The paediatric assessment
Children and doctors
The speciality of paediatrics is very different to adult medicine. Children grow, change, and mature. Your style and approach to history taking and examination will very much depend on the child's age, independence, and understanding, so flexibility is essential. The most important thing to remember during your time as a student is that paediatrics should above all be pleasurable.
An approach to the child patient
The child needs to be put at ease and made to feel welcome.
• Make a complimentary remark about their clothes, or show them an interesting toy.
• Tell the child your name and ask theirs.
• Make friends with them by asking what their favourite lesson is at school or what they had for breakfast.
• Shake hands with children, even toddlers enjoy this formality.
A structured approach to history taking is important to avoid forgetting things, but this must not become too rigid, as it is sometimes necessary to pursue a different line of questioning to gain essential information. The table opposite is a list of useful headings in paediatric history taking, and this should be memorized.
Talking to the child
Children should be asked to give their account of events with parental corroboration. Children under 5 years old will lack the vocabulary and communication skills to describe their symptoms, but will be able to point to parts that hurt.
Talking to the parents
Most of the history is likely to be gained from the parents or guardians.
• Ask if they have the infant medical record book—this contains information about height and weight centiles, immunizations, development, and illnesses in the first few years of life.
• Ask whether the parents have any views on what the cause of the child's trouble is. Listen carefully to the parents; they are acute observers of their children.
• Ensure that all terms used are appropriately defined—you should be gleaning information from the parents’ observations and not their interpretation of the symptoms. For example, the word ‘wheeze’ is often used incorrectly and sometimes a demonstration can be helpful. Further, the parent may interpret a baby's cries as pain when, in fact, it is your task to establish the circumstances of the cries and, therefore, the cause.
• As children get older, the parents may have a hazy memory for early events. Establishing symptoms in relation to easily remembered events (e.g. first walked) may clarify the timeline.
‘You can do anything with children if you only play with them.’
Otto von Bismarck, 19th century.
The examination: an approach
Examination in children varies depending on the age and co-operation of the child. School-age children and babies may be examined on a couch with a parent nearby, whereas toddlers are best examined on the parent's lap. If the child is asleep on the parent's lap, much of the examination should be completed before waking them up.
Let the parent undress the child: and only expose the part of the body you will be examining.
Some children may prefer to be examined standing up. Only lay the child down when you have to, as this can be very threatening.
Putting the child at ease
Slowly introduce yourself to the child's space during the examination by exchanging toys, for example.
Explain what you are going to do and be repeatedly reassuring, children can be embarrassed by silence after a doctor's question, but will be comforted by endless nattering. And remember—don't ask permission, as this will often be refused!
Firstly, use a hands-off approach. Allow the child to look at you, and let them play in your presence. Watch the child. How do they interact with their parents? Do they look well or ill? Do they look clean, well nourished, and well cared for?
Kneel on the floor so that you are at the child's level. Use a style and language appropriate to the age of the child—a toddler will understand the word ‘tummy’ better than the word ‘abdomen’.
Do not adhere to a rigid examination schedule, e.g. you may have to listen to the heart first while the child is quiet, then look at the hands later. Never examine the presenting part only. Be thorough and train yourself to be a generalist.
Leave unpleasant procedures, such as examination of the tonsils, until last.
Presenting your findings
When presenting your findings, translate what you see into appropriate terminology. Informing a senior that a child ‘looks funny’ is not very helpful but the saying the child is dysmorphic, followed by a detailed description is acceptable. Describe in simple terms the relevant features that make the child look unusual, e.g. low set ears, wide set eyes.
There is no substitute for examining lots of normal children.
‘Paediatrics is a specialty bound by age and not by system.’
The respiratory system
Key points from the history
• Is the child short of breath or wheezy (remember to define terms)?
• Is there stridor or croup?
• Is there a cough? Does it disturb sleep?
• Does anything trigger the symptoms—sport, cold weather, pets?
• Has the child expectorated or vomited any sputum?
• Is the infant short of breath during breast or bottle feeding?
• Is there a possibility the child could have inhaled a foreign body?
• Is there any FHx of respiratory problems such as asthma or cystic fibrosis?
• Does the child have a fever—suggestive of infection?
• Has anyone else been unwell? Any contacts with tuberculosis?
• Has the child travelled abroad recently?
• How does the respiratory problem limit the child's life—how much school is missed, can they play sport, how far can they run, is sleep disturbed?
Look around for any clues—is the patient on oxygen? Are there inhalers or nebulizers at the bedside?
• Are they comfortable or in respiratory distress? Look for:
• Nasal flaring.
• Use of accessory muscles of respiration.
• Intercostal recessions (sucking in of the muscles between the ribs) and subcostal recessions (drawing in of the abdomen).
• Grunting (a noise at the end of expiration which is the infant's attempt to maintain a positive end expiratory pressure).
• Is the child running around or just sitting on the parent's knee?
• Are they restless or drowsy?
• Count the respiratory rate.
• Listen for wheeze or stridor (a harsh inspiratory sound caused by upper airways obstruction).
• What type of cough does the child have?
• Has the child coughed up any sputum (children under 5 years will swallow sputum, which is often vomited after a bout of coughing).
• Clubbing (cystic fibrosis, bronchiectasis).
• Measure the radial pulse—pulsus paradoxicus ( [link]) is an important feature of acute severe asthma in children.
• Check the conjunctiva for anaemia.
• Look for central cyanosis in the tongue.
• Look for petechiae (non-blanching spots from small burst blood vessels) around the eyes from a prolonged bout of coughing.
• Look for chest movement. Is it symmetrical? Is the child splinting (failing to move) one side of the chest?
• Children who splint their chest as a consequence of pneumonia often also have a slight spinal scoliosis.
• Look at the chest shape. Is there any chest wall deformity?
• Harrison's sulcus: permanent groove in the chest wall at the insertion of the diaphragm in longstanding asthma.
• Barrel chest: air trapping in asthma.
• Pectus carinatum: ‘pigeon chest’ seen in longstanding asthma.
• Pectus excavatum: normal variant.
Table 16.1 Normal respiratory and heart rates by age
• Feel the neck for enlarged cervical lymph nodes.
• Palpate the trachea to ensure that it is central.
• Then move onto the chest:
• Feel for the apex beat. This may be displaced in effusion, collapse, or tension pneumothorax.
• Assess expansion (see [link]) commenting on extent and symmetry.
• In young children, you may be able to feel crackles.
Percussion is rarely useful in infants and toddlers. Remember to also percuss for the normal cardiac dullness as well as the upper and lower borders of the liver.
• Dull = consolidation.
• Hyperresonant = air-trapping or pneumothorax.
• Stony dull = pleural effusion.
Before using a stethoscope on the child, pretend to auscultate the parent's chest or a less vulnerable part of the child's body (e.g. their leg).
Remember to listen under the axillae as well as the anterior and posterior chest wall.
Especially in young children, the upper airway noises may be transmitted to the chest, so if the child is old enough, ask them to cough to clear them.
• Breath sounds.
• Are they vesicular (normal), absent or bronchial?
• Added sounds (e.g. wheeze or crackles—see adult pages for more details.)
• Absent breath sounds in one area suggests a pleural effusion, pneumothorax, or dense consolidation.
Table 16.2 Some common respiratory conditions and signs
Pale, coryza, cough, recessions, tachypnoea
Wheeze and crackles throughout chest
Stridor, hoarse voice, barking cough
Tachypnoea, recessions ± audible wheeze and use of accessory muscles
Wheeze, variable air entry throughout chest. Crackles in young children
Tachypnoea, recessions, flushing due to fever, grunting
May be clear, reduced breath sounds over affected area, crackles
Tachypnoea, recessions, flushed, generally unwell
Abdominal pain (may be the only symptom), crackles and bronchial breathing over affected area
↑ respiratory rate and work of breathing are the most important signs of a lower respiratory tract infection in infancy, as sometimes palpation, percussion, and auscultation will be normal.
Ear, nose, and throat
ENT conditions are a common reason for children to present to the doctor.
Examination of this system should be left until last, as children find it unpleasant.
Key points from the history
• Does the child pull at their ears (suggests infection)?
• Does the child complain of earache or a sore throat?
• Are they coryzal (runny nose)?
• Does the child have a fever?
• Does the infant drool more than normal (suggests sore throat)?
• Sit the child on the parent's lap facing to the side.
• Ask the parent to hold the child's head against their chest with one hand, and to firmly hold the child's arms and upper body with the other hand (see Box 16.7).
• With an infant, gently pull the pinna back before inserting the auroscope. When examining an older child, pull the pinna upwards.
• Use the auroscope as in adults— see [link].
• Examine the nose externally for discharge.
• The nose may be examined very gently using an auroscope.
• Polyps are a common finding in asthma and cystic fibrosis.
• Pale, boggy nasal mucosa suggests allergic rhinitis.
• Sit the child upright on the parents lap facing towards you.
• Ask the parent to hold the child's forehead with one hand, with the back of the child's head against their chest.
• The parent should firmly hold the child's arms with their other hand.
• The difficulty now is encouraging the child to open their mouth!
• Ask the child to open their mouth ‘as wide as a lion’.
• Tempt an infant to open their mouth with a dummy.
• Sometimes children will be more inclined to open their mouth if you promise not to use a spatula.
• When the child's mouth is open, gently depress the tongue with the spatula if it is obstructing the view of the tonsils.
• Decide whether the tonsils are:
• Normal: pink and small.
• Acutely inflamed: red, enlarged, sometimes with pus spots.
• Chronically hypertrophied: enlarged and pitted, but not inflamed.
• Always feel for cervical and supraclavicular lymphadenopathy.
Table 16.3 Some common findings when examining the ear drums
Appearance of drum
Translucent, clear light reflex
Red, bulging, loss of light reflex
Acute otitis media
Retracted, loss of light reflex, dull
Glue ear (chronic otitis media with effusion)
The cardiovascular system
Key points from the history
• Does the child ever have blue spells (cyanosis)?
• Does the child ever become tired, pale, or sweaty (indicating heart failure)?
• If the patient is an infant, ask how long the child takes to feed from a bottle. Breathlessness may inhibit feeding.
• Is the child growing normally? Plot on a centile chart.
• Does the child suffer from recurrent chest infections?
• Does the child suffer from abdominal pain (caused by organomegaly)?
• Is there a history of fainting or collapse?
• Has the child ever complained of their heart racing (would imply an arrhythmia such as supraventricular tachycardia)?
• Is there a FHx of congenital heart disease?
Search for evidence of heart failure: pallor, cyanosis, sweating, respiratory distress and tachypnoea.
• Clubbing—seen in cyanotic congenital heart disease.
• Search for signs of endocarditis, including splinter haemorrhages, Janeway lesions and Osler's nodes.
The jugular venous pulse and pressure are difficult to appreciate in young children, due the relative shortness of the neck.
Palpate the radial, brachial, and femoral pulses.
The femoral pulse, although sometimes awkward to feel, must always be sought to ensure coarctation of the aorta is not missed. Assess:
• Volume: is it full or thready? (You will need to practice feeling lots of pulses to appreciate the difference.) A thready, weak, or small volume pulse is indicative of hypovolaemia. Look for pulsus paradoxicus ( [link]).
• Rate: heart rate varies with age, activity, distress, excitement and fever (the pulse rate will ↑ by 10bpm with every temperature rise of 1°C).
• Sinus arrhythmia: an ↑ in pulse rate on inspiration, with slowing on expiration. Very common in children.
• Occasional ventricular ectopic beats: normal in children.
• Collapsing pulse in children is most commonly due to a patent ductus arteriosus.
• Slow rising pulse suggests ventricular outflow obstruction.
Blood pressure recordings in children are not easy, but they are important, so remember perform this test. The use of the correct cuff size is vital here to prevent inaccurate readings.
Anxiety and poor technique are the most common causes for raised blood pressure in children, so it should be measured several times.
Note the presence of:
• Precordial bulge: causes the sternum and ribs to bow forwards.
• Visible ventricular impulse: RV impulse may be visible under the xiphisternum. The LV impulse (apex beat) is often visible in thin children, and in children with true LV hypertrophy.
• Scars: indicative of previous heart surgery.
• Feel the apex beat to determine its location and character. It is usually situated in the 4th intercostal space in the mid-clavicular line in infants or toddlers (often difficult to localize if they are plump), and in the 4th or 5th intercostals space in older children.
• LV hypertrophy results in a diffuse, forceful, and displaced apex beat, felt as a ‘heave’.
• If the apex is impalpable, consider dextrocardia (inverted heart with apex pointing to the right) or pericardial effusion.
‘Laevocardia’ is the normal orientation of the heart to the left.
• Right ventricular heave: place your fingertips along the left sternal edge. If the child has right ventricular hypertrophy you will feel your fingers lift up with each impulse.
• Palpate in the four valve areas (aortic, pulmonary, tricuspid, and mitral) for thrills.
• Palpate the abdomen for hepatomegaly, which suggests heart failure (remember to percuss the upper border of the liver—a normal-sized liver may be displaced downwards by lung disease such as bronchiolitis). Raised JVP, pulmonary, and peripheral oedema is rarely seen in children.
Listen to the heart sounds in the 4 valve areas with the diaphragm and bell of the stethoscope (preferably paediatric size).
First heart sound (S1)
Best heard at the apex with the bell.
• Loud S1 heard with high cardiac output states (e.g. anxiety, exercise, fever).
• Soft S1 heard with emphysema and impaired left ventricular function.
Second heart sound (aortic = A2 and pulmonary = P2)
Best heard at the base with the diaphragm. It is normally split in children.
• Soft P2 heard with stenotic pulmonary valve (e.g. tetralogy of Fallot).
• Loud P2 heard with pulmonary hypertension.
• Wide fixed splitting caused by atrial septal defect.
Third heart sound
Due to rapid ventricular filling.
• Causes include ↑ LV stroke volume (aortic or mitral regurgitation) and restricted ventricular filling (constrictive pericarditis, restrictive cardiomyopathy). It may be normal in children.
Auscultate for murmurs over the 4 valve areas, and at the back. About 30% of children have innocent murmurs.
Patient asymptomatic. Systolic (except venous hum). No radiation or thrill. Change with altering patient posture.
• Venous hum: due to turbulent flow in the head and neck veins. A continuous murmur in diastole and systole heard below the clavicles which disappears when child lies flat.
• Ejection murmur: due to turbulent flow in the outflow tracts of the heart. Heard in the 2nd–4th left intercostals spaces.
Systolic or diastolic. May radiate. May have a thrill. Patient may be symptomatic.
• Atrial septal defect: soft ejection systolic murmur at the upper LSE due to ↑ RV outflow. Fixed wide splitting of the 2nd heart sound may first be detected at school entry.
• Ventricular septal defect: parasternal thrill. Loud pansystolic murmur at the lower LSE. Radiates throughout precordium. Signs of heart failure may be present.
• Coarctation of the aorta: ejection systolic murmur heard between the shoulder blades. Femoral pulses weak or absent.
• Patent ductus arteriosus: Collapsing pulse. Continuous ‘machinery murmur’ below the left clavicle.
Also see [link].
Table 16.4 Quick-spot guide to common paediatric murmurs
Cyanosis + murmur
Usually tetralogy of Fallot
Cyanosis + murmur + operation
Possibly tetralogy of Fallot or transposition of the great arteries
Pink + loud systolic murmur
Probable ventricular septal defect (commonest form of CHD)
Pink + murmur + impalpable femorals
Coarctation of the aorta
Continuous low pitched murmur
Probable patent ductus arteriosus
The abdomen and gastrointestinal system
Key points from the history
Determine whether the child takes in sufficient calories for growth and has a well balanced diet. Ask about height and weight gain.
When taking a history, start at the head and work down to avoid missing things.
• Does the child have a good appetite?
• Does the child vomit?
• How much?
• Are they hungry afterwards?
• Is it forceful or effortless?
• Is it related to feeds?
• What does it contain? Ask about coffee-grounds or other appearances of the vomit. (Bile-stained vomiting in an infant always indicates obstruction and must be considered as pathological.)
• Does the child suffer from abdominal pain?
• Does the child ever have a bloated abdomen?
• Are there any urinary symptoms?
• Ask about bowel habit—is the child constipated?
• Have there been any frequent or loose stools? Are the stools particularly offensive (suggests malabsorption).
• Is there a relevant FHx (e.g. Coeliac or inflammatory bowel disease)?
Start with a general inspection of the patient, looking especially for:
• Visible liver edge or spleen.
• Peristalsis (important in diagnosing pyloric stenosis during a test feed).
• Observe for signs of liver disease (see [link]), including spider naevi, xanthomata, and purpura.
• Oedema over the tibia and sacrum.
• Whether the child is under- or overweight.
• Wasted buttocks (suggesting weight loss—typical of coeliac disease).
• Abdominal distension.
• Gross ascites may be evident—the abdomen will be distended and the umbilicus everted.
• Caput medusae (cutaneous collateral veins with blood flowing away from the umbilicus due to ↑ portal venous pressure— [link]).
Young children may resist abdominal examination. First try distraction techniques. If these fail, use the child's hand to guide yours around the abdomen. If there is doubt as to the significance of tenderness in a child's abdomen, listen with your stethoscope and gently apply more pressure. Often quite firm pressure can be tolerated in this way where there was previously tenderness.
The aims of palpation are to:
• Determine the presence of normal abdominal organs.
• Detect enlargement of the abdominal organs.
• Detect the presence of abnormal masses or fluid.
• Ensure the child is relaxed and that your hands are warm.
• Enquire about pain before you begin.
• Palpate for tenderness (light palpation first, then deep palpation).
• Feel for guarding (tensing of the abdominal muscles which may indicate underlying tenderness).
• Palpate the spleen. This is normally felt 1–2cm below the costal margin in infancy. It is soft and can be ‘tipped’ on inspiration. Begin palpation in the right iliac fossa and move towards the left upper quadrant to avoid missing a very large spleen. It may help to turn the child onto their right side.
• To palpate the liver, start in the right iliac fossa and move upwards in time with the child's respiratory movements until the liver edge meets your fingers. A liver edge 1–2cm below the costal margin is normal up to the age of 2 or 3 years.
• Kidneys are not easy to palpate in children (they are easier to palpate in newborns), so if you can feel them they are probably enlarged. They are best palpated bimanually. The kidneys move with respiration, have a smooth outline, and one can get above them (unlike the liver and spleen).
• Palpate for other masses and check for constipation (usually felt as a hard, indentable, non-tender mass in the left iliac fossa).
• Ascites. Test for shifting dullness (described on [link]) as a sign of ascites.
• Gaseous distension.
• Percuss to determine the size of the liver and spleen.
This is rarely indicated in children. However, it is often useful to inspect the perianal region for fissures, tags, soiling, and threadworms.
True micropenis is rare. If the penis looks small, it is probably because it is buried in suprapubic fat.
Check the urethral orifice is at the tip of the glans. If not, is there epispadius (dorsal opening, very rare), or hypospadias (ventral opening)?
The child should be standing up.
• Inspect for normal rugosity of the scrotum.
• Palpate for the testes.
• If they are not present in the scrotum, feel at the inguinal canal and, if found, try to milk the testis down.
• Many undescended testes are subsequently found on re-examination as retractile testes, so be gentle in your approach to avoid provoking a cremasteric reflex!
The nervous system
Key points from the history
• Detailed birth and perinatal history—including maternal drugs/illness.
• Careful history of the developmental milestones.
• Hearing or visual concerns. Did they pass the newborn hearing screen?
• Any change in school performance, personality or behaviour (e.g. aggression)?
• Ask about symptoms of raised intracranial pressure (e.g. headache, vomiting).
• Any change in gait or frank ataxia?
• Does the child have limited function—what can they do? What do they need help with?
• Relevant FHx of learning difficulties or genetic conditions.
Examination of the nervous system in school-age children should be performed as in adults. Young children cannot cooperate with a formal neurological examination, so assessment is opportunistic—observation becomes important. The assessment of a young child is described below.
Young children—where to start
• Palpate the anterior fontanelle when the child is quiet to:
• Determine the presence of raised intracranial pressure (felt as fullness or bulging).
• Determine the degree of dehydration (felt as a sunken fontanelle).
• It is impossible to assess fontanelle tension in crying babies.
• Pulsation of the fontanelle is normal.
• Measure the maximum occipito-frontal head circumference and plot this on a centile chart.
It is not possible to systematically examine cranial nerves in infants or young children, below is a rough guide. (See Chapter 10.)
• I (olfactory): very difficult.
• II (optic): ask parents—can the child see?
• III, IV, VI (eye movements): gain the infant's visual attention with an object and move it back and forth. Watch for the range of ocular movements as the child tracks the object. Pendular nystagmus may indicate a visual defect.
• V (trigeminal): rooting reflex.
• VII (facial): facial palsy will become apparent when the child cries. Asymmetry will be more obvious. Does the child close both eyes?
• VIII (vestibulocochlear): formal hearing tests are performed at birth.
• IX, X: swallowing.
• XI (accessory): neck and shoulder movements.
• XII (hypoglossal): tongue movement.
• Pupils: check for size, shape, and reaction to light.
• Fundi: should be examined but should be left to the end of the examination, as it is unpleasant (and sometimes impossible).
• Observe the child's response to gravity (see [link]).
• Hypotonic infant: slips through in ventral suspension (holding them up with a hand in each axilla), droops over your hand during ventral suspension, head lag when pulled to sit, ‘frog legs’ posture.
• Hypertonic infant: scissoring of lower limbs when the baby is picked up. Resistance to movement of limbs. Baby will seem to move ‘in one piece’.
• Move the limbs through their range of movements. Important areas to examine include:
• Arm flexors and extensors.
• Arm supinators and pronators (most sensitive for ↑ tone).
• Hip adductors.
• Leg extensors.
• Leg flexors.
• Ankle extension.
• Spontaneous movements. (Reduced movement is indicative of muscle weakness.)
Difficult to assess. Only response to pain can be confidently elicited in young children, but please don't try this!
• Tendon reflexes: can be elicited by tapping the tendon with a finger in babies and using a tendon hammer in children.
• The examiner should know the nerve roots responsible for the reflexes ( [link]).
• Remember that the plantar response is upwards until 8 months.
• Primitive reflexes: the presence of ‘primitive reflexes’ beyond 6 months of age is abnormal and will inhibit normal development.
• Persistence is indicative of an UMN lesion (e.g. cerebral palsy). See Table 16.5.
Table 16.5 Some primitive reflexes and age of extinction.
Age of extinction
Asymmetric tonic neck reflex
Coordination (assess in older children)
• Stand on one leg and then hop.
• Walk on tip toes.
• Walk on heels—a good test for co-ordination and overall neurological integrity. Patients with any kind of spasticity, for example, will be unable to do this.
• Finger–nose test and heel–shin test if the child is old enough.
Gait (assess in older children)
• Spastic gait: spasticity of extensor muscles causes a stiff gait on a narrow base. Toes catch the ground first (e.g. cerebral palsy).
• Hemiplegic gait: if the spasticity is unilateral, the affected leg drags stiffly and is circumducted as it is brought forward
• Ataxic gait: broad based, unsteady, with frequent falls.
• Lower limb weakness (distal): affected leg is lifted over obstacles, then the foot returns to the ground with a slap.
• Lower limb weakness (proximal): waddling gait as the pelvis is thrown side to side, being poorly supported by the lower limbs (e.g. muscular dystrophy).
• Limp: has several causes, but always rule out dislocation of the hip.
Development is a continuous process, the rate of which varies considerably between normal children.
Development is divided into 4 areas:
• Gross motor.
• Fine motor and vision.
• Speech and hearing.
Delay in all 4 areas is usually abnormal, but delay in one area may not be. For example, some children become expert at bottom shuffling and, having learned an effective means of travelling, the need to walk becomes less important.
Performing a developmental assessment
• Observation is key. Young children will often not cooperate. Take a history from the parents of which milestones the child has achieved.
• Be systematic and evaluate each of the 4 developmental areas in turn.
• Learn a few essential milestones, as it is difficult to remember them all.
• If an infant was born prematurely, allow for this by calculating their ‘corrected age’ from their expected due date.
• Limit distractions and present one task at a time.
Equipment for developmental assessment
• Wooden blocks: for assessing palmar grasp and building towers.
• ‘Hundreds and thousands’: for testing pincer grip.
• Pencil and paper: for assessing fine motor skills.
• Different coloured card/colourful book.
Table 16.6 Developmental warning signs
Regression in previously acquired skills or a halt in developmental progress.
Persistent primitive reflexes. Hand preference (this should not appear until 18 months).
No sitting. No pincer grip. No double babble.
Not walking. No words.
Table 16.7 Developmental milestones
Head control, pushes up with arms
Smiles (6 weeks)
Palmar grasp, reaches, transfers
Babbles (monosyllabic—ba, ka, da)
Eats solid food
Crawls, pulls to stand
Pincer grip begins to develop
Double babble (dada, baba)
Stranger awareness, waves bye-bye
Developed pincer grip
Walks upstairs, jumps
Scribbles, 3 block tower
Draws straight line, 6–8 block tower
Beginning to use clauses (including verbs)
Uses spoon skilfully, undresses, symbolic play
Hops, walks upstairs adult-style
Draws a circle, builds a bridge with blocks
Says name, knows colours
Dresses, has a friend, dry nappies by day
Stands on one leg, hops
Draws a cross, makes 3 steps with blocks
Sentences of 5+ words
Does up buttons
Can ride a bicycle
Draws a triangle
Ties shoe laces, dry by night
The vast majority of newborns have a normal intrauterine life, normal birth, and are physically normal. However, there is a wide variation in the spectrum of normal, and it is important to stress the value of examining a large number of neonates to appreciate the normal spectrum.
In the delivery room
All newborns should have a brief examination at birth to determine whether resuscitation is needed and to rule out any major abnormalities.
The APGAR score is used to gauge the need for resuscitation (Table 16.8).
Table 16.8 APGAR score
Blue extremities, pink trunk
Grimace on stimulation of foot
Some limb flexion
On the post natal ward
A more thorough examination is carried out prior to discharge. At this stage, the baby is unrecognizable from the one you met in the delivery room—they will be pink, vigorous, and feeding well.
Ask briefly about whether the baby has passed urine and meconium (the first, black sticky stool), and enquire as to the progress of feeding, as well as a FHx of congenital anomalies. Of particular importance is a FHx of dislocated hips, renal abnormalities, and deafness.
• Examination should start at the top and work down, to ensure nothing is missed.
• Undress the baby yourself as the examination proceeds, to get a feel for how the baby handles.
First observe the baby without disturbing him/her.
• Colour: pink, pale, cyanosed, or jaundiced? Acrocyanosis (cyanosis of the hands and feet) is normal provided the lips and tongue are pink.
• Rash: a blotchy erythematous rash occurs in about half of all neonates, this is usually harmless and is called erythema toxicum.
• Peeling of skin is common, especially in post-dates babies.
Head and face
• Shape of the head: can vary widely in the first week.
• Fontanelles: they should be soft and flat. The size of the anterior fontanelle also varies widely, from 1–4cm in diameter. The posterior fontanelle may accept a little fingertip.
• Cranial sutures: are they fused?
• Look for trauma from the birth: such as caput succedaneum (oedema caused by pressure over the presenting part) and moulding (head changing shape as it passes through the birth canal), forceps marks, and subconjunctival haemorrhages. In general, these conditions will resolve within the first week.
• A cephalhaematoma is a localized fluctuant swelling usually over the parietal bone, caused by subperiosteal bleeding. This will resolve over a few months.
• Ears: can be of different shape and size. Look for preauricular sinuses and ear tags, and observe their position.
• Palate: look at it when the infant cries, then palpate it for a cleft with a clean finger.
• ‘Epstein's pearls’ are small white cysts in the midline of the hard palate. They are normal and resolve spontaneously.
• Jaw: a small jaw (micrognathia) may be part of the Pierre Robin sequence (midline cleft, small jaw, posterior displacement of the tongue—can cause upper airway obstruction).
• Tongue: note the size. If it is large and protruding, this may indicate a number of syndromes (e.g. Down's syndrome).
• Note position and size.
• Look for the red reflex with an ophthalmoscope to exclude a cataract, which would be seen as a white reflection.
• To encourage the baby to open their eyes, wrap them in a blanket (a crying baby will not open their eyes) and sit them upright.
• If this fails, give the baby something to suck on, or startle with the Moro reflex.
• Sticky eyes can be the result of ophthalmia neonatorum (purulent conjunctivitis in the first 3 weeks of life). Usually due to accumulation of lacrimal fluid due to incomplete drainage of the nasolacrimal duct.
Respiratory system and chest
• Observe: this is best done in a quiet baby (either sleeping or with the aid of a dummy).
• Chest: comment on size, symmetry, and shape.
• Respiratory rate: should be <60/minute. Note the work of breathing. Are there any subcostal or intercostal recessions? Is the baby grunting?
• Normal newborn respiration should be quiet, effortless, and predominantly diaphragmatic (abdomen moves more than the chest).
• Auscultate: the lung fields to ensure symmetrical air entry. Crepitations may be normal in the first few hours of life.
• Breasts: engorgement is common in male and female infants.
• Observe: note colour, respiratory effort and precordial heave.
• Apex beat: palpate and feel any thrills (not uncommon in neonates).
• Femoral pulse: this is extremely important; its absence may imply coarctation of the aorta. This requires a relaxed, still baby and lots of patience. Remember that too much pressure may obliterate it. A collapsing pulses suggest patent ductus arteriosus.
• Heart rate: should be between 100–160bpm.
• Auscultate: for the heart sounds and murmurs. Systolic murmurs are common, and usually best heard along the left sternal edge.
• Observe: distension could be bowel obstruction or abdominal mass.
• Umbilical stump: count the three vessels. Note any signs of infection such as an unpleasant smell, discharge, or periumbilical erythema.
• The cord will spontaneously separate around the 4th or 5th day.
• Palpate: gently feel the abdomen for the intra-abdominal organs and exclude organomegaly. Use warm hands and a soother if necessary.
• The liver edge is soft and easily missed.
• Kidneys: determine presence and size by balloting.
• It is possible to palpate the lower poles of the kidneys in normal neonates.
• Bladder: palpate suprapubically. If felt, suggests outlet obstruction.
• Anus: infants with an imperforate anus may still pass meconium via a fistula, so check the anus is patent and in the correct position.
• Urethra: identify the urethral orifice and exclude hypospadias.
• Testes: palpate gently. If they cannot be found in the scrotum, commence in the inguinal area and palpate downwards.
• If a testis appears larger than normal, transilluminate the scrotum ( [link]) to check for the common condition of hydrocele.
• Inguinal herniae: these are more common in preterm infants.
• Put the nappy back on quickly for obvious reasons.
• Labia minora: may not be fully covered, especially in preterm infants.
• Vaginal tags: are common and resolve spontaneously in the first week.
• Vaginal discharge: and occasionally bleeding can occur, and is normal.
• Note ↑ pigmentation and clitoromegaly.
• Ensure all joints have full range of movement to exclude any congenital contractures.
• Examine fingers and toes for syndactyly (fused digits) or polydactyly (extra digits).
Examination of the hips
• This is to detect congenital dislocation and instability of the hips, and should be left until last as it will make the baby cry.
• Observe for unequal leg length and asymmetry of skin creases.
• Hip examination is in 2 parts. Lay the infant supine on a flat surface with hips and knees positioned at 90°. Stabilize the pelvis with one hand, and with the other grasp the knee between thumb and palm, with the finger tips over the greater trochanter.
• Barlow test: assesses whether the hip can be dislocated. Pull the hip up and then push downwards and laterally.
• Ortolani test: assesses whether the hip is dislocated. Pull the hip upwards into the acetabulum (producing a ‘clunk’), then the hip can be abducted. (Ortolani = out).
• Talipes equino varus: primary club foot. Usually a fixed structural deformity requiring early manipulation and fixation.
• Calcaneo valgus: common. Dorsum of the foot is in a position close to the shin. Resolves after about 2 months with ↑ calf muscle tone.
• Positional talipes is extremely common and involves no bony deformity. It is easily corrected by movement and treated with physiotherapy.
Because infants with little or no cerebral cortex can show normal reflexes and tone, you should observe the baby's state of consciousness throughout the examination. This should vary from quiet sleep to semiwakefulness to an alert state. A normal infant will be consolable when they cry, whereas it is very difficult to settle a neurologically abnormal infant.
Inspection of the spine
Any midline lesion over the spine requires immediate investigation. Even a single hair might indicate communication with the spinal column (spina bifida).
Generally flexor, although abnormal intrauterine positions can distort this, such as extended breech position.
Assess and compare the flexor recoil of the limbs.
Evaluate tone in response to gravity:
• Pull to sit test. Let the baby grasp your fingers and pull them up to sit. The head should flex and follow the traction to an upright position and hold momentarily. Also observe the tone in the baby's arms.
• Ventral suspension is assessed by grasping the infant under each axilla. A normal infant will support themselves in this position by extending their back and hips, lifting their head, and flexing their arms and legs.
Primitive reflexes (See Box 16.12)
These are used to assess asymmetry of function, gestational age, and neurological function.
Assessment of vision should be carried out with the infant in an alert state. The baby will fix on an interesting object 20cm away, and will follow the target.