upper left sternal Full to bounding pulses
to lung fields Long-term persistence of to pulmonary artery border and to left Noticed at birth in the
Intensity. Usually grade III–IV cyanosis accompanied by throughout the cardiac cycle Radiation. Sometimes to the premature infant who may
clubbing of fingers and toes when ductus arteriosus back have bounding pulses, a
Quality. Systolic ejection does not close after birth
murmur Persistent hypoxemia leads Intensity. Varies depending hyperdynamic precordium,
to polycythemia, which will on size of the shunt, usually and an atypical murmur
accentuate the cyanosis. grade II–III/VI. Noticed later in the full-term
Quality. A rather hollow, infant as pulmonary vascular
Transposition of the Great Arteries sometimes machinery-like resistance falls
murmur that is continuous May develop heart failure at
A severe defect with failure General. Intense Single loud second sound of throughout the cardiac 4–6 weeks if large shunt
of rotation of the great generalized cyanosis the anterior aortic valve cycle, although occasionally Poor weight gain related to
vessels, leaving the aorta to Location. No characteristic Frequent rapid development almost inaudible in late size of shunt
arise from the right ventricle murmur. If present, it may of heart failure diastole, uninterrupted by
and the pulmonary artery Pulmonary hypertension
reflect an associated defect Frequent associated defects the heart sounds, louder in
from the left ventricle affects murmur as above.
such as ventricular septal as described at the left systole
defect (VSD).
Radiation and Quality. Atrial Septal Defect
Depends on associated
abnormalities Left-to-right shunt through Location. Upper left sternal Widely split second sounds
an opening in the atrial border throughout all phases of
Ventricular Septal Defect septum, possible at various Radiation. To the back respiration, normal intensity
levels Usually not heard until after
Intensity. Variable, usually
Blood going from a high- Location. Lower left sternal With large shunts, there may grade II–III/VI age of 1 year
pressure left ventricle border be a low-pitched middiastolic Gradual decrease in weight
through a defect in the murmur of relative mitral Quality. Ejection but without
Radiation. Little the harsh quality gain as shunt increases
septum to the lower- stenosis at the apex.
Intensity. Variable, only Decreased exercise
pressure right ventricle As pulmonary artery
partially determined by the tolerance, subtle, not
creates turbulence, usually pressure increases, the
size of the shunt. Small dramatic
throughout systole. pulmonic component of the
shunts with a high-pressure Heart failure is rare.
Small to Moderate gradient may have very loud second sounds at the base
murmurs. Large defects increases in intensity. When
with elevated pulmonary pulmonary artery pressure
vascular resistance may equals aortic pressure there
may be no murmur and P2
have no murmur. Grade II– Table 25-12. Physical Signs of Sexual Abuse
IV/VI with a thrill if grade IV/VI will be very loud.
or higher. In low-volume shunts, growth
is normal. Possible Indications
Quality. Pansystolic, usually
harsh, may obscure S1 and 1. Marked and immediate dilatation of the anus in knee–chest position, with no
In larger shunts, heart failure
constipation, stool in the vault, or neurologic disorders
S2 if loud enough may occur by 6–8 weeks;
2. Hymenal notch or cleft that extends >50% of the inferior hymenal rim (confirmed in
knee–chest position)
 3. Condyloma acuminata in a child older than 3 years Erythema and superficial abrasions to the labia minora (5-year-old)
4. Bruising, abrasions, lacerations, or bite marks of labia or perihymenal tissue
5. Herpes of the anogenital area beyond the neonatal period
6. Purulent or malodorous vaginal discharge in a young girl (culture and view all
discharges under a microscope for evidence of a sexually transmitted infection)
Strong Indications
1. Lacerations, ecchymoses, and newly healed scars of the hymen or the posterior
fourchette
2. No hymenal tissue from 3 o’clock to 9 o’clock (confirmed in various positions)
3. Healed hymenal transections especially between 3 and 9 o’clock (complete cleft)
4. Perianal lacerations extending to external sphincter
A child with concerning physical signs must be evaluated by a sexual abuse expert
for a complete history and sexual abuse examination.
Any physical sign must be evaluated in light of the entire history, other parts of the physical
examination, and laboratory data.
Healed interruption of hymenal membrane at 9 o’clock (4-year-old)

Acute hemorrhage and ecchymoses of tissues (10-month-old)

Narrowed posterior ring continuous with floor of vagina (12-year-old)

Copious vaginal discharge and erythema (9-year-old)
Hypospadias
Hypospadias is the most common congenital penile abnormality. The urethral meatus
opens abnormally on the ventral surface of the penis. One form is shown above; more
severe forms involve openings on the lower shaft or scrotum.

Extensive condylomata around the anus (2-year-old)

Source: Reece R, Ludwig S, eds. Child Abuse Medical Diagnosis and Management. 2nd Undescended Testicle
ed. Lippincott Williams & Wilkins; 2001.
You should distinguish between undescended testes, shown above (with testes in the
inguinal canals—see arrows), from highly retractile testes from an active cremasteric
reflex.
Table 25-13. Common Abnormalities in the Male Sources of photos: Hypospadias—Courtesy of Warren Snodgrass, MD, Hypospadias
Specialty Center; Undescended Testicle—Fletcher M. Physical Diagnosis in Neonatology.
Genitourinary System Lippincott-Raven; 1998.

Table 25-14. Common Musculoskeletal Findings in

Young Children
 Pronation in a toddler. A: When viewed from behind, the hindfoot is everted. B: When
viewed from the front, the forefoot is everted and abducted.

Flat feet or pes planus from laxity of the soft tissue structures of the foot

Table 25-15. Power of Prevention: Vaccine-

Preventable Diseases
This table shows photographs of children with vaccine-preventable diseases. Childhood
vaccines have been named the single most important clinical intervention in the world in
terms of influence on public health. Because of vaccinations, we hope you will never see
many of these conditions, but you should be able to identify them. Try to identify the
diseases before reading the captions.

Inversion of the foot (varus)

Metatarsus adductus in a child. The forefoot is adducted and not inverted. Polio
The deformed leg of this child is from polio
 Tetanus
Rigid newborn with neonatal tetanus

Measles
Characteristic rash of measles, in the presence of a child who also has coryza,
conjunctivitis, fever, and this diffuse rash

Haemophilus Influenzae
Type b
Buccal cellulitis from this invasive bacterial disease

Rubella
Rubella rash on a child’s back
Varicella Pertussis
An infant with a severe form of varicella. Paroxysmal cough with a “whoop” at the end

Cervical Cancer
Largely prevented through vaccination with human papillomavirus vaccine.

Meningitis
Nuchal rigidity

Sequelae of Human Papillomavirus: Oropharyngeal Cancer.

Sources of photos: Polio—Courtesy of World Health Organization; Haemophilus influenzae

—Courtesy of Children’s Immunization Project, St. Paul, Minnesota; Tetanus—Courtesy of
Centers for Disease Control and Prevention. Pertussis—Courtesy of Centers for Disease
Control and Prevention; Varicella—Tagher G, Knapp L. Pediatric Nursing. Wolters Kluwer;
2020, Fig. 29-8; Cervical Cancer—Berek J. Berek & Novak’s Gynecology. 16th ed.
Wolters Kluwer; 2020, Fig. 38-1; Oropharyngeal Cancer—From
[Link] Reprinted with permission from
Bechara Y. Ghorayeb, MD.

REFERENCES