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Chapter 18
Assessing Children: Infancy Through Adolescence
Chapter 18
Assessing Children: Infancy Through Adolescence
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Areas of AssessmentAreas of Assessment
• Physical development
– Assessed in depth at each visit
• Cognitive development
– Assessed generally at each visit
• Social and emotional development
– Assessed generally at each visit
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Stages of DevelopmentStages of Development
• Newborn (birth)
• Infancy (0 to 12 months)
• Early childhood (1 to 4 years)
• Middle childhood (5 to 10 years)
• Adolescence (11 to 20 years)
– Early
– Middle
– Late
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Vital Signs Throughout DevelopmentVital Signs Throughout Development
• Height – every visit
• Weight - every visit
– Calculate BMI (body mass index) at every visit
• Head circumference – birth to 36 months
• Blood pressure – start measuring at age 2
• Pulse – higher in infancy; slows down with aging
• Respiratory rate – higher in infancy; slows down with aging
• Temperature
– <2 months of age: rectal temperature
– >= 2 months of age: tympanic temperature
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Newborn AssessmentNewborn Assessment• General assessment – Apgar score
• Sequence of examination:– Careful observation of
activity– Head, neck, heart, lungs,
abdomen, genitourinary system
– Lower extremities, back– Ears, mouth– Eyes whenever they open
spontaneously– Skin (throughout the exam)
o Vernix caseosa: present at birth
o Lanugo: shed within the first few weeks of life
– Nervous system– Hips
The Apgar Scoring System
Assigned Score
Clinical Sign
0 1 2
Heart rate Absent <100 >100
Respiratory effort
Absent Slow and irregular Good; strong
Muscle tone Flaccid Some flexion of the arms and legs
Active movement
Reflex irritability
No response
Grimace Cry vigorously, sneeze, or cough
Color Blue, pale Pink body, blue extremities
Pink all over
1–Minute Apgar Score 5–Minute Apgar Score
0-4 Severe depression, requiring immediate resuscitation
0-7 High risk for subsequent central nervous system and other organ system dysfunction5-7 Some nervous system
depression
8-10 Normal 8-10 Normal
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Infancy: 0 to 12 monthsInfancy: 0 to 12 months
• Most rapid rate of growth
– Birth weight triples, height increases by 50% by the end of year one
• Sequence of examination
– Perform non-disturbing maneuvers early
– Perform potentially distressing maneuvers near the end; e.g., ears, mouth, and abdomen
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Infancy: Physical Examination FeaturesInfancy: Physical Examination Features
• Head
– Inspect for symmetry
– Palpate:
o Anterior fontanelle – closes between 4 and 26 months of age
o Posterior fontanelle – closes by 2 months of age
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Infancy: Physical Examination Features (cont.)
Infancy: Physical Examination Features (cont.)
• Eyes:– Inspect sclerae, pupils, irides,
extraocular movements, and presence of red reflex
• Ears:– Inspect position, shape,
landmarks, patency of ear canal– Acoustic blink reflex
• Nose and paranasal sinuses:– Infants are obligate nasal
breathers for first the 2 months of life
– Only the ethmoid sinuses are present at birth
– Inspect for position of nasal septum
• Mouth/pharynx:– Inspect mucosa, tongue,
gums, palate, tonsils, and posterior pharynx
– Palpate gums and teetho Teeth: 6 to 26 months of
age, 1 tooth per montho Central and lateral
incisors erupt first, molars last
• Neck:– Inspect for masses– Palpate for presence of
adenopathy: unusual in infancy
– Assess mobility of neck
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QuestionQuestion
A mother presents to the pediatrician concerned that her 8-month-old child is not developing appropriately. She bases this concern on the fact that the posterior fontanelle closed 6 months ago, but the anterior fontanelle is still open and soft. Your response to this concern is based on which fact?
a. The anterior fontanelle closes between 4 to 26 months of age
b. Both fontanelles should close within 2 to 4 months of each other
c. The posterior fontanelle has closed earlyd. None of the above are true
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AnswerAnswer
a. The anterior fontanelle closes between 4 to 26 months of age
• The posterior fontanelle closes by 2 months of age
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Infancy: Physical Examination Features (cont.)
Infancy: Physical Examination Features (cont.)
• Thorax: – Inspect respiratory rate,
color, nasal component of breathing, and listen for audible breath sounds
– Palpate tactile fremitus if infant is crying or making noise
– Percussion is not helpful in infantso Thorax is more
rounded in infants than in older children and adults
• Lungs - auscultation:– Generally, sounds are louder
and harsher– Distinguish between upper
and lower airway soundso Upper airway: loud,
symmetric transmission throughout the chest - loudest as stethoscope is moved upward; coarse during inspiratory phase
o Lower airway: loudest over site of pathology; asymmetric; often has an expiratory phase
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Infancy: Physical Examination Features (cont.)
Infancy: Physical Examination Features (cont.)
• Heart
– Inspect for cyanosis
– Palpate:
o Peripheral pulses, especially brachial
o PMI is not always palpable; 1 interspace higher than in adults
o Thrills
– Auscultate:
o S1, S2 (split is normal but fuse together as single sound during deep expiration)
o S3 is frequently heard and is normal
o Murmurs – functional murmurs vs. pathologic
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Infancy: Physical Examination Features (cont.)
Infancy: Physical Examination Features (cont.)
• Breasts
– Inspect – enlarged in newborns secondary to maternal estrogen
– Palpate for masses
• Male genitalia
– Inspect
– Palpate for descent of testes into scrotal sac
• Female genitalia
– Inspect
• Abdomen
– Inspect – umbilical cord remnant is gone by 2 weeks of age
– Auscultate bowel sounds
– Palpate - liver edge 1-2 cm below costal margin is normal; palpable spleen tip is normal
– Rectal – generally not done
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Infancy: Physical Examination Features (cont.)
Infancy: Physical Examination Features (cont.)
• Musculoskeletal
– Inspect the spine
– Palpate the clavicle, hips, legs, and feet
o Bowlegged growth to age 18 months is normal
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Infancy: Physical Examination Features (cont.)
Infancy: Physical Examination Features (cont.)
• Nervous system– Inspect motor tone– Palpate motor tone through passive ROM of major
joints– Normal reflexes
o Newborn: Palmar grasp, plantar grasp, moro reflex,
asymmetric tonic neck reflex, positive support reflex, anal reflex, positive Babinski
o Infancy: Triceps, brachioradialis, and abdominal reflexes
present starting at age 6 months
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Tips for Examining the Young ChildTips for Examining the Young Child
• Use a reassuring voice throughout the examination
• Let the child see and touch the examination tools you will be using
• Avoid asking permission to examine a body part because you will do the examination anyway; instead, ask the child which body part he or she would like to have examined first
• Examine the child in the parent’s lap; allow the parent to undress the child
• If unable to console the child, allow a short break
• Make a game out of the examination
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Early Childhood (1 to 4 years): Physical Examination FeaturesEarly Childhood (1 to 4 years): Physical Examination Features
• Rate of growth slows to 50% of that of infancy
• Tips for examination sequence:
– Start with the child seated – examine the eyes, palpate neck, percuss/auscultate
– Move child to supine position – examine abdomen, musculoskeletal, nervous system; examine genitalia last
– End the examination with the patient upright; look at the throat and ears
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Early Childhood: Unique Physical Examination Features
Early Childhood: Unique Physical Examination Features
• Vital signs:– Measure blood
pressure starting at age 2
• Neck:– Palpate for lymph
nodes; adenopathy is common
• Eyes:– Cover and uncover
test for position and alignment of eyes
• Ears:– Visualization of tympanic
membrane is the greatest challenge
• Nose/sinuses:– Maxillary sinuses present by
age 4
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Early Childhood: Unique Physical Examination Features (cont.)
Early Childhood: Unique Physical Examination Features (cont.)
• Heart– Brachial pulses still easier to feel than radial
• Abdomen– Protuberant abdomen still normal– Liver span 1-2 cm below costal margin is still normal– Spleen edge 1-2 cm below costal margin is normal– Use the scratch test to palpate for the liver size
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Early Childhood: Unique Physical Examination Features (cont.)
Early Childhood: Unique Physical Examination Features (cont.)
• Male genitalia:
– Testes undescended in scrotal sac by age 1 is abnormal and need to refer
• Musculoskeletal system:
– Knock-knees from 18 months to 4 years of age
– Inspect spine for scoliosis in any child who can stand
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QuestionQuestion
You enter the room of a 2-year-old female who is visibly upset and afraid of being at the clinic. To facilitate the examination, which of the following actions would be most appropriate?
a. Leave the room and return when the child is calm
b. Have the parent leave the room since his or her presence is making the “acting out” worse
c. Ask the child’s permission to examine a body part
d. Examine the child in the parent’s lap
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AnswerAnswer
d. Examine the child in the parent’s lap
• Do not ask the child for permission to begin the examination on a part of the body. The examination will take place whether the child gives permission or not.
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Middle Childhood (5 to 10 years):Physical Examination Unique Features
Middle Childhood (5 to 10 years):Physical Examination Unique Features
• Physical examination is more straightforward; the same sequence that is used in adults can be used starting in this age group
Nose and paranasal sinuses
Sphenoid sinuses present by age 8
Frontal sinuses present by age 6-7Tonsils Peak growth is between ages 8-16 years
Breasts Development in girls is the first sign of puberty; may start as early as age 6
Musculoskeletal system Inspect legs and feet
Inspect spine for scoliosis
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Adolescence: Unique FeaturesAdolescence: Unique Features
• Puberty
– Tanner stages to determine stage of puberty
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Adolescence: Unique Features (cont.)Adolescence: Unique Features (cont.)
• Male puberty
– Tanner stages to determine stage of puberty
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Adolescence: Unique Features (cont.)Adolescence: Unique Features (cont.)
• Female puberty
– Tanner stages to determine stage of puberty