PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Perform less invasive maneuvers early and potentially distressing maneuvers near the end of the examination
For example, palpate the head and neck and auscultate the heart and lungs early, and examine the ears and mouth and palpate the abdo- men
near the end
First principle
Child development proceeds along a predictable pathway
You can measure age-specific milestones and characterize development as normal or abnormal
Once a milestone is met, the child proceeds to the next one
Because an office visit takes place at one point in time, you need to determine where the child fits along a
developmental trajectory
o Loss of milestones is a cause for concern
Understanding the normal physical, cognitive, and social development of children is critical to performing effective interviews
and physical exams and is the basis for distinguishing normal from abnormal findings
Second principle
The range of normal development is wide
Children mature at different rates
Each childs physical, cognitive, and social development should fall within a broad developmental range
Third principle
Various physical, social, and environmental factors, as well as diseases, can affect child development and health
Chronic illness, child abuse, and poverty are some examples of factors that can cause detectable physical
abnormalities and alter the rate and course of development
Children with physical or cognitive disabilities may not follow expected age-specific developmental trajectory
Fourth principle
The childs developmental level affects how you conduct the history and physical exam (specific to examination)
Differs between age groups
The order and style differ from an adult examination
You must adapt your physical exam to developmental level of child while simultaneously attempting to ascertain the
developmental level
An understanding of normal helps achieve these tasks
Adult visits
1-2x per year
Infant visits
5-7x per year
Age-appropriate
Physical (maturation, growth, puberty)
developmental
Motor (gross and fine motor skills)
achievement of the child
Cognitive (developmental milestones, language, school performance)
Emotional (self-efficacy, self-esteem, independence, morality)
Social (social competence, integration with family and community)
Anticipatory guidance
Healthy habits
Nutrition and healthy eating
Safety and injury prevention
Physical activity
Sexual development and sexuality
Self-responsibility and efficacy
Family relationships
Emotional and mental health
Oral health

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Recognition of illness
Screen time
Prevention of risky behaviors
School and vocation
Peer relationships
Community interactions

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

ASSESSING THE NEWBORN

Infancy the first year of life, is divided into two parts
o Neonatal period first 28 days
o Postneonatal period 29 days to 1 year
First exam is done immediately after delivery by obstetrical or pediatric clinicians
A comprehensive pediatric exam is performed within 24 hours of birth
Subsequent physical exams occur at regular intervals or when the child is ill

TIPS FOR EXAMINING THE NEWBORN

Examine in presence of parents
o Stating normal findings as you go can be reassuring
o Newborns are most responsive 1-2 hours after feeding
Swaddle and then undress newborn as exam proceeds
o If newborn becomes agitated, use a pacifier, bottle (if not breastfeeding, gloved finger for sucking, or reswaddle
Dim the lights and rock newborn to encourage opening of eyes
Observe feeding if possible
Demonstrate calming maneuvers to parents
Observe and teach parents about transitions as the newborn arouses

TYPICAL EXAM SEQUENCE FOR NEWBORN

Careful observation
Head, neck, heart, lungs, abdomen, genitourinary system
Lower extremities and back
Ears and mouth
Eyes, whenever they are spontaneously open
Skin as you go along
Neurologic system
Hips

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

ASSESSMENT AT BIRTH
Important for determining general condition, developmental status, abnormalities in gestational development, and any congenital abnormalities
Exam may reveal diseases of cardiac, respiratory, or neurologic origin
APGAR SCORE
o An assessment of newborn immediately after birth
o 5 components classify newborns neurologic recovery from birth and immediate adaptation to extrauterine life
o Scoring done at 1 and 5 minutes after birth but may continue at 5 minute intervals until score >7

Clinical Sign
Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color

0
Absent
Absent
Flaccid
No response
Blue or pale

APGAR SCORING SYSTEM

1
<100
Slow and irregular
Some flexion of the arms and legs
Grimace
Pink body, blue extremeties

2
>100
Good & strong
Active movement
Cry vigorously, sneeze or cough
Pink all over

ASSESSMENT AT BIRTH
Gestational Age and Birth weight
o Classifications help predict medical problems and morbidity
o Gestational age is based on specific neuromuscular signs and physical characteristics that change with gestational maturity

CLASSIFICATION BY GESTATIONAL AGE AND BIRTH WEIGHT (1 lb = 0.45 kg)

Preterm = <37 weeks
Extremely low birth weight = <1 kg
Late preterm = 34-36 weeks
Very low birth weight = <1.5 kg
Term = 37-42 weeks
Low birth weight = <2.5 kg
Postterm =>42 weeks
Normal birth weight = 2.5 kg
Postterm infants are at increased risk of perinatal mortality or morbidity such as asphyxia and meconium aspiration

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Newborn Classification
th
Small for gestational age SGA <10 percentile
th
Appropriate for gestational age AGA 10-90 percentile
th
Large for gestational age LGA >90

Types of Abnormalities
LGA (large for gestational age) infants may experience difficulties during birth. Infants of mothers with diabetes are often LGA and may have metabolic
abnormalities shortly after birth, as well as congenital anomalies.
A common complication among LGA newborns is hypoglycemia, which can result in jitteriness, irritability, cyanosis, or other health issues
Preterm AGA infants are more prone to respiratory distress syndrome, apnea, patent ductus arteriosus with left-to-right shunt, and infection
Preterm SGA infants are more likely to experience asphyxia, hypoglycemia, and hypocalcemia
ASSESSMENT SEVERAL HOURS AFTER BIRTH
Observe undressed newborn
Note color, size, body proportions, nutritional status, posture, respirations, and movements of head and extremities
o In breech babies (buttock first), the knees are exed in utero
o In a frank breech baby, the knees are extended in utero. In both, the hips are flexed.
Note babys spontaneous motor activity, with flexion and extension alternating between arms and legs
Fingers usually flexed in tight fist
o By 4 days after birth, tremors at rest signal central nervous system disease from various possible causes, ranging from asphyxia to
drug withdrawal
May observe brief tremors of the body and extremities during vigorous crying, and even at rest
o Asymmetric movements of the arms or legs at any time suggest central or peripheral neurologic defecits, birth injury (such as a
fractured clavicle or brachial plexus injury), or congenital anomalies

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

AREAS OF ASSESSMENT
Physical development
o Neurologic development progresses centrally to peripherally
o Thus, first comes head control before trunk control and use of arms and legs, then use of hands and fingers
Cognitive and Language development
o Exploration fosters increased understanding of self and environment
o Infants learn cause and effect, object permanence, and use of tools
o Language proceeds from cooing to babbling to saying words
Social and emotional development
o Social tasks include bonding, attachment to caregivers, and trust that needs will be met
o Temperaments vary. Some respond positively to new stimuli whereas others respond intensely or negatively

GENERAL GUIDELINES
Use developmentally appropriate methods such as distraction and play to examine infant
Start with infant lying or sitting in parents lap
Observe infant and parent-infant interactions closely
Undress infant but leave on diaper
Check milestones at the end of the interview, just before examination
o AAP recommends use of standardized developmental screening instruments as adjuncts to comprehensive developmental exam
o Developmental DDST (Denver Developmental Screening Test)
o Autism - MCHAT (Modified Checklist for Autism in Toddlers)

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Infancy

2 months

4 months

6 months

0-12 months
most rapid rate of growth
birth weight triples, heigh increases by 50%
Social and Emotional
o Begins to smile at people
o Tries to look at parent
Language/Cognitive
o Coos, makes gurgling sounds
o Turns head toward sounds
o Pays attention to faces
o Begins to act bored (cries, fussy) if activity doesnt change
Physical
o Can hold head up; begins to push up when lying on tummy
o Makes smoother movements with arms and legs
Social and Emotional
o Smiles spontaneously, especially at people
o Copies some movements and facial expressions,
Language/Cognitive
o Babbles with expression and copies sounds he hears
o Cries in different ways to show hunger, pain, or being tired
o Responds to affection
o Reaches for toy with one hand
Physical
o Holds head steady, unsupported
o Pushes down on legs when feet are on a hard surface
o May be able to roll over from tummy to back
Social and Emotional
o Knows familiar faces and begins to know if someone is a stranger

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

9 months

1 year

Health supervision visits

o Likes to look at self in a mirror

Language/Cognitive
o Strings vowels together when babbling (ah, eh, oh)
o Responds to own name; Looks around at things nearby
Movement/Physical Development
o Rolls over in both directions (front to back, back to front)
o Begins to sit without support
o When standing, supports weight on legs and might bounce
Social and Emotional
o May be afraid of strangers (STRANGER DANGER)
o May be clingy with familiar adults; Has favorite toys
Language/Cognitive
o Understands no; copies sounds and gestures
o Picks up things like between thumb and index finger
Physical
o Stands, holding on
o Can get into sitting position; Sits without support
o Pulls to stand; Crawls
Social and Emotional
o Puts out arm or leg to help with dressing
o Plays games such as peek-a-boo and pat-a-cake
Language/Cognitive
o Shaking head no or waving bye-bye
o Says mama and dada and exclamations like uh-oh!
o Drinks from a cup, brushes hair
o Follows simple directions like pick up the toy
Movement/Physical Development
o Gets to a sitting position without help
o Pulls up to stand, walks holding on to furniture (cruising)
o May take a few steps without holding on; May stand alone

HEALTH PROMOTION AND COUNSELING

Periodicity schedule
At birth
3-5 days
By 1 month

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Opportunities at visit

Length
Weight
Head circumference

at 2, 4, 6, 9, and 12 months
Answer parent questions
Assess infants growth and development
Perform a comprehensive exam
Provide anticipatory guidance
Infants that are generally well during these visits enhances the quality of experience
GENERAL SURVEY AND VITAL SIGNS
For children < 2 years, measure body length by placing child supine with hips and knees extended and marking top of
head and bottom of feet then using a tape measure to measure length or by use of measuring tray/board
Directly weigh child on scale while naked or only in diaper
Should always be measured during first 2 years. Use tape measure to directly measure

Types of Abnormalities
A common cause of an apparent deviation in somatic growth is measurement error. Confirm by repeat measurement
Although many normal infants cross percentiles, a sudden or significant change in growth may indicate systemic disease due to various possible organ
systems
Failure to thrive is inadequate weight gain for age
A small head size may result from premature closure of the sutures or microcephaly, which may be familial or due to chromosomal abnormalities, congenital
infections, maternal metabolic disorders, and neurologic insults
th
An abnormally large head (> 95 percentile) is macrocephaly, which may result from hydrocephalus, subdural hematoma, or other rare causes

Blood pressure

Pulse

Age
Birth-1 month
1-6 months
6-12 months
Respiratory rate

GENERAL SURVEY AND VITAL SIGNS

This measurement is important for some high-risk infants
Should routinely be performed after age 3 years with doppler method
SBP gradually increases throughout childhood
o Birth=70 mmHg
o 1 month= 85 mmHg
o 6 months= 90 mmHg
More sensitive to effects of illness, exercise, and emotion than that of adults
Use femoral or brachial artery or auscultate the heart for accurate measurement
Average Heart Rate
140
130
115
Similar to pulse in responsiveness
Rate ranges from 30-60 breaths/minute in newborn

Range
90-190
80-180
75-155

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Temperature

Rate may vary considerably from moment to moment in newborn alternating from periods of rapid to slow
breathing
Sleeping respiratory rate is most reliable
Respiratory pattern should be observed for at least 60 seconds to assess both rate and pattern
In infancy and early childhood, diaphragmatic breathing is predominant; thoracic excursion minimal
Tachypnea:
<2 months= > 60/min
2-12 months= > 50/min
Because fever is common in children, obtain an accurate body temperature
Axillary and thermal tape skin temperature recordings in infants and children are inaccurate
Auditory can recordings are accurate
Rectal temperature is usually above 99.0 F (37.2 C)until after age of 3 years
Fever: temp > 38C or > 100.4F

Types of Abnormalities
Causes of sustained HTN in newborns include RAS (stenosis, thrombosis), congenital renal malformations, and coarctation of aorta
Extremely rapid and shallow respiratory rates are seen in newborns with cyanotic cardiac disease and right-to-left shunting, and metabolic acidosis
Fever can raise respiratory rates in infants by up to 10 respirations per minute for each degree centigrade of fever
Tachypnea and increased respiratory effort in an infant are signs of lower respiratory disease such as bronchiolitis or pneumonia
Fever in infants < 2-3 months may be a sign of serious infection or disease. These infants should be evaluated promptly
Anxiety may elevate temp
Excessive bundling of infant may elevate skin temperature but not the core temperature

Inspection

Cutis Marmorata

SKIN IN THE INFANT

Newborn has unique characteristic texture and appearance
Within 10 minutes from birth skin usually progresses from generalized cyanosis to pinkness
An erythematous flushed boiled lobster appearance may appear in lighter-skinned infants
Vasomotor changes in dermis and subcutaneous tissue
A response to cooling or chronic exposure to heat can produce a mottled, latticelike appearance

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Acrocyanosis

Blue clast to hands and feet when exposed to cold

Common in newborns for the first few days
Consider cyanotic congenital heart disease if it does not disappear within 8 hours or
with warming

Mongolian Spots

Pigment changes
Varying amounts of melanin in the skin of newborns
Dark or bluish pigmentation over buttocks and lower lumbar region
Common in newborns of African, Asian or Mediterranean descent
Usually disappear in childhood
DOCUMENT them! This is to avoid later concerns about bruising

Lanugo

Fine, downy growth of hair over the entire body

Especially shoulders and back
All original hair is shed within a few months and replaced with new hair, sometimes
of a different color
Lanugo is prominent in premature infants

Vernix Caseosa

Cheesy white material composed of sebum and desquamated epithelial cells

covering the body

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Superficial Desquamation

Some newborns have edema over their hands, feet, lower legs, pubis, and sacrum
This disappears within a few days
Superficial desquamation of the skin is often noticeable 24 to 36 hours after birth,
particularly in postterm babies (>40 weeks gestation)

Miliaria Rubra

Prickly heat
Scattered vesicles on an erythematous base, usually on face and trunk
Result from obstruction of the sweat gland ducts
Disappears spontaneously within weeks

Erythema Toxicum

Usually appears on days 2-3 of life

Rash consists of erythematous macules with central pinpoint vesicles scattered
diffusely over the entire body

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Pustular Melanosis

More common in black infants

Rash presents at birth as small vesiculopustules over a brown macular base
Can last for several months

Milia

Pinhead-sized smooth white raised areas without surrounding erythema on nose,

chin, forehead
Results from retention of sebum in openings of sebaceous gland
Occasionally present at birth but usually appears within the first few weeks and
disappears over several weeks

Jaundice

Normal physiologic
Yellowish staining of the skin and whites of the newborn's sclerae by pigment of
bile (bilirubin)
Physiologic jaundice of the newborn is also referred to as neonatal
hyperbilirubinemia and neonatal jaundice
o Physiologic jaundice occurs in half of all newborns, appears on the second
or third day, peaks at about the fifth day and usually disappears within the
week
Breast milk jaundice: indirect hyperbilirubinemia in a breastfed newborn that
develops after the first 4-7 days of life, persists longer than physiologic jaundice,
and has no other identifiable cause.
Breastfeeding jaundice: manifests in the first 3 days of life and is caused by
insufficient production or intake of breast milk
Jaundice can be best seen in natural daylight rather than artificial light
Newborn jaundice seems to progress from head to toe with more intense jaundice
on the upper body and less intense yellow color in the lower extremities
Apply pressure to skin to press out normal pink or brown color



Salmon Patch

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

AKA nevus simplex, flame nevi, telangiectatic nevus, capillary hemangioma

Flat, irregular, light pink patches and are most often seen on nape of neck (stork
bite), upper eyelids, forehead or upper lip (angel kisses)
Not true nevi
Result from distended capillaries
Disappear by 1 year and are covered by hairline

Caf-au-lait spots

Light brown pigmented lesions

Usually have borders and are uniform
Noted in more than 10% of black infants
If > 5 exist, consider the diagnosis of neurofibromatosis

Turgor

Assessing degree of hydration

Roll a fold of loosely adherent skin in the abdominal wall between your
thumb and forefinger to determine its consistency
Well hydrated skin will return to its normal position immediately upon release
Delay in return is a phenomenon called tenting and usually occurs in children with
significant dehydration

Turners Syndrome

Significant edema of the hands and feet of a newborn girl may be suggestive of
Turners syndrome

Assessing the head

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Anterior fontanelle
Posterior fontanelle
Assessing the fontanelles

Head
o
o

Inspect for symmetry

Palpate:
Sutures (feel like ridges)
Fontanelles (feel like soft concavities)
Head of newborn accounts for of body length and 1/3 of body weight
Sutures: membranous tissue spaces that separate the bones of the skull from
one another
Fontanelles: area where major sutures intersect in the anterior and posterior
parts of the skull

At birth measures 4-6 cm in diameter

Usually closes between 4-26 months of age (90% between 7-19 months)
At birth measures 1-2 cm
Usually closes by 2 months
Carefully examine the fontanelle, because its fullness reflects intracranial
pressure
Palpate while baby is sitting quietly or being held upright
Clinicians often palpate the fontanelles at the beginning of the exam
In normal infants, the anterior fontanelle is soft and flat
Pulsations of the fontanelle reflect the peripheral pulse

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

TYPES OF ABNORMALITIES
A bulging, tense fontanelle is observed in infants with increased intracranial pressure
o May be caused by CNS infections, neoplastic disease, or hydrocephalus
Early closure of the fontanelles can be due to developing microcephaly or other conditions
Delayed closure of the fontanelles is usually a normal variant, but can be due to hypothyroidism, megalocephaly, increased intracranial pressure or rickets
A depressed anterior fontanelle may be a sign of dehydration
ASSESSING THE SKULL
Carefully assess skull symmetry
Various conditions can cause asymmetry
o Some are benign while others reflect underlying pathology
Look for asymmetric head swelling
o A newborns scalp may be swollen over the occipitoparietal region (caput succedaneum)
o Subperiosteal hemorrhage from the trauma of birth (cephalohematoma)
o Asymmetry of cranial vault (positional plagiocephaly) occurs when infant lies mostly on one side
o Pick up infant and examine skull shape from behind
o Measure head circumference
Craniosynostosis
Premature closure of cranial sutures
On palpation, a raised bony ridge at suture line suggests craniosynostosis

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Caput Succedaneum

Swelling over occipitoparietal region: capillary distention and extravasation of blood

and fluid resulting from the vacuum effect of rupture of amniotic sac.
Swelling typically crosses suture lines and resolves in 1-2 days

Cephalohematoma

Common type of localized swelling of the scalp

Caused by subperiosteal hemorrhage from the trauma of birth
Swelling does not cross suture lines and resolves within 3 weeks
As it resolves and calcifies, there may be a bony rim with a soft center

Deformational
Plagiocephaly

AKA Positional Plagiocephaly

When infant lies mostly on one side, resulting in a flattening of the parieto-occipital
region on the dependent side and a prominence of the frontal region on the
ipsilateral side
Disappears as baby becomes more active

FACIAL SYMMETRY
Inspect the face of infants for symmetry
Examine the face for overall impression of the facies
Chvosteks sign percuss top of cheek just below zygomatic bone in front of ear, using tip of index or middle finger

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

o
o

+ sign produces facial grimacing caused by repeated contractions of facial muscles.

Noted in cases of hypocalcemic tetany, tetanus and tetany due to hyperventilation
EYES
Inspect sclerae, pupils and pupillary reaction, irises, extraocular movements, and red reflex
o Subconjunctival hemorrhages are common in newborns
Check for nystagmus
In first 10 days of life dolls eyes may be present (Normal in infants up to 3 months)
o Fixed eyes, staring in one direction
During first few months, some infants have intermittent crossed eyes or laterally deviated eyes
o Alternating stabismus persisting beyond 3 months, or persistent strabismus of any type may indicate ocular motor weakness or another abnormality in
the visual system
Opthalmoscopic Exam
Red reflex and fundus 0 diopters from 10 inches
Cornea seen at +20 diopters
Lens seen at +15 diopters
Examine optic disc
o In infants, optic disc is lighter in color, with less macular pigmentation
Look for retinal hemorrhages

Convergent strabismus

AKA Esotropia
Misalignment of the eyes, can lead to visual impairment
Inward deviation

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Divergent stabismus

AKA Extropia
Misalignment of the eyes, can lead to visual impairment
Lateral deviation

EARS
Inspect position, shape, features and for any abnormalities
o Positioned horizontally as the eyes
Otoscopic exam
o Pull auricle downward to view eardrum
o Note the light reflex is diffuse
Does not become cone shaped for several months
o Acoustic blink reflex blinking in response to sudden sharp sound approximately 1 foot away
Habituation phenomenom after elicited several times, the reflex disappears
Crude test for hearing
Most newborns in US are given hearing screenings
NOSE AND SINUSES
Most important component is to test for patency of nasal passages
Gently occlude each nostril alternately while holding infants mouth closed
o Normally does not cause stress
o Obligate nasal breathers for first 2 months
Inspect for midline position of nasal septum
Only ethmoid and maxillary sinuses are present at birth
o Palpation of newborns not helpful
MOUTH AND PHARYNX
Inspect with tongue blade and flashlight
Palpation of mouth and pharynx
o mucosa, tongue, frenulum, gums, palate, and posterior pharynx, upper hard palate
o Do not expect to visualize tonsils
Palpate gums and teeth
o Predictable pattern of tooth eruption and also wide variation
o Teeth: Rule of thumb- one tooth for each month of age between 6 to 26 months of age up to 20 primary teeth
o Central and lateral incisors erupt first, molars last
INFANT CRY

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Normal
Shrill/High-pitched
Hoarse
Continuous Inspiratory Expiratory Stridor

Absence of Cry

Lustry, strong
ICP
Narcotic addicted mothers
Hypocalcemic tetany
Congeital hypothyroidism
Upper airway obstruction
Infantile laryngeal stridor
Tracheomalacia
Severe illness
Vocal cord paralysis
Profound brain damage
THORAX AND LUNGS

Inspection
Carefully asses respirations and breathing patterns
Observe for nasal flaring
Listen to sounds of breathing noting any:
o Grunting, audible wheezing, or lack of breath sounds
Retractions
o Supraclavicular
o Intercostal
o Subcostal
Thoracoabdominal paradox: inward movement of the chest and outward movement of the abdomen during inspiration (abdominal breathing) is a normal finding in
newborns.
As muscle strength increases and chest wall compliance decreases with age, abdominal breathing should no longer be noted. If observed, may signify
respiratory disease
Palpation
o Assess tactile fremitus
o Percussion is not helpful in infants except in extreme instances
Auscultation
o Breath sounds are louder and harsher than in adults
o Characteristics of breath sounds (vesicular and bronchovesicular) and adventitious lung sounds (crackles, wheezes, and rhonchi) are the same as for
adults, except they may be more difficult to distinguish in infants and often occur together
LUNGS
Type of Assessment
Specific Observable Pathology
General appearance
Inability to feed or smile
Lack of consolability
Respiratory rate
Tachypnea
Color
Pallor
Cyanosis

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Nasal component of breathing

Audible breath sounds

Work of breathing

Techniques
Compare sounds from nose/stethoscope
Listen to harshness of sounds
Note symmetry
Compare sounds at different locations (higher or
lower)
Inspiratory vs. Expiratory

Nasal flaring
(enlargement of both nasal openings during inspiration)
Grunting (repetitive, short expiratory sound)
Wheezing (musical expiratory sound)
Stridor (high-pitched, inspiratory noise)
Obstruction (lack of breath sounds)
Nasal flaring
Grunting
Retractions (chest indrawing)
o Supraclavicular (soft tissue above clavicles)
o Intercostal (indrawing of the skin between ribs)
o Subcostal (just below costal margin)
LUNGS
Upper Airway
Same sounds
Harsh and loud
Symmetric
Sounds louder as stethoscope is moved up chest
Almost always inspiratory

Lower Airway
Often different sounds
Variable
Often symmetric
Often sounds louder lower in chest towards
abdomen
Often has expiratory phase

HEART
Inspect for cyanosis
Palpate:
o Peripheral pulses, especially brachial artery pulse in antecubital fossa, temporal arteries, femoral, dorsalis pedis, and posterior tibialis
o PMI is not always palpable
o Chest wall
o Thrills

Evaluate heart rhythm

Evaluate heart sounds normally crisp
Evaluate for heart murmur

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

MURMURS
Most children will have one or more functional murmurs
Two Common Benign Murmurs in Infants
o Closing ductus: transient, soft ejection
o Peripheral Pulmonary Flow Murmur: soft systolic

ABDOMEN
Inspect abdomen while infant is supine
o Infants abdomen is protuberant due to poorly developed abdominal musculature
Inspect newborn umbilical cord to detect abnormalities
Inspect area around umbilicus for redness and swelling
Inspect for umbilical hernia
o Maybe detected at a few weeks but most disappear by 1 year, nearly all by 5 years
Auscultate
o May hear an orchestra of tinkling bowel sounds
Percussion
o May note greater tympanitic sounds because of propensity to swallow air
Palpation
o Start gently palpating liver moving upward with fingers
o Assess liver size
o Palpate spleen
o Other structures and to identify abnormal masses
INFANT GENITALIA
Breasts
o Inspect and palpate for masses
o May also be engorged with a white liquid that may last 1-2 weeks
Male genitalia
o Inspect appearance of penis, testes, and scrotum
Foreskin completely covers glans penis and is non-retractable at birth (though you may be able to visualize external urethral meatus
Retraction occurs months to years later
o Palpate the testes in scrotal sacs
o Testes should descend by 1 year
Female genitalia
o Inspect all structures: labia majora/minora, clitoris, hymen, urethral orifice
o Often a white, milky blood-tinged discharge is present
MUSCULOSKELETAL
Focused on detection of congenital abnormalities, particularly in hands, spine, hips, legs, and feet
Inspect hands and fingers
Palpate the clavicle, noting lumps, tenderness or crepitus
Inspect the spine carefully-note any deformities, pigmented spots, hairy patches, deep pits
o Do NOT probe sinus tracts

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

Palpate spine in lumbosacral region

Examine hips carefully at each examination for signs of dislocation
Examine the hips for signs of dislocation
o Ortolani test and Barlow test
Examine legs and feet to detect developmental abnormalities
Assess symmetry, bowing, and torsion of legs
Feet may appear deformed from retaining intrauterine positioning
Ortolani & Barlow
Ortolani: tests for presence of posteriorly dislocated hip
Barlow test: tests for ability to sublux or dislocate an intact but unstable hip
Femoral Shortening
Galeazzi or Allis test

NERVOUS SYSTEM
Neurologic abnormalities in infants often present as developmental abnormalities such as failure to do age-appropriate tasks
Neurologic and developmental exams need to proceed together
Assess mental status
Inspect and palpate motor function and tone
Assess sensory function
Cranial Nerves
Deep tendon reflexes
Primitive Reflexes
o Palmar grasp
o Plantar grasp

PHYSICAL DIAGNOSIS: ASSESSING CHILDREN: INFANTS THROUGH ADOLESCENCE

o Rooting
o Moro (startle)
o Asymmetric tonic neck
o Trunk incurvation (Galants)
o Landau
o Parachute
o Positive support
o Placing and stepping
Development
Normal Reflexes:
Triceps
Brachioradialis
Abdominal reflexes