Age-Specific Examination
Infants, Children, and Adolescents
Examination Guidelines
A pediatric physical examination must, of course, be age and developmentally appropriate. Not every observation and examination maneuver must be made on every child at every examination. What you do depends on the individual circumstance and your clinical judgment, each step dependent on the patient’s age, physical condition, and emotional state. The order of the examination can and should be modified according to need. There is no one right way. The safety of the child on the examining table must be ensured. During most of infancy and into the pre–elementary school years (and even later), an adult’s lap is most often a more secure surface for much and often all of the examination.
• Your notes should include a description of the child’s behavior and the nature of the relationship during interactions with parent (or caregiver) and with you.
• Offer toys or paper and crayons to entertain child (if age appropriate), to develop rapport, and to evaluate development and neurologic status. Attempt to gain child’s cooperation, even if it takes more time; future visits will be more pleasant for both of you.
• Only if absolutely necessary, restrain child for funduscopic, otoscopic, oral examinations; restraint is easier on an adult lap with the aid of the adult.
• Lessen fear of these examinations by permitting child to handle instruments, blow out light, or use them on a doll, a parent, or yourself.
• Take and record temperature, weight, length, or height; also take blood pressure (record extremity or extremities used, size of cuff, and method used).
• Note percentiles for all measurements, including body mass index for children ≥2 years.
• If clinical issues require it, include arm span, upper segment measurement (crown to top of symphysis), lower segment measurement (symphysis to soles of feet), upper/lower segment ratio, and chest circumference.
• Review parent-completed developmental screening tool to assess language, motor abilities, and social skills.
• Evaluate mental status as child interacts with you and parent.
Child Playing
• While child plays on the floor, evaluate musculoskeletal and neurologic system while developing a rapport with child.
• Observe child’s spontaneous activities.
• Ask child to demonstrate skills: turning pages in a book, building block towers, drawing geometric figures, coloring.
• Evaluate gait, jumping, hopping, range of motion.
• Muscle strength: Observe child climbing on parent’s lap, stooping, and recovering.
Child on Parent’s Lap
• Perform examination on parent’s lap; the adult and the patient generally enjoy the experience more, and you, sitting on a stool, preferably with your eyes at the child’s eye level, will find it easier than the examining table.
• Begin with child sitting and undressed except for diaper or underpants.
Head and Neck
• Inspect shape, alignment with neck, hairline, eyelids, palpebral folds, conjunctivae, sclerae, irides, position of auricles.
• Palpate anterior fontanel for size (age appropriate); head for sutures, depressions; hair for texture.
• Measure head circumference (up to age 36 months).
• Inspect neck for webbing, voluntary movement.
• Palpate neck: thyroid, muscle tone, lymph nodes, position of trachea.
Chest, Heart, Lungs
• Inspect chest for respiratory movement, size, shape, precordial movement, deformity, nipple and breast development.
• Palpate anterior chest, locate point of maximal impulse.
• Auscultate anterior, lateral, and posterior chest for breath sounds; count respirations.
• Auscultate all cardiac listening areas for S1 and S2, splitting, murmurs; count apical pulse.
Child Relatively Supine, Still on Lap, Diaper Loosened
Child on Parent’s Lap
The following steps, often delayed to the end of the examination, are more easily performed with a child of appropriate age sitting on a parent’s or caregiver’s lap.
• Inspect eyes: pupillary light reflex, red reflex, corneal light reflex, extraocular movements, funduscopic examination.
• Perform otoscopic examination. Note position and description of pinnae.
• Inspect mouth and pharynx. Note number of teeth, deciduous or permanent, and any special characteristics.
Note: By the time child is of school age, it is usually possible to use an examination sequence very similar to that for adults.
Age-Specific Anticipated Observations and Guidelines
Again, this is a suggested outline, always modified by human variation, and all percentages are subject to Gaussian distribution. History building can be facilitated by referring to baby books, report cards, pictures, and other materials the family may have at home.
2 Weeks of Age
History (particular attention)
• Social: sleeping arrangements, housing
• Maternal mood and social support
Plans and Problems
• What risks have revealed themselves as you have gotten to know the family? What are apparent problems? Start a problem list and make appropriate dispositions.
• Review results of newborn metabolic screening.
• Consider immunization needs and, throughout, attempt to follow American Academy of Pediatrics guidelines; on each visit, discuss benefits, risks, and side effects of immunizations (always remember risks for the immunocompromised).
2 Months of Age
History (particular attention)
• Expressions of parental concern
• Child’s apparent temperament
• Stooling pattern, frequency, color, consistency, straining
Anticipatory Guidance
• Feeding (delay or at least downplay solids; avoid citrus, wheat, mixed foods, eggs; minimize water)
• When and if mother returns to work
• Visual and auditory stimulus (mobiles, mirrors, rattles, singing and talking to baby)
• Sibling rivalry (if there are siblings or other children in home)
• Babysitters and other caregivers (checking references, reliability)
• Safety (rolling over, playpen, car seat, smoke detectors in home)
Development
Anticipatory Guidance
• Introduction of solid food (cereal)
• Stool changes with changes in diet
• Thumb sucking, pacifiers, bottles at bedtime
• Safety (aspiration, rolling over, holding baby with hot liquids, re-emphasize earlier discussions [e.g., car seat])
• Re-emphasis on environmental stimulus
6 Months of Age
History (interim details)
• Further exploration of social issues
• If either parent has not attended these care visits regularly, encourage his or her participation and address relevant issues.
Anticipatory Guidance
9 Months of Age
History (interim details)
Anticipatory guidance
• Oral hygiene—for example, water without sugar in bottles (avoid tooth decay)
• Sleep and desirability of routine (naps, separation anxiety, and how to deal with it)
• Re-emphasis on checking references and reliability of babysitters and caregivers
• Safety—for example, stair gates and toddlers, falls, poisoning, burns, aspiration (never enough emphasis on safety, smoking in the home, etc.)
12 Months of Age
History (interim details)
15 Months of Age
History (interim details)
18 Months of Age
History (interim details)
Development
55% will have begun to walk up stairs without much help.
70% will have started to walk backward.
More than that will have tried running with at least some success.
45% will have tried with some success to kick a ball forward, given the opportunity.
80% will scribble if given a crayon.
80% will make a tower with two cubes.
About half of those will attempt with some success a tower of as many as four cubes.
Plans and Problems
• Review immunizations and provide as appropriate.
• Perform developmental and autism screening (using parent-administered validated tools).
• Consider need for serum lead level, hemoglobin or hematocrit value, tuberculin test.
• Maintain problem list, making appropriate plans and, if necessary, referrals.
2 Years of Age
History (interim details)
Development
Plans and Problems
• Review immunizations and provide as appropriate.
• Perform developmental screening (using parent-administered validated tool).
• Consider need for serum lead level, hemoglobin or hematocrit value, dental referral, tuberculin test.
• Maintain problem list, making appropriate plans and, if necessary, referrals.
3 Years of Age
History (interim details)
Development
4 Years of Age
History (interim details)
Development
Anticipatory Guidance
5 Years of Age
History (interim details)
Development
Anticipatory Guidance
• School readiness (plays with others, endures separation from parents)
• Discipline (consistency, praising)
• Sex identification, education
• Safety (booster seat, guns in home, bike helmets, pool safety)
It is not usually possible to cover so many topics at one visit, so it is usually necessary to be selective based on your knowledge of the family situation.
Elementary School Years (6-12 Years of Age)
History (interim details)
• Reassess social and system review
• Behavior at home and in school
Development
By this time gross and fine motor problems have most often become apparent (but not always; neurologic examination should not be shortchanged). Language and psychosocial skills can be readily investigated in talks with parents and child, and in explorations of school and play experiences. Socialization and developing maturity may have different expressions at home, on the playground, and in school, and when with people of different ages and different degrees of acquaintance. Talks with teachers, report cards, and various drawings and other efforts that the child brings home from school can be very helpful.
Adolescents
We have assumed a continuing relationship with the patient from birth on. If you are seeing a patient for the first time, begin with a full history and physical examination.
History (interim details)
• Use of tobacco, alcohol, recreational drugs
• Sexual activity (relationships, partner violence, pregnancy and contraceptive use); exact timing for all of this should rely on your assessment of the situation and your judgment; in general, social experience
• Suicidal ideation; always be on the alert, and bring it up when necessary
An adolescent patient (and some elementary-school children) may prefer to be or should be seen alone at times and as they get older, most often or always. This does not mean, however, that the parents are not involved. Proper balance in this relies on your judgment.
Anticipatory Guidance
• Puberty and its issues; body image
• Sexuality, sexually transmitted infections, contraception
• Safety (guns in the home, seat-belt use, bike helmets)
• Family and other social relationships
Time constraints almost always make it necessary to adjust the menu for anticipatory guidance to your judgment about the adolescent’s and/or the family’s needs.