Introduction

The skill of clinical examination is the true art of medicine and nowhere more so than in the examination of children. Children are not small adults and as such the approach to their examination is different. The examiner needs to be flexible, opportunistic and able to tailor the structure of the examination to the individual infant, child or young person. In order to maximize the success of the examination, time must be spent trying to gain their confidence. Some discomfort is inevitable in some parts of the physical examination, but during most of the examination the child should be contented. Do not give false reassurances as this will result in a loss of trust which will hinder the examination. The consulting room must have a range of toys suitable for all ages, and the child should be allowed to play with whatever takes his fancy. Younger children may be happier sitting on their parent’s lap. If old enough, the child should be allowed to explore the room which should be free from accessible, expensive or potentially dangerous equipment. Initial suspicion can be reduced by pulling a face or offering a toy that seems to have caught the child’s attention.

As the family enters the room they should be greeted in a friendly manner and introductions made. Adapt the approach according to the age of the child. An adolescent may want to be the focus of the consultation from the start. Younger children usually will want to have time to observe and assess their surroundings before being observed themselves. They will often take a cue from their carer’s response. If everyone relaxes and laughs in the first few minutes, the child will relax and the subsequent history and examination will be easier. Ascertain who is with the child. It may not be the mother or father but another family member, who, in a mixed ethnic population, may be the only one who speaks English.

For the experienced clinician, much of the information needed to reach a diagnosis for a child is gleaned from careful observation. While talking to the parent, watch and listen to the child. Assess his behaviour and use this information to adapt the approach. Does the child look unwell? Is he interested in the surroundings and exploring them, or apathetic? Watch the child running around: are there any obvious abnormalities in the gait? Is the face normal, or are there features of abnormal development? Are there any obvious physical abnormalities? Is the breathing unusually noisy? Does the child seem well-nourished, or wasted? What is the child’s interaction with his carer like?

History

The history (Box 5.1) will normally be taken from the accompanying carer, but an older child can be invited to give his version of events first. It is appropriate to give an adolescent the opportunity for a few minutes of confidential time during the consultation. Use this to ask questions about alcohol, drugs and sexual activity which he may be uncomfortable discussing in front of his parents. Even younger children should be asked simple things in words they can understand. Involve them by asking relevant points such as the site of the pain, etc. Remember that the carer is giving their version of the problem, not the child’s. Parents may also welcome an opportunity to talk in private away from the child, and it is often during such discussion that the real reason for the consultation emerges. Always take notice of what the carer is saying, and listen to their concerns. Any interruptions should be to clarify rather than try and direct the history. Make sure they are given full attention and that they feel their concerns are being taken seriously. All the time they are talking, keep watching everything that the child is doing and their reactions.

The structure and focus of the history is slightly different from that of an adult. The core elements of the presenting complaint, a history of the present illness and a history of any previous illness are the same; however, greater emphasis will be placed on aspects such as the developmental history and less on the systems enquiry, for example. Much of the key information will be collected in the history of the presenting complaint. Most children have a single system involved and enough time needs to be spent evaluating this carefully. Consider the timing of the symptoms: do they tend only to occur at school? Are there any associating or triggering factors? Are the symptoms interrupting with daily activities such as sleep, school attendance, participation in sport or play? Is the child’s perception of the symptoms different to that of the parent? Ask about symptoms from other systems in relation to the presenting history rather than as abstract questions. For example, a child presenting with cough may be asked about symptoms of gastro-oesophageal reflux which may be an underlying cause for the cough.

In children, the previous medical history starts from birth and specific attention should be paid to the pregnancy and newborn period (Box 5.2). Is the child fully immunized? This can be checked in the parent-held ‘red book’ or child health record, which should have documentation of child health clinic attendances, weights, immunizations, etc. Enquire particularly as to the nature and severity of previous illnesses and the age at which they occurred, for example common childhood infections such as chickenpox, admissions to hospital and, in particular, to intensive care, significant injuries and accidents. Is the child taking any regular medication and is he allergic to anything? It is important to ask about the child’s developmental progress: when did the child first sit up, smile, crawl, walk and talk? Fuller details regarding the ‘milestones of development’ are given in Table 5.1. Some useful general questions are outlined in Box 5.3.

Family history

Social history

Approach the social history with diplomacy; sometimes it is more prudent to leave deeper probing to a later occasion. It is useful to know about living conditions, and whether either or both parents are employed. Who is the main carer for the child? Is the child in any form of day care? Ask if the child has ever been separated from the main carer for any time in the past, as this may be the basis of a variety of behavioural difficulties. Find out if the child’s parents live together, and whether there is any difficulty in the relationship. Is there a supportive family structure involving other relatives, for example grandparents? If the family are immigrants, it is important to know how long they have been in their new country. The depth of enquiry in a paediatric social history must always be judged on an individual basis. Prying too deeply risks losing the initial rapport that will have been built up.

After forming an impression of the child, the family and their relationship, the examination can now proceed. By now, a younger child should have found the occasion so fascinating that he will be prepared to cooperate in most parts of the physical examination. Alternatively, the child may have become so bored that he is asleep. If the child is now crying loudly, things will be difficult and strategies to calm him down to allow examination will be needed.

Examination

A key principle in the examination of children is that most of the information needed to make a diagnosis will be gleaned from careful observation, including listening to the child and playing with him. Findings can then be consolidated with the remaining techniques requiring laying on of hands. Older children will usually cooperate sufficiently to be examined lying down, and routine physical examination is similar to an adult examination. A younger child should be examined sitting on his carer’s lap, as any attempt to get him to lie down will result in instant distress. Always talk to children however young; do not be afraid of looking silly if the result is a cooperative child. Those parts of the examination that are painful or unpleasant should be left until last: if an attempt is made to examine a child’s throat at the outset, the immediate response will be crying. Offer the child something to play with – even a stethoscope will be a source of amusement to a young infant. Children often find it amusing if their toy is examined first. The scheme set out in Box 5.4 can be adapted opportunistically, provided all areas are covered.

Always wash your hands before and after the examination in front of the parent. This will inspire confidence and show that you take infection control seriously. The examination techniques include the usual methods of inspection, palpation, percussion and auscultation; however, no set routine can be followed, and the examination is by regions rather than by systems. The older the child, the more the examination will be akin to that for an adult. Bear in mind the age of the child and his level of understanding and ability to cooperate, when planning the examination. Infants and younger children will need alternative strategies and adapted techniques to elicit clinical signs. The examination may have to be opportunistic, as each child will dictate the order of the examination by his reactions to various procedures.

The head, face and neck

Look at the child’s face and ask the following questions:

Does it look normal? If not, try to identify which features seem unusual. There are many hundreds of syndromes diagnosable by the facial appearance, and the salient features should be carefully noted.

If the baby looks dysmorphic, then do not forget to look at the parents. It may then be obvious that what seems abnormal may be nothing more than a family trait. If the appearance is still not too clear, ask who the baby looks like.

Does the child have a large or protruding tongue?

Are the ears in the normal position, or are they low set and abnormal in any way?

Are the eyes small (microphthalmus)? Are they set close together or wide apart (hypo- or hypertelorism)?

Next note the shape of the head. This needs to be done by viewing the child’s head from the front, sides and from above. It may be small if the baby is microcephalic, globular if the baby is hydrocephalic, sometimes with dilated veins over the skin surface, or brachycephalic (flattened over the occiput), for example in trisomy 21. It is often asymmetrical (plagiocephalic) in normal infants who tend to lie with their heads persistently on one side (Fig. 5.1). This is now much more common because babies are placed on their backs to sleep in order to reduce the risk of sudden death in infancy. It becomes much less noticeable as the child grows older.

Figure 5.1 Plagiocephalic skull.

Assuming that the child is still being friendly, there should be little objection to feeling the child’s head now. Leave the measurement of the head circumference until near the end of the examination, as some babies find this a little threatening and may start crying. Feel the anterior fontanelle. It is normally small at birth, enlarges during the first 2 months, and then gradually reduces until final closure. It is normally closed by 18 months but can close much earlier, and has been reported as staying open in a few normal girls until 4 years of age. Delayed closure may be seen, however, in rickets, hypothyroidism and hydrocephalus. An assessment of the tension of the anterior fontanelle is important. In health, it pulsates and is in the same plane as the rest of the surrounding skull. A tense, bulging fontanelle indicates raised intracranial pressure, but it does also become tense with crying. A sunken fontanelle is a feature of severe dehydration. The posterior fontanelle is located by passing the finger along the sagittal suture to its junction with the lambdoid sutures. It should normally be closed after 2 months of age. Sometimes, when passing the finger along the sagittal suture, a small notch is felt over the vault of the cranium. This is the third fontanelle and, although it can be normal, it is seen in some chromosome abnormalities and in congenital infections such as rubella. While feeling the head, any ridging of the sutures should be noticed, suggesting premature fusion (craniostenosis). In the neonatal period, the sutures tend to be separated, and there is sometimes a continuous gap from the forehead to the posterior part of the posterior fontanelle. Sutures close rapidly, and are normally ossified by 6 months of age.

Having assessed the skull, the neck can be checked, paying particular attention to the presence of lymph nodes. It is common in childhood to feel small lymph nodes in the anterior and posterior triangles of the neck. They change in size in response to local infections such as tonsillitis (reactive lymphadenopathy). Enlarged glands in the neck are a common reason for referral to a paediatrician, but parents can generally be reassured that they are of no major significance as they can persist for some years. Examination of other lymphatic areas can be carried out at a later stage of the examination – the inguinal nodes when the napkin area is checked, and the axillary nodes when the chest is examined. In young babies, the sternomastoid muscles should be checked for the thickened area known as a sternomastoid tumour. This is a benign lesion occuring usually as a result of birth trauma but can lead to difficulties with neck movement and an abnormal head and neck posture. Torticollis is a potentially more sinister sign and can be associated with posterior fossa tumours, vertebral osteomyelitis and urinary tract infections.

The abdomen

The abdomen can be a little difficult to examine if the baby is crying, which is why it is important to have gained the child’s cooperation by this point in the examination. Most infants and toddlers will need to be examined while sitting on their carer’s lap (Fig. 5.2). It is sometimes possible to quieten a crying infant by placing him over his mother’s shoulder and examining him from behind. Small infants can be given a feed to quieten them. Older children can be asked if they would be happy to lie on an examination couch.

Figure 5.2 Baby sitting on mother’s lap while the abdomen is examined.

The examination needs to be structured along the three essential components of looking (observation), feeling (palpation) and listening (auscultation). During the first 3 years of life, the abdomen often gives an impression of being protuberant due to the laxity of the rectus muscles. Causes of true abdominal distension are shown in Box 5.5. Look for any obvious distension or for peristaltic waves suggesting intestinal obstruction. Note the umbilicus, and whether or not there is a hernia. Palpation should be gentle and light. Always ask the child if his tummy hurts anywhere and watch his facial expression during palpation. The liver edge can be felt in normal children up to the age of 4 years; it can be anything up to 2 cm below the costal margin. When enlarged, the spleen may be felt below the left costal margin, and in infancy it is more anterior and superficial than in the older child or adult. Slight enlargement of the spleen can occur in many childhood infections. Causes of hepatosplenomegaly are listed in Table 5.2. Faecal masses can be felt in the left iliac fossa in constipated children. They often feel like a sausage which can be rolled underneath the finger tips. A full or distended bladder presents as a mass arising from the pelvis. Deep palpation of the kidneys can be carried out last. Although it would be logical to examine the groin area at this time, it is often better to do this at a later stage. If the child has cried persistently, it is still possible to examine the abdomen. When the baby breathes in and the abdominal muscles relax, the abdominal viscera and other masses, if present, can be palpated.

Box 5.5 Causes of abdominal distension

Obesity

Faeces (constipation, Hirschsprung’s disease)

Ascites (nephrotic syndrome, cirrhosis)

Gas (intestinal obstruction, swallowed air)

Pregnancy in adolescent girls

Distended bladder (lower abdomen)

Pyloric stenosis (upper abdomen)

Table 5.2 Causes of hepatomegaly and splenomegaly in children

Hepatomegaly	Splenomegaly	Hepatosplenomegaly
Glycogen storage disorders Congenital infections Heart failure Haemolytic disease of the newborn

Sickle cell disease

Spherocytosis

Malaria

The chest

Examining the chest in a child takes in both the respiratory and cardiovascular systems. The basic structure remains the same, at first looking then feeling then listening with the stethoscope. It helps to have let the child play with the stethoscope at an earlier stage of the examination to alleviate any worries about this strange instrument. Observation will give much of the information required for the diagnosis, particularly in younger children and infants. On observation, check for abnormalities which are fixed and those which become obvious on movement. Static deformities in children include pectus excavatum and carinatum which are a source of great anxiety to many parents, but are not usually of any clinical importance. Fixed indentation of the lower ribs at the line of insertion of the diaphragm (Harrison’s sulcus) may be seen in obstructive airway disease, due either to asthma or to a nasopharynx blocked by adenoidal hypertrophy or in conditions leading to increased pulmonary blood flow. Look from the side for an increased anteroposterior diameter of the chest, which could be a sign of a chronic lung disease such as cystic fibrosis. Thickening of the costochondral junction is felt in rickets (rachitic rosary). Note any scars as a result of cardiac surgery. It is important to look for the thoracotomy scar under the arms or even round the back, otherwise you will miss it (Box 5.6). Sternotomy scars usually indicate the child has had major heart surgery involving valves or closure of septal defects. Asymmetry of the chest becomes more obvious on movement (dynamic deformity) and may indicate an underlying pneumothorax or empyema. Look for any increased work of breathing. This may be indicated by seeing recession (intercostal or subcostal), tracheal tug or flaring of the nares when breathing or use of accessory muscles. Count the respiratory rate (Table 5.3) which, in infants, must be done over a minute to be accurate, due to periodic breathing. Listen for grunting respiration which is audible in infants who are attempting to prevent alveolar collapse by creating their own positive airway pressure. The grunting expiration is followed by inspiration, and then a pause.

Palpate the anterior chest wall for the cardiac impulse and for thrills. In children under the age of 5 years, the apex is normally in the fourth intercostal space just to the left of the mid-clavicular line. Midline shift can be assessed in this way as palpation for the trachea in the suprasternal notch can be difficult and unpleasant for the child. Vocal fremitus is of less clinical value the smaller the child. This is because of difficulty with cooperation and the small size of the precordium. Expansion is also better assessed by observation for the same reasons. The axillary nodes may now be felt in the same way as in adults.

Percussion of the chest is useful in older children, but in young children and infants it is only rarely of value. Tell the child ‘I am going to make you sound like a drum’. Percuss very lightly in babies, directly tapping the chest wall with the percussing finger rather than using another intervening finger. The chest is more resonant in children than in adults.

A stethoscope with a small bell chest piece is suitable for auscultation of the child’s chest. Do not use adult-sized chest pieces, as it is impossible to localize added sounds accurately with a chest piece covering such a wide area in a small child. Often it is less threatening to examine the back of the chest first, and much more information about the lungs can be acquired in this way. Listen for the breath sounds and adventitious sounds. Because of the thin chest wall, breath sounds are louder in children than in adults, and their character is more like the bronchial breathing of adults (puerile breathing). Upper respiratory tract infections in children often give rise to loud, coarse rhonchi, which are conducted down the trachea and main bronchi (Table 5.4). All is not lost if the child is crying, as this is associated with deep inspiration, and this is the time to listen for the character of the breath sounds.

When you are auscultating the front of the chest, the child’s immediate instinct is to push the stethoscope away. You can ask the parent to hold the child’s hands or try and distract the child with toys held in the hand (Fig. 5.3). It is a good idea to examine a doll or teddy bear first if the child is playing with one. The normal splitting of the first and second sounds is easier to hear in children than in adults. Venous hums and functional systolic flow murmurs are often heard in normal children (Box 5.7). If the murmur does not fit into this classification, remember that most cardiac problems in children are as a result of congenital heart disease and not acquired as in adults (Table 5.5). Count the heart rate in young children (see Table 5.3). Arrythmias are uncommon in children unless they have had cardiac surgery.

Figure 5.3 Attracting the attention of a 10-month-old baby while examining her heart.

Table 5.5 Categories of key congenital heart disease lesions

Neurological examination

The neurological examination can usually be carried out in the normal way in older children, but in younger children the extent of the neurological examination will depend on the child’s age and willingness to cooperate. Although a great deal should have been learned already from initial observations, still look at the child’s posture. Asymmetry may indicate a hemiparesis. A hypotonic child may sit on his back rather than his bottom and an infant may display a ‘frog leg’ posture when lying down. If the child is walking, the gait should have been observed. Look for toe walking (spasticity), wide-based gait (seen in cerebellar ataxia but normal in toddlers) and limping (antalgic gait or hemiplegia). Hemiplegia may become more obvious on running as the affected upper limp is brought up closer to the body.

Note any abnormal movements. Tics or habit spasms are repetitive but not purposeful movements, such as shrugging of the shoulders or facial grimacing. Choreiform movements are involuntary, purposeless jerks that follow no particular pattern. Athetoid movements are writhing and more pronounced distally. Fits may be seen as lip smacking or flickering eye movements.

Take the opportunity to check for spinal abnormalities such as scoliosis or kyphosis or any evidence of spina bifida such as a tuft of hair. Be careful to pick up on any signs of a neurocutaneous disorder such as café au lait spots or telangiectasia.

Coordination can best be checked by watching a child at play. It is useful to have toys available that require a degree of coordination, such as a toy farm or garage. Otherwise, a modification of the finger–nose test using a toy held in the hand can be used. If the child is old enough, watching him dressing or doing up shoelaces is a good way to assess coordination.

Check muscle tone if this has not already been done. Pick the child up if there is still a friendly relationship. This gives a good idea of the feel of a child and of the muscle tone. If the child is hypotonic, it will feel as though he or she is slipping through your hands. Muscle power is difficult to check in young children except by watching playing habits, and assessing power by ability at a variety of lifting games. Always remember to check for neck stiffness, by testing resistance to passive neck flexion rather than by testing for Kernig’s sign.

Testing of sensation is difficult in young children, and is probably best omitted unless there is a strong suspicion of neurological disease.

Testing the cranial nerves takes a little ingenuity. Eye movements are relatively easy using a toy moved in different directions in front of the baby’s face. Young infants will often copy poking out the tongue at them, which will check the twelfth cranial nerve. If the child can be made to smile, and even if he is crying, any asymmetry of facial movements can be seen. If a child is able to bite on a wooden spatula, the trigeminal nerve is probably intact.

Getting a child’s limbs into the correct position to test tendon reflexes may take some time. Often they can be elicited by using a finger rather than a patellar hammer. Tendon reflexes in young infants tend to be brisk, and up to 18 months of age the plantar responses are extensor. The persistence of an extensor response beyond the age of 2 years indicates an upper motor neurone lesion. Note whether primitive reflexes have persisted (Box 5.8) indicating significant neurodevelopmental dysfunction.

The eyes

The eyes should now be checked. Inspect them for ptosis, conjunctivitis, cataracts or congenital defects such as colobomata. Watch for spontaneous nystagmus or roaming eye movements which may indicate a visual impairment. It is very important to check for squints, as immediate ophthalmological referral is necessary, however young the infant. Squints are checked for by shining a light in the eyes from in front of the face; the light reflex should be at the same position in each cornea. A cover test should then be used (see Ch. 14), using a doll or some other appropriate toy on which the child can focus his gaze. Pupillary accommodation and light reactions can be noted at the same time. Examination of the fundus is particularly difficult in infants and will require dilatation of the pupils. It should be possible to see the red reflex which, if absent, is suggestive of a corneal, lens or vitreous opacity, such as cataract or retinoblastoma. Usually, enough of the disc can be seen to detect papilloedema. The testing of vision in young children is included in the section on developmental screening examination (see p. 72).

With the possible exception of the eye examination, nothing so far should have upset a baby unduly. The following examinations should be carried out at the end of the consultation, as they are more likely to upset the child.

The genitalia, groins and anus

The nappy or underpants can now be removed if it is necessary to examine the groin or anus. In boys, notice the penis. The lack of retraction of the foreskin can be a source of worry to parents but it is normal for it not to retract under the age of 5 years. Forcibly attempting retraction is not only painful but can also result in balanitis. Check the hernial orifices and see whether the testes have descended. To feel the testes, make sure that the examining hand is warm and place a finger in the line of the inguinal canal; advance the finger towards the scrotum. This will stop the cremasteric reflex causing the testes to disappear into the inguinal canal, which tends to happen if the scrotum is approached from below. In young babies, it is not unusual to find a testis in the inguinal canal, but it can usually be pushed into the scrotum without too much difficulty. The testis can be expected to descend into its normal position with increasing maturity.

In girls, check the vulva for redness, soreness or discharge which are commonly seen in vulvovaginitis. Fusion of the labia is not uncommon, so check that they separate normally. Enlargement of the clitoris suggests an endocrine disorder. Check for inguinal lymph nodes at this time, and palpate the femoral arteries (simultaneously with the radials) to exclude coarctation of the aorta.

Examination of the anal margin can best be carried out by gently separating the buttocks with one hand on either side; the anal orifice can then easily be seen and inspected for fissures which are commonly associated with constipation. Rectal examination is rarely necessary in children and, if carried out, should be done with a well-lubricated, gloved little finger, which should be advanced very slowly.

In older children and adolescents, it is important to assess puberty using the Tanner stage (Table 5.6). This will involve examination of the genitalia and looking for breast development and body hair.

The nose, ears, mouth and throat

The worst parts of the examination as far as the child is concerned are the nose, ears, mouth and throat.

The nose need only be examined superficially, looking for nasal patency, any deviation of the septum or the presence of polyps or inflamed nasal turbinates. Older children are quite good at sniffing, and this will give some idea of nasal patency.

A cooperative child will allow a look into his ears but, if not, the child should be held by the mother, as shown in Figure 5.4. Held in such a way, the child can be kept still long enough for the eardrums to be inspected. Look carefully for the light reflex, which can be lost if the child has chronic secretory otitis media (‘glue ear’). In acute suppurative otitis media, the drum may be bright red and bulging.

Figure 5.4 How to hold a baby to allow the ears to be examined. The mother faces the baby to one side and holds him firmly, with one arm around the head and the other around the upper arm and shoulder.

The mouth and throat can be examined by encouraging a cooperative child to ‘show me your teeth’; an open mouth will then allow a clear view of the mouth and fauces. If uncooperative, the child will need to be held as shown in Figure 5.5. Sometimes it is not too disastrous if the child cries at this point, as this will give a very clear view of the teeth, the tonsils and sometimes even the epiglottis. A spatula is a terrifying instrument to the average child, causing most to clamp their teeth shut. If this happens, the spatula should be advanced to the back of the tongue to induce a gag reflex. Look for the presence of the white patches of candida infection, ulcers seen in Crohn’s disease and the Koplik’s spots seen in measles.

Figure 5.5 How to hold a baby to allow the mouth and throat to be examined. The baby faces the examiner, with the mother holding him firmly with one hand on the forehead and the other holding both arms.

The general physical examination has now been completed. It is to be hoped that the child is still friendly. Once the child is dressed, the examiner should sit with the parents and explain what has been found. It is always best for the child to have finished dressing before talking to the parents: they are more likely to listen and take in what you have to say if they are not worrying about buttons or shoelaces. Always involve an older child in the discussion, as they have every right to know what is wrong. Even young children can be told that they will be all right. Never under any circumstances deceive a child. The eventual truth will lose their confidence at that time and with later medical attendants.

Routine measurements

Height and weight

Childhood is a period of growth, the pattern of which may be adversely affected by many disturbances of health as well as social deprivation. Serial measurements of height and weight are therefore essential in the examination of children. In children able to stand, height can be measured against a wall-mounted gauge. Younger children can be measured lying down on special measuring boards. Measurements should be made under standard conditions, and children should be weighed unclothed. If the child keeps any clothes on, this should be noted against the weight so that subsequent weights can be taken with the child wearing the same quantity of clothing. Heights and weights should be compared with those of healthy children of similar sex, age and build on percentile charts. Figures 5.6 and 5.7 show standard height, weight and head circumference charts for UK boys and girls from birth to 4 years. The corresponding charts for children aged 4-18 years are in development at the time of writing – full-size versions of the current charts for 0-20 years are available in clinical settings in the meantime.

Figure 5.6 Height, weight and head circumference: boys aged 0-4 years.

Figure 5.7 Height, weight and head circumference: girls aged 0-4 years.

Comparison should also be made against the parents’ height by calculating the mid-parental height. This is done by adding together the height of the father and mother (cm) and dividing by two. Add 7 cm for a boy and take away 7 cm for a girl. Plot the final value in centimetres at the final adult height line (either at 18 years or 20 years depending on the chart used) to find the child’s expected centile. A child who fails to grow at an appropriate velocity (growth rate) needs to be investigated further. The term ‘failure to thrive’ is used to denote children whose weight gain is below that expected (fallen across two centiles on the chart). He will need a very careful history and examination to be carried out. It is important to pick up any markers of potential disease (such as chronic diarrhoea, recurrent chestiness). There are as yet no satisfactory growth charts for children of Asian origin born in the UK, who tend to be smaller than Caucasian children at least in the first few years of life. As a rough guide, the mean percentile for an Asian child is the 25th percentile on the standard UK charts.

There are special growth charts for children with Down’s syndrome and Turner’s syndrome. The meaning of the term ‘10th percentile’ is that 10% of all normal children are respectively lighter or shorter at the age concerned. Slightly different standards are applicable in different races and in different countries. Preterm infants should be plotted according to their corrected age (chronological age minus the number of weeks born early) up until the age of 2 years.

Developmental screening examination

The developmental examination assesses the acquisition of learned skills. Development progresses from head to toe (a child needs to be able to hold his head up before he can sit unsupported). It also requires the loss of primitive reflexes (see Box 5.8) at the appropriate age to progress (a child cannot transfer objects between his hands if he still has a grasp reflex). Developmental progress can be affected by emotional difficulties, environment (e.g. lack of stimulation due to neglect) and illnesses.

All infants should have a simple developmental screening examination at regular intervals. Table 5.1 lists the important milestones. Detailed developmental assessment is a specialist subject, but it is important for all those who examine children to be able to carry out a simple developmental screening examination, and to be aware of all the basic milestones.

It is usual to consider development under four main headings:

Screening for developmental delay involves testing the child’s performance of a few skills in each of the four fields of development, and comparing the results with the average for children of the same age. The range of normal developmental progress is wide, and the milestones shown in Table 5.1 are those of an average normal baby. Delay in all fields of development is more significant than delay in one only, and severe delay is more meaningful than slight delay. Allowance must always be made for those infants who were born prematurely, at least until the age of 2 years, by which time they should have caught up.

By 18 months of age, obvious deviations from normal development should become apparent. Beyond this age, developmental testing is more specialized, and is beyond the scope of this chapter. A baby who appears to have delayed development on screening will need further specialized assessment to establish the cause and subsequent management.

Techniques used

The same rules apply to the techniques used in developmental screening as to those of general physical examination. As with all parts of the examination, much more is learned by simply watching a child play and watching his reactions to the surroundings. Time has to be spent gaining the friendship of the child. For example, when offering a 10-month-old baby a small toy, watch to see how he grasps it and reacts to it. Let the baby play with the toys and bricks while sitting on the mother’s lap, and if the child remains suspicious, get the mother to offer the various objects.

In the UK, developmental screening is usually carried out by a health visitor who is trained in developmental skills and will refer to a doctor babies about whom there is any suspicion. There is always an assessment at 6 weeks and at 8 months of age. The 18- and 24-month tests are now focused on ‘at-risk’ children and are more selective.

Head control

By 4 months, babies can normally keep their head in line with the trunk when pulled from supine to sitting and, when held in the sitting position, will keep their head upright. Before this age, the head lags behind the trunk (Figs 5.8 and 5.9).

Figure 5.8 Head control at 6 weeks of age.

Figure 5.9 Head control at 4 months of age.

Testing vision

Much will be learned about a child’s vision by observation. Note whether the child is looking around the room and at particular toys, or staring at nothing in particular, especially if there are random or nystagmoid eye movements, the latter suggesting that the child is unable to see. When he picks toys up, is accommodation normal? The routine examination of the eye has been dealt with in the first part of this chapter.

Checks of visual acuity are not easy in young babies. By 6 weeks of age, babies should be following their mother with their eyes, and by 6 months they should be able to follow a rolling ball at 3 metres. This is the basis of one method of visual testing at this age. The ability of the child to follow rolling balls of differing diameters gives an accurate assessment of visual acuity. At the 8-month check, the baby should be able to see and pick up an object the size of a raisin at arm’s length. From the age of approximately 2 years, the Sheridan-Gardiner test is used. This is a simple comparison test, with the examiner indicating letters or familiar toys on a board and asking the child to indicate a similar object on a board held by the mother. The acuity is the ability of the child to pick out the smallest objects (see Ch. 19).

Testing hearing

In the past, it was usual to check the hearing for the first time between 6 and 8 months of age using the distraction test (Fig. 5.10). This can still be used as a screening method but has a large observer error and has largely been replaced by a national screening programme for all newborn babies, based on otoacoustic emissions. This measures vibration reflected from the normally functioning cochlea. Additionally, brainstem auditory evoked potentials are used to assess the more vulnerable babies with the risk factors detailed in Box 5.10. This measures electrical activity in the baby’s brain in response to sound. Audiometry and tympanometry are methods used in older children who can cooperate with the tests. They are useful for detecting middle-ear disease or glue ear which is more common in this group of children (see Ch. 20).

Figure 5.10 Testing hearing at 8 months: the child is held upright and forward on his parent’s lap and distracted by an examiner in front of him. An examiner then presents sounds at 35 dB at different frequencies behind him and observes if the child turns towards the direction of the sound.

Box 5.10 Risk factors for hearing impairment

Family history of deafness

Congenital malformations (particularly ear, facial and spinal)

Congenital infections (rubella, cytomegalovirus)

Perinatal illness (gestation below 32 weeks at birth, low birth weight, jaundice)

Postnatal illness (meningitis)

Examination of the newborn

The Apgar Score (Box 5.11) is used immediately after birth as a basic indicator of neurological status and will be the first assessment a baby will have in his life. An Apgar Score of 6 or less at 5 minutes after birth is associated with neurological deficit in about 10% of cases. A high Apgar Score at 5 minutes, on the other hand, may not be sensitive to focal brain injury or infarction.

The routine examination of the newborn infant (Box 5.12) is much more useful and is designed to assess the general state of health and to detect congenital abnormalities. It must always be interpreted in the context of the history of the pregnancy and birth and in the knowledge of any known history of inherited disorders in the family. It is recommended that all babies should be examined within the first 24 hours of life, and again before the end of the first week.

Weight will usually have been measured by the midwife. The head circumference (occipitofrontal) may not be measured before 48 hours, to allow for moulding to subside. Note whether meconium, the dark green, sticky stool of the newborn baby, has been passed within the first 24 hours. If not, Hirschsprung’s disease (agangliosis of the rectum) might be present.

It provides reassurance to the baby’s mother to conduct the examination in front of her. Have the baby undressed, in a warm place and treat the baby gently, leaving the most unpleasant parts of the examination until last. Talk to the baby: he is as aware of what is going on as an older child and should be afforded the same courtesy.

Much of the time can be spent just watching the baby, noting the state of awareness. If the baby is awake, seemingly looking around and not crying, examination of the nervous system will yield more information.

Primitive reflexes

Primitive responses are present in the normal newborn infant and disappear at variable times in accordance with developmental progress (see Box 5.8). They are responses to specific stimuli, and depend to some extent on the infant’s state of wakefulness. The absence of one or more of these reflexes in the newborn infant may indicate some abnormality of the brain, a local abnormality in the affected limb or a neuromuscular abnormality. The most well-known startle reflex is the Moro reflex (Fig. 5.11). As it is a startle reflex and may make the baby cry, it should be left until the end of the examination. A clearly unilateral response suggests some local abnormality, such as a fracture or brachial plexus injury in the arm on the side that does not respond. Persistence of primitive reflexes beyond the fourth month of life should alert you to the possibility of developmental delay.

Figure 5.11 Eliciting the Moro reflex.

Examination of the hips

Examination of the hips is essential but should be left to the end because it can be uncomfortable for the baby. It is performed by carrying out two provocation manoeuvres to demonstrate that the femoral head can be dislocated and then lifted back into the acetabulum, as illustrated in Figures 5.12 and 5.13. It is usual to differentiate between a tendinous ‘click’ and the typical ‘clunk’ of a hip moving in and out of its socket. The latter is more a feeling than an actual noise. Asymmetry of skin creases on the upper posterior thigh and limitation of abduction are signs which do not develop until 6 weeks of age. If there is any doubt about the hip, ultrasound examination should be carried out. Routine ultrasound examination of the hips of all at-risk newborn babies should be carried out to screen for congenital dislocation. At-risk babies are those where there is a breech delivery, a family history of congenital dislocation of the hip (especially if female) and any baby in an unusual intrauterine position.

Figure 5.12 Stage 1 of the examination of the hips: the hips are flexed, rotated medially and pushed posteriorly. This will dislocate dislocatable hips.

Figure 5.13 Stage 2 of the examination of the hips: the hips are abducted and a ‘click’ or a ‘clunk’ is felt for (see text). Note the position of the examiner’s hands, with the thumbs on the medial aspect of the thigh and the fingers over the lateral trochanters.

Summary

Throughout this chapter, emphasis has been placed on getting to know the child and treating him as gently as possible. Time has to be spent gaining the child’s confidence. This can only be acquired by examining or playing with children at each and every opportunity. Students and doctors new to working with children have a natural anxiety when approaching young children, and it is only by playing and being with them that confidence in examining them will develop. Developing and practising the skills of the examination of children is a challenge that is immensely rewarding when completed satisfactorily.