Chapter 18 Assessing Children: Infancy Through Adolescence

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Chapter 18

Assessing Children: Infancy Through Adolescence

Chapter 18

Assessing Children: Infancy Through Adolescence


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


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


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


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


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


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


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


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


AnswerAnswer

a. The anterior fontanelle closes between 4 to 26 months of age

• The posterior fontanelle closes by 2 months of age




• 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




• 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




• 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




• Musculoskeletal

– Inspect the spine

– Palpate the clavicle, hips, legs, and feet

o Bowlegged growth to age 18 months is normal




• 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


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


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


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


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




• 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


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


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.


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


Adolescence: Unique FeaturesAdolescence: Unique Features

• Puberty

– Tanner stages to determine stage of puberty


Adolescence: Unique Features (cont.)Adolescence: Unique Features (cont.)

• Male puberty



Adolescence: Unique Features (cont.)Adolescence: Unique Features (cont.)

• Female puberty


Chapter 18 Assessing Children: Infancy Through Adolescence

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