PEDIATRIC HEALTH ASSESSMENT

INTRODUCTION

The clinical assessment of infants and children differs in many ways from that for adults. Because
children are growing and developing both physically and mentally, values for parameters such as
dietary requirements and prevalence of disease, expected normal laboratory values and responses
to drug therapy will be different from those observed
in adults.

HEALTH MAINTENANCE REQUIREMENTS

Healthy children should have regular health maintenance visits, often done at well-baby clinics.
Such visits customarily occur at 1 and 2 weeks of age, at 1, 2, 4, 6, 9, 12 and 18 months of age,
and subsequently at 1- or 2-year intervals.
At each visit, the child should undergo an appropriate history, physical examination and
developmental assessment. Immunizations should also be given according to provincial
guidelines. Anticipatory guidance should be provided about the following topics:
– Appropriate nutrition
– Safety measures
– Expected developmental and behavioral events

In addition, an assessment should be made of the quality of physical care, nurturing and
stimulation that the child is receiving.
The most important components that should be assessed at each health maintenance visit
 Components of Well-Child Assessments at Various Ages
Health Parameter Most Important Ages for Assessment

Height, weight Every visit, from birth to 16 years of age

Head circumference Every visit in the first 2 years of life

Growth chart plotting Every visit

Blood pressure Once in the first 2 years, then every year starting at age 31

Eye assessment Every visit in the first year of life, then every well-child visit

Strabismus assessment Every visit in the first year of life, then every well-child visit

Visual acuity testing Initial screening (for example, Snellen chart) at 3–5 years of age;
every 2 years between 6 and 10 years of age, then every 3 years
until 18 years of age
Dental assessment Every visit

Speech assessment Every visit

Developmental assessment Every visit

Sexual development Every visit

School adjustment Every visit after child reaches school age

Chemical abuse Consider during assessments of children > 8 years of age

Immunizations According to provincial schedule: often at 2, 4, 6, 12 and 18

months and at 4–6 and 14–16 years
Haemoglobin Screen at 6–12 months

Safety counselling Every visit

Nutrition counselling Every visit

Parenting counselling Every visit

Parent/caregiver–child interactions Every visit

Formal developmental testing is done only if there is a concern on the part of the parents or caregiver or the health
care professional. Refer to the appropriate primary health care provider (for example, speech-language pathologist,
physician, psychologist) for assessment

The Rourke Baby Record (RBR), revised May 2009, is an evidence-based health supervision guide for
primary health care practitioners of children in the first 5 years of life.
The forms are available from the Rourke Baby Record web site (http://www.rourkebabyrecord.ca).
– Rourke Baby Record 2009: Evidence-based infant/ child health maintenance guides I–IV (birth to 5 years)
and immunization record
The Greig Health Record is an evidence-based child and adolescent health promotion guide for primary
health care practitioners caring for children aged 6 to 17 years

PEDIATRIC HISTORY
TIPS AND TECHNIQUES

CHILDREN
Children who can communicate verbally should be included as historians, with additional details provided
as necessary by parents or caregivers. Health care professionals should interact (for example, smile, coo) or
play with children so as to not scare them or make them cry.
Questions, explanations and discussions occurring with children present should take into account their
level of understanding. Young children may be assisted in providing details of the history by such
techniques as having them play roles or draw pictures. The interviewer should gain an understanding of the
child’s terminology for various body parts.

ADOLESCENTS
Adolescents should be granted privacy and confidentiality.
– Interview the adolescent alone
– Discuss with parents or caregiver separately, with the adolescent’s permission

COMPONENTS OF THE PEDIATRIC HISTORY

The pediatric history includes many of the same components as the adult history,
including:
– Identifying data
– Chief complaint
– History of present illness
– History of past illnesses
– Allergies
– Medication history
– Tobacco, alcohol and/or drug use
– Family history
– Personal and social history (including grade level, family of origin, interests, lifestyle)
– Review of systems
In addition, the pediatric history should include the following information:
– Who the primary caregiver is?
– Who is providing the history?
– Pregnancy and perinatal history
– Birth history, including Apgar score
– Immunization history
 – Detailed dietary history for the first year of life, including history of vitamin supplements and
fluoride use. Also include dietary intake for other age groups, including how much tea,
carbonated beverages and juice are being consumed
– Developmental history (including physical, cognitive, language, social and emotional)
– Social history, including questions about how many people live in the home, recent separations,
deaths, family crises, friends, peer relationships, daycare arrangements, progress in school,
smoking in the home and secure food access for child and family
– Physical environment at home, including presence of mold and poor heating or insulation

PHYSICAL EXAMINATION OF THE NEWBORN

Observe the entire infant at the beginning of the examination, before the assessment of specific organ
systems. It is important that the infant be completely undressed and in a warm environment with adequate
illumination

GENERAL APPEARANCE
Assess the following:
– Level of consciousness, alertness, general behavior and appearance (how well the baby looks)
– Symmetry of body proportions
– Posture of limbs (flexed, extended)
– Body movements (for example, arms and legs, facial grimace)
– State of nutrition and hydration
– Color
– Any sign of clinical distress (for example, respiratory distress includes dyspnea, pallor, cyanosis,
irritability)

VITAL SIGNS
Average values of vital signs for new-born’s:
– Temperature 36.5°C to 37.5°C
– Heart rate 120–160 beats/minute
– Respiratory rate 30–60/minute, up to 80/minute if infant is crying or stimulated
– Systolic blood pressure 50–70 mm Hg

GROWTH MEASUREMENTS
Measure and record length, weight and head circumference. If the infant appears premature or is
unusually large or small, assess gestational age
– Average length at birth 50–52 cm
– Average weight at birth 3500–4400 g
– Average head circumference at birth 33–35 cm (this is done only at well-child visits unless
hydrocephalus is suspected)
These parameters should be recorded on gender- appropriate growth curves, which should form
part of the child’s health record. Printable electronic versions of the growth charts are available
at:
– Growth charts for boys: Birth to 36 months, and 2 to 20 years
– Growth charts for girls: Birth to 36 months, and 2 to 20 years

SKIN
COLOUR
– Pallor associated with low hemoglobin or vasoconstriction (for example, in shock)
– Cyanosis associated with hypoxemia
– Plethora associated with polycythemia or vasodilation
– Cherry red face associated with carbon monoxide poisoning
– Jaundice associated with elevated bilirubin

LESIONS
 Milia: Pinpoint white papules of keratogenous material, usually on nose, cheeks and
forehead, which last several weeks and then spontaneously resolve
 Miliaria: Obstructed eccrine (sweat) ducts appearing as pinpoint vesicles on forehead,
scalp and skin folds; usually clear within 1 week
 Transient neonatal pustular melanosis: Small vesicopustules, generally present at birth,
containing white blood cells (WBCs) and no organisms; intact vesicle ruptures to reveal
a pigmented macule surrounded by a thin skin ring; spontaneously resolves by 3 months
of age
 Erythema toxicum: Most common newborn rash, consisting of variable, irregular
macular patches and lasting a few days
 Stork bite: Pink and flat nevus simplex, usually on face or back of the neck; those on face usually
disappear by 18 months4
 Café au lait spots: Irregular brown, flat macules. Suspect neurofibromatosis if there are many
(more than 5 or 6) large spots
 Mongolian spots: dark bluish/purplish patches present at birth, usually on back and buttocks but
may be on limbs; common in First Nation’s and Inuit children; usually fade away in first year of
life

HEAD AND NECK

HEAD
Check for:
– Overriding sutures
– Anterior and posterior fontanelles (size, consistency, bulging or sunken)
 – Abnormal shape of head (for example, caput succedaneum, molding, cephalohematomas,
encephaloceles, microcephaly)
– Bruising of head, behind the ears or periorbitally Measure head circumference.

EYES: INSPECTION
– Check cornea for cloudiness (sign of congenital cataracts)
– Check conjunctiva for erythema, exudate, orbital edema, subconjunctival hemorrhage,
jaundice of sclera
– Check for pupillary size, shape, equality and reactivity to light (PERRL: pupils equal, round,
reactive to light), accommodation normal
– Red reflex: hold ophthalmoscope 15–20 cm
(6–8 inches) from the eye and use the +10-diopter lens. If normal, the newborn’s eye transmits
a clear red color back; black dots may represent cataracts; a whitish color may suggest
retinoblastoma

EARS: INSPECTION
–Check for asymmetry, irregular shape, setting of ear in relation to corner of eye (low-set ears
may suggest underlying congenital problems such as renal anomalies, fetal alcohol spectrum
disorder or Down’s sydrome)
– Look for fleshy appendages, lipomas or skin tags
– Dimples may suggest a brachial cyst
– Perform otoscopic examination; check canals for discharge and colour, and tympanic membranes
for colour, brightness, perforation, effusion, bony landmarks and light reflex

NOSE: INSPECTION
– Look for nasal flaring, which is a sign of increased respiratory effort
– Look for hypertelorism or hypotelorism (increased or decreased space between eyes)
– Check for choanal atresia (posterior nasal passage blockage uni- or bilaterally), as manifested by
respiratory distress. Neonates are obligate nose breathers, so first check to determine if air is coming
from nostrils; if not and choanal atresia is suspected, a soft nasogastric tube can be passed through
each nostril to check patency

PALATE: INSPECTION AND PALPATION

– Check for defects, such as cleft lip (some may have a membrane covering the cleft so it may not be
obvious) and palate or a high arched palate

MOUTH: INSPECTION
– Observe size and shape of mouth
– Microstomia (small mouth): seen in trisomy 18 and 21
– Macrostomia: seen in mucopolysaccharidosis
– “Fish mouth”: seen in fetal alcohol syndrome
– Epstein pearls: small white cysts containing keratin, frequently found on either side of the
median line of the palate (benign)
 TONGUE: INSPECTION
– Macroglossia: indicates hypothyroidism or mucopolysaccharidosis

TEETH: INSPECTION
– Natal teeth (usually lower incisors) may be present
– Risk of aspiration if these are attached loosely

CHIN: INSPECTION
– Micrognathia (abnormally small lower jaw) may occur with Pierre Robin syndrome, Treacher
Collins syndrome and Hallerman-Streiff syndrome
NECK: INSPECTION
– Symmetry of shape
– Alignment: torticollis is usually secondary to sternocleidomastoid hematoma
– Tracheal tug: can occur with dyspnea
– Neck mass (cystic hygroma is the most common type)

NECK: PALPATION
– Palpate all muscles for lumps and the clavicles for possible fracture
– Neck range of motion for nuchal rigidity: decreased movement may be present in meningitis
– Lymph nodes cannot usually be palpated at birth; their presence usually indicates congenital
infection

RESPIRATORY SYSTEM

VITAL SIGNS
– Respiratory rate

INSPECTION
– Cyanosis, central or peripheral (transient bluish color may be seen in extremities if infant is
cooling off during the examination)
– Respiratory effort, rate and pattern (for example, periodic breathing, gasping, periods of true apnea)
– Observe chest movement for symmetry and retractions
– Anatomical abnormalities of chest (for example, pectus excavatum)
– Use of accessory muscles, tracheal tug, indrawing of intercostal or subcostal muscles

PALPATION
– Any abnormal masses (palpate gently)
– Breasts may be slightly enlarged secondary to presence of maternal hormones

AUSCULTATION
– Breath sounds
– Inspiratory to expiratory ratio
– Adventitious sounds (for example, stridor, crackles, wheezes, grunting)
Percussion is of little clinical benefit and should be avoided, especially in low-birth-weight or
preterm infants, as it may cause injury (for example, bruising, contusions)

CARDIOVASCULAR SYSTEM
VITAL SIGNS
– Heart rate
– Blood pressure in upper and lower extremities

INSPECTION
– Colour: pallor, cyanosis, plethora

PALPATION
– Locate usual point of maximal impulse (PMI) by positioning one finger on the chest, in the
fourth intercostal space medial to the midclavicular line
– Abnormal location of PMI can be a clue to pneumothorax, diaphragmatic hernia, situs
inversus viscerum, congenital heart disease or other thoracic problem
– Capillary refill (< 2 seconds is normal)
– Peripheral pulses: note character of pulses (bounding or thready; equality); any decrease in
femoral pulses or radial-femoral delay may be a sign of coarctation of the aorta

AUSCULTATION
– Note rate and rhythm
– Note presence and quality of S1 and S2 heart sounds
– Assess for S3 and S4: S3 may be a normal finding in infants and children3
– Note presence of murmurs (consider murmurs pathologic, as in congenital heart defects,
until proven otherwise)

ABDOMEN
INSPECTION
– Shape of abdomen: flat abdomen may signify decreased tone, presence of abdominal
contents in chest or abnormalities of the abdominal musculature
– Contour: note any abdominal distension
– Masses
– Visible peristalsis
– Diastasis recti
– Obvious malformations (for example, bowel contents outside of abdominal cavity
[omphalocele]; this abnormality has a membranous covering [unless it has been ruptured during
delivery], whereas gastroschisis does not)
 – Umbilical cord: count the vessels (there should be one vein (large and thin-walled) and two
arteries (small and thick-walled); note color, any discharge

AUSCULTATION
– Bowel sounds

PALPATION
– Check for any abnormal masses
– Liver and spleen: it may be normal for the liver to be located about 2 cm below the right
costal margin; spleen is not usually palpable; if it
can be felt, be alert for congenital infection or extramedullary hematopoiesis
– Kidneys: should be about 4.5–5 cm vertical length in the full-term newborn
– Techniques for kidney palpation: place one hand with four fingers under the baby’s back, then
palpate by rolling the thumb over the kidneys; or place the right hand under the left lumbar
region and palpate the abdomen with the left hand to palpate the left kidney (do the reverse for
the right kidney)
– Check for hernias: umbilical or inguinal
Percussion usually omitted unless a problem such as abdominal distension is noted.
Inspect the anal area for patency and for presence of fistulas or skin tags.

GENITALIA
The genitalia should be carefully assessed, with particular attention to any malformation,
abnormalities or sexual ambiguity.

MALE GENITALIA

Inspection
– Glans: colour, edema, discharge, bleeding
– Urethral opening: should be located centrally on the glans (in hypospadias, the opening is found
on the undersurface of the penis)
– Foreskin (prepuce): never force retraction of the foreskin
– Scrotum: in full-term infant, scrotum should have brownish pigmentation and should be fully
rugated
– Palpation
– Testes: ensure that both testicles are descended into scrotum. Palpate inguinal area. If one or
both are not descended, consult a physician

FEMALE GENITALIA

Inspection
– Check labia, clitoris, urethral opening and external vaginal vault
 – Whitish discharge is often present; this is normal, as is a small amount of bleeding, which
usually occurs a few days after birth and is secondary to maternal hormone withdrawal
– Hymenal tags, if they occur, are normal

MUSCULOSKELETAL SYSTEM

INSPECTION AND PALPATION

Spine
– Check for scoliosis, kyphosis, lordosis, spinal defects, a patch of hair along the spine,
meningomyelocele
Upper Extremities
– Assess the shoulder girdle for injury and the clavicles for fracture (especially if the delivery was
traumatic and in large infants with a history of shoulder dystocia)
– Assess mobility of the shoulder and extension of the elbow
– Inspect palmar creases for assessment of gestational age (see Table 3, “Assessment of Gestational
Age”): they may appear different in some hereditary syndromes
– Count the fingers

Lower Extremities
– Assess the feet and ankles for deformity and mobility
– Count the toes
– Examine foot creases for assessment of gestational age (see Table 3, “Assessment of Gestational
Age”)
– Examine the hips for neonatal hip instability using Ortolani and Barlow maneuvers (see descriptions
below). These tests may be somewhat unreliable depending on the examiner’s experience, so further
assessment may be needed

Ortolani Maneuver
– Flex the knee and hip
– Place middle fingers over greater trochanters
– Position thumbs on medial sides of knees
– Abduct the hip to 90° by applying lateral pressure with thumb
– Push forward with the middle fingers that are over greater trochanters
– If there is a “clunk,” the hip may be dislocated

Barlow Maneuver
– Flex the knee and hip
– Place thumbs on knees
– Place middle fingers over greater trochanters
– Adduct the hip medially and push backward on the knee with thumbs
– If there is a “clunk” or telescoping sensation, the hip may be dislocatable
CENTRAL NERVOUS SYSTEM
– Assess state of alertness
– Check for lethargy or irritability
– Posture: For term infant, normal position is one with hips abducted and partially flexed and
with knees flexed; arms are adducted and flexed at the elbow; the fists are often clenched,
with fingers covering the thumb
– Assess tone: for example, support the infant with one hand under the chest; the neck
extensors should be able to hold the head in line for 3 seconds. There should not be more
than 10% head lag when the infant is moved from a supine to a sitting position

REFLEXES
Reflexes are involuntary movements or actions that help to identify normal brain and nerve
activity and development. Some are present at birth and serve a variety of purposes, others
develop later. Abnormal reflexes – ones that persist after an age they should disappear, or are
absent at birth when they should be present – can help identify neurological or motor disease
early

DEEP TENDON REFLEXES

These are not normally examined in the child under 5 years.

APGAR SCORE
Apgar scoring is done at 1 and 5 minutes after birth. If necessary, it is repeated at 10 minutes
after birth.

INTERPRETATION
At 1 Minute
< 7: depression of nervous system
< 4: severe depression of nervous system
At 5 Minutes
> 8: no asphyxia
< 7: high risk for subsequent dysfunction of central nervous system
5–7: mild asphyxia
3–4: moderate asphyxia
0–2: severe asphyxia
Determination of Apgar Score

Feature Evaluated 0 Points 1 Point 2 Points

Heart rate 0 < 100 beats/min > 100 beats/min
Respiratory effort Apnea Irregular, shallow or Vigorous, crying
gasping breaths
Colour Pale or blue all Pale or blue Pink
over extremities
Muscle tone Absent Weak, passive tone Active movement
Reflex irritability Absent Grimace Active avoidance
* Sum the scores for each feature. Maximum score = 10; minimum score = 0

ASSESSMENT OF GESTATIONAL AGE

Gestational age can be assessed on the basis of the newborn’s external characteristics.

Assessment of Gestational Age

External 28 Weeks 32 Weeks 36 Weeks 40 Weeks

Characteristic
Ear cartilage Pinna soft, Pinna harder, but Pinna harder, Pinna firm,
remains springs stands
folded remains folded back into place erect from head
when
folded
Breast tissue None None Nodule 1–2 mm Nodule 6–7 mm
in in
diameter diameter
Male genitalia Testes Testes in inguinal Testes high in Testes
undescended, descended,
scrotal surface canal, a few scrotum, more scrotum
scrotal scrotal pendulous,
smooth rugae rugae covered in rugae
Female genitalia Prominent clitoris Prominent Clitoris less Clitoris covered
clitoris; by
with small, larger, well- prominent, labia labia majora
widely separated
separated labia labia majora cover
labia
minora
Plantar surface of Smooth, no 1 or 2 anterior 2 or 3 anterior Creases cover
foot creases the
creases creases sole
SCREENING TEST
PHENYLKETONURIA
– All newborns should be screened for phenylketonuria (PKU) by means of a capillary blood
sample before discharge from the hospital.
– For any newborn who undergoes this type of screening at less than 24 hours of age, the
screening test must be repeated between 2 and 7 days of age.

CONGENITAL HYPOTHYROIDISM
– All newborns should be screened by taking a thyroid-stimulating hormone (TSH) or
thyroxine (T4) level by means of a dried capillary blood sample in the first week of life
– If a child was born in hospital, verify that this type of screening was done before discharge
– For more information on congenital hypothyroidism

PHYSICAL EXAMINATION OF THE INFANT AND CHILD

Clinicians should be aware of the different sizes of body parts in children relative to adults: the head
is relatively larger, limbs relatively smaller and, in
small children, the ratio of surface area to weight is relatively larger.

TECHNIQUE
Much information can be obtained by observing the child’s spontaneous activities while the history is
being conducted, without touching the child. For this purpose, it is useful to have an age-appropriate toy
available. Approach infants and young children slowly and start by playing with them to gain their trust.
For a young child, do as much of the physical examination as possible with the child either being held
by the parent or caregiver or supported on that person’s lap.
Generally, the least stressful parts of the exam should come first, with more intrusive or distressing parts
later (for example, examination of the pharynx and/ or ears with the child restrained). Allowing the child
to play with the equipment can often decrease anxiety about certain parts of the exam.
One must choose the quietest moment to do the respiratory and cardiac exam. This is usually at the
beginning of the exam. The order of the
examination must be varied to suit the situation.
Care should be taken to select appropriate-sized equipment when examining a child (for example, blood
pressure cuff width should be greater than two- thirds of the length of the upper arm).

GENERAL APPEARANCE
Without touching the child, observe (if applicable):
– Level of consciousness, alertness, general behavior and appearance (how well the infant/
 child looks)
– Symmetry of body
– Posture of limbs (flexed, extended)
– Body movements (for example, arms and legs, facial grimace)
– State of nutrition and hydration
– Color
– Any sign of clinical distress (for example, respiratory distress includes dyspnea, pallor,
cyanosis, irritability)
– Gait
– Breathing frequency and pattern
– Responses to sound
– Fine and gross motor skills as the child plays
– Lesions (for example, petechiae, eczema, impetigo)
– Responses to parental comforting measures
– Ability to entertain themself while the caregiver is talking
– Quality of infant’s cry or quality of child’s voice
– Interaction pattern, speech and nature of child’s responses to parent(s) and health care staff

VITAL SIGNS
Assess for:
– Heart rate
– Blood pressure
– Respiratory rate
– Temperature (if warranted) (see “Temperature Measurement in Children”)
– Oxygen saturation (if warranted)
Blood pressure measurements are influenced by sex, age and height. Therefore blood pressure
charts should be used to interpret the values. Blood pressure should be recorded once in the
healthy child under 2 years and then annually after that.

Normal Pediatric Heart Rate, Blood Pressure and Respiratory Rate By Age

Heart Rate Range Lower Limit of Respiratory Rate

Age (beats/minute Systolic Blood Range
[mean]) Pressure (mm Hg) (breaths/minute)
Birth to 6 months 80–180 [140] 60 30–60
6 months to 12 70–150 [130] 70 30–50
months
1 to 3 years 90–150 [120] 72–76 24–40
3 to 5 years 65–135 [110] 76–80 22–34
5 to 12 years 60–120 [85–100] 80–90 16–30
12 years to adult 60–100 [80] 90 12–20
TEMPERATURE MEASUREMENT IN CHILDREN
Proper temperature measurement is essential for clinical decision making in the pediatric population.
Children should be unbundled for at least 15 minutes prior to taking their temperature. One needs to be
aware of the normal temperature ranges for each measurement method and use recommended temperature
measurement methods in children .

Normal Temperature Ranges

Measurement Method Normal Temperature Range

Rectal 36.6 to 38°C

Tympanic 35.8 to 38°C
Oral 35.5 to 37.5°C
Axillary 34.7 to 37.3°C

Recommended Temperature Measurement Methods in Children

Age Definitive Method Method to Screen Low-risk Children

Less than 2 years Rectal Axillary
2–5 years Rectal Axillary
Tympanic
Older than 5 years Oral Axillary
Tympanic

Tympanic temperature measurement is contraindicated in newborns due to the shape of the ear canal and
the potential for vernix or amniotic fluid in the canal.

GROWTH MEASUREMENTS
Weight should be done at each visit for any infant under 1, those presenting for a well-child visit, at least
annually for older children, and for any infant or child who presents with vomiting, diarrhea, signs of
shock, or in need of a medication where dosage is dependent on weight.
Measurements of recumbent length (until 24 months old) or height, weight and head circumference (until
24 months old) should be part of every health maintenance visit. These parameters should be recorded on
gender-appropriate growth curves, which should form part of the child’s health record.
The Canadian Pediatric Society recommends using the Centers for Disease Control Growth Charts,
specific to each sex. They can be found at:
Growth chart for boys (Birth to 36 months, and 2 to 20 years):
Growth chart for girls (Birth to 36 months, and 2 to 20 years):

SKIN
Note color, condition and lesions on all aspects of the body.

COLOUR
– Pallor associated with low hemoglobin or vasoconstriction (for example, in shock)
– Cyanosis associated with hypoxemia
– Plethora associated with polycythemia or vasodilation
– Cherry red face associated with carbon monoxide poisoning
– Jaundice associated with elevated bilirubin

LESIONS
– Stork bite: Pink and flat nevus simplex; usually on face or back of the neck; those on face usually
disappear by 18 months4
– Café au lait spots: Irregular brown, flat macules. Suspect neurofibromatosis if there are many (more
than 5 or 6) large spots
– Mongolian spots: dark bluish/purplish patches present at birth, usually on back and buttocks but may
be on limbs; common in First Nation’s and Inuit children; usually fade away in first year of life
– Acne: blackheads, whiteheads; more severe forms have papules, pustles and nodules; usually on face
and sometimes on back, chest and shoulders; most common in adolescence

HEAD AND NECK

HEAD AND FACE
– Palpate anterior and posterior fontanelles (size, consistency, bulging or sunken) and cranium
– Bruising of head, behind the ears or peri orbitally
– Size and shape of the head
– Facial symmetry at rest and while crying for the infant

EYES: INSPECTION
To open the infant’s eyes, support their head and shoulders and gently lower the infant
backward.
– Check cornea for cloudiness (sign of congenital cataracts)
– Check the lids and external structures; note palpebral slant
– Assess for nystagmus
– Check conjunctiva for erythema, exudate, orbital edema, subconjunctival hemorrhage,
jaundice of sclera
– Check for position and alignment of the eyes using cover-uncover test
– Check for corneal light reflex and ability to track movement for cardinal fields of gaze
– Check for pupillary size, shape, equality and reactivity to light (PERRL: pupils equal,
round, reactive to light), accommodation normal
– Red reflex: hold ophthalmoscope 15–20 cm (6–8 inches) from the eye and use the +10
diopter lens; if normal, the newborn’s eye transmits a clear red color back; black dots may
represent cataracts; a whitish color may suggest retinoblastoma
– Inspect fundus, if possible
– Check visual acuity in children over 3 years of age

EARS
– Check for asymmetry, irregular shape, setting of ear in relation to corner of eye (low-set ears
may suggest underlying congenital problems such as renal anomalies, fetal alcohol spectrum
disorder or Down’s syndrome)
– Look for fleshy appendages, lipomas or skin tags
– Palpate and inspect auricles
– Perform otoscopic examination; check canals for discharge, foreign bodies and color, and
tympanic membranes for color, brightness, perforation, effusion, bony landmarks and light
reflex

NOSE: INSPECTION
– Determine if nares are patent. Look for foreign body
– Look for nasal flaring, which is a sign of increased respiratory effort
– Look for hypertelorism or hypotelorism (increased or decreased space between eyes)
– Note nasal discharge or sneezing
– Look at the mucosa, septum and turbinates with otoscope

MOUTH
– Inspect lips, gums, palate, buccal mucosa, tongue, palate, tonsils
– Inspect tongue size and frenulum of tongue in infants
– Inspect teeth for number, character, condition, position and caries
– Palpate palate in young infants
– Note if uvula is midline

NECK: INSPECTION
– Symmetry of shape, midline trachea
– Alignment: torticollis is often secondary to positional plagiocephaly
– Tracheal tug: can occur with dyspnea
– Neck mass
NECK: PALPATION
– Palpate any masses (may signify congenital cysts), trachea, lymph nodes and thyroid
– Neck range of motion for nuchal rigidity: may be present in meningitis; in older children (over 5)
Kernig and Brudzinski reflex may be helpful in assessing for meningitis
– Palpate clavicles

RESPIRATORY SYSTEM

INSPECTION
– Cyanosis, central or peripheral (transient bluish colour may be seen in extremities if infant is
cooling off during the examination)
– Respiratory effort, rate and pattern (for example, periodic breathing, gasping, periods of true apnea)
– Observe chest movement for symmetry and retractions
– Note any movement of the abdomen with respirations
– Note chest size, shape, configuration and anatomical abnormalities of chest (for example, pectus
excavatum)
– Use of accessory muscles, tracheal tug, indrawing of intercostal or subcostal muscles
– Note any nipple and breast development

PALPATION
– Any abnormal masses (palpate gently)
– Nipples and breast tissue – it may be slightly enlarged secondary to presence of maternal
hormones in infants

AUSCULTATION
– Breath sounds
– Rate and rhythm
– Inspiratory to expiratory ratio
– Adventitious sounds (for example, stridor, crackles, wheezes, grunting)
– Percussion as indicated.

CARDIOVASCULAR SYSTEM

INSPECTION
– Color: pallor, cyanosis, plethora
– Pulsations on precordial area

PALPATION
– Locate point of maximal impulse (PMI) by positioning one finger on the chest and note this location.
Abnormal location of PMI can be a clue to pneumothorax, diaphragmatic hernia or other thoracic
 problems
– Palpate chest wall for thrills
– Capillary refill (< 2 seconds is normal)
– Peripheral pulses in each extremity and femoral: note character of pulses (bounding or thready;
equality); compare strength of femoral pulses with radial pulses

AUSCULTATION
– Note rate and rhythm
– Note presence and quality of S1 and S2 heart sounds
– Assess for S3 and S4: S3 may be a normal finding in infants and children3
– Note presence of murmurs (consider murmurs pathologic, as in congenital heart defects, until
proven otherwise)

ABDOMEN
INSPECTION
– Shape of abdomen: flat abdomen may signify decreased tone or abnormalities of the abdominal
musculature
– Periumbilical area
– Contour: note any abdominal distension
– Masses
– Visible peristalsis
– Diastasis recti
– Anal area for presence of fistulas, excoriation or fecal soiling

AUSCULTATION
– Bowel sounds

PERCUSSION
– All quadrants

PALPATION
– Note muscle tone, skin turgor and underlying organs
– Check for any abnormal masses
– Check for enlarged organs
– Techniques for kidney palpation with infants: place one hand with four fingers under the
infant’s back, then palpate by rolling the thumb over the kidneys; or place the right hand
under the left lumbar region and palpate the abdomen with the left hand to palpate the left
kidney (do the reverse for the right kidney)
– Check for hernias: umbilical or inguinal
– Check for inguinal lymph nodes
 GENITALIA
Inspect the external genitalia and note stage of sexual maturity.

MALE GENITALIA

Inspection
– Glans: color, edema, discharge, bleeding
– Urethral opening: should be located centrally on the glans (in hypospadias, the opening is
found on the undersurface of the penis)
– Foreskin (prepuce): never force retraction of the foreskin
– Testes: ensure that both testicles are descended into scrotum in infants. Palpate inguinal area.
If one or both are not descended, consult a physician
– If masses are present, transilluminate the scrotum

FEMALE GENITALIA

Inspection
– Check labia, clitoris, urethral opening and external vaginal vault
– Hymenal tags, if they occur, are normal

MUSCULOSKELETAL SYSTEM

INSPECTION AND PALPATION

Spine
– Check for scoliosis, kyphosis, lordosis, spinal defects, a patch of hair along the spine,
meningomyelocele

Upper Extremities
– Inspect and note ROM and muscle tone of the shoulder, wrist and elbow
– Note aligment of arms and hands
– Inspect fingers and palmar creases

Lower Extremities
– Inspect and note ROM and muscle tone of the toes, knees, and ankles
– Note alignment of legs, feet and toes
– Note arch of foot
– In infants, examine the hips for hip instability using Ortolani and Barlow maneuvers (see descriptions
below). These tests may be somewhat unrealiable depending on the examiner’s experience, so further
assessment may be needed
Ortolani Maneuver
– Flex the knee and hip
– Place middle fingers over greater trochanters
– Position thumbs on medial sides of knees
– Abduct the hip to 90° by applying lateral pressure with thumb
– Push forward with the middle fingers that are over greater trochanters
– If there is a “clunk,” the hip may be dislocated
Barlow Maneuver
– Flex the knee and hip
– Place thumbs on knees
– Place middle fingers over greater trochanters
– Adduct the hip medially and push backward on the knee with thumbs
– If there is a “clunk” or telescoping sensation, the hip may be dislocatable

CENTRAL NERVOUS SYSTEM

– Assess state of alertness
– Check for lethargy or irritability
– Posture
– Assess muscle tone (for example, support the infant with one hand under the chest; the neck
extensors should be able to hold the head in line for 3 seconds; there should not be more than 10%
head lag when the infant is moved from a supine to a sitting position)

REFLEXES
Reflexes are involuntary movements or actions that help to identify normal brain and nerve
activity and development. Some are present at birth and serve a variety of purposes, others
develop later. Abnormal reflexes – ones that persist after an age they should disappear, or are
absent at birth when they should be present – can help identify neurological or motor disease
early. The following are some of the reflexes that should be tested in newborns and infants up to
2 years of age.
New-born and Infant Reflexes

Age Appears/
Reflex Stimuli Response Disappears Pathology if Abnormal
Rooting Stroke cheek Head turns toward Birth/3–4 months (up to May not be present if
stimuli and mouth may 12 months during sleep) asleep; CNS disease or
open depressed infant
Sucking Object touching lips or sucking to stimuli Birth/4 months (up to May not respond well if
in mouth 7 months during sleep) sleeping or satisfied; If
premature it may not be
present; CNS depression
Tonic Neck Head turned to one side Arm and leg extension Birth–2 months/4–6 Persistence –
for 15 seconds while on the side the head is months neurological damage;
laying supine turned toward; arm and infant unable to get out of
leg flexed on opposite position is abnormal
side
Palmar Grasp Put finger onto palm Grasps finger strong and Birth/3–6 months CNS disease
from ulnar side symmetric
Stepping Held upright, one-foot Alternating stepping Birth/2–4 months Absence – paralysis,
touches a flat surface movement depressed infant; cerebral
palsy
Moro Sudden drop in position Symmetrical arm, spine Birth/4 months at the Asymmetry – paralysis
or jarring and leg extension, head latest or fractured clavicle;
moves back and fingers absence or persisting
spread; then arms flex beyond 6 months –
toward each other brainstem problem
Plantar Grasp Place thumb at base of Toes curl downward; Birth/4–8 months Cerebral palsy,
newborn’s toes should be symmetrical obstructive CNS lesion
Babinski Lateral sole stroked from Hyperextension Birth/Variable (usually by CNS lesion, cerebral
heel up and across ball (fanning) of toes 1 year) palsy
of foot
Landau Held around waist in Lifts head and legs and By 3–6 months/ 15–24 Hypotonicity indicates
horizontal prone position extends the neck and months motor system deficits;
trunk hypertonic arms with
internal rotation, arm held
at side or arm does not lift
is abnormal
Parachute Held around waist in Extends arms and By 6–8 months/ Never Asymmetry indicates
horizontal prone position hands to break the fall, Unilateral motor abnormality
and lowered quickly symmetrically
head first to surface

DEEP TENDON REFLEXES

Deep tendon reflexes are not usually tested in children under 5 years of age. In older children, deep
tendon reflexes may be tested. Reflexes must be symmetric. The child must be relaxed and comfortable.
The reflexes include the biceps, brachioradialis, triceps, patellar and achilles.
CRANIAL NERVE ASSESSMENT
After 2 years of age, cranial nerves can be tested with some modifications according to the
developmental stage of the child

Cranial Nerve Assessment in Children

Cranial Nerve Number Name/Function How to Test

I Olfactory For older children, as in adults
II Optic Use Snellen chart(s) after age 3; ask parent to hold head if needed to test
visual fields
III, IV, VI Extraocular Get child to follow (track) a light or a toy with the parent holding the child’s
movement head if needed
V Trigeminal Play a game, asking them to identify where the cotton ball touched them on
the face (sensory); ask the child to clench their teeth or chew and swallow
a piece of food
VII Facial Ask the child to imitate your faces
VIII Acoustic After age 4, whisper a word while covering one of the child’s ears and have
the child repeat it
IX, X Swallow and gag Ask the child to say “ahh” or stick their tongue and observe the the
uvula and soft palate; test the gag reflex
XI Spinal accessory Ask the child to shrug, pushing your hands away, and push your hand away
with their head to see how strong they are
XII Hypoglossal Ask the child to stick out their tongue

SCREENING
DEVELOPMENTAL MILESTONES
Assessment of developmental progress should be part of each complete health assessment (well-child visit) and
take place at all visits for children who do not present regularly for well-child care. Developmental assessment
is done by making inquiries of the parents or caregiver and by clinical observation of the child’s achievement of
major age-appropriate milestones.
These are in areas of gross and fine motor, speech and language, and personal and social development.

Table Developmental Milestones by Age and Type (should be present by this age) (adapted from 24,25,26)
Age Gross Motor Fine Motor Personal/Social Language/Cognitive
Newborn • Reflex head turn side
to side

1 month • Back completely • Focuses gaze • Able to suck on a • Startles to loud or

• Tracks horizontally to nipple sudden noise
rounded when sitting,
head forward midline • Social smile
2 months • Follows movement with • Enjoys being touched • A variety of sounds and
eyes cries
3 months • Lifts up on elbows • Unfisted >50% of time
• Head steady when • Eye tracks 180 degrees
upright

4 months • Lifts up on hands • Reaches for bright • Turns head toward

object sounds
• No head lag when • Laughs or squeals
pulled to sitting from
supine
• Follows a moving • Babbles
6 months • Rolls back to front or object
front to back
• Brings objects to mouth
• Sits with support
7 months • Has stranger anxiety
• Plays peek-a-boo
9 months • Sits and stands with
• Opposes thumb and • Reaches to be picked • Babbles different sounds
support
index finger up and held • Makes sound to get
• Looks for hidden toy attention
12 months • Crawls or ‘bum’ • Pincer grasp • Shows many emotions • Responds to own name
shuffles • Drinks from a cup • Understands simple
commands
• Pulls to stand or walks • “Talks” making 3
holding on different sounds
15 months • Crawls up stairs or steps • Removes socks and • Looks at parent/ • Attempts 2 or more words
• Tries to squat (picking tries to untie shoes caregiver to see how to (may not be clear)
up toys) • Stacks 2 blocks react (for example, for • Tries to get something
falls or with strangers) by reaching, making
• Picks up and eats
finger foods sounds or pointing
18 months • Walks backward 2
• Feeds self with spoon • Behaviour is usually • Points to 3 different body
steps without support and spills little manageable parts
• Removes hat/socks • Usually easy to soothe • Tries to get your
without help • Comes for comfort attention to see
• Hand preference when distressed something of interest
• Pretend play with toys
(for example, feeds
animal)
• Turns upon hearing
name
• Imitates speech sounds
regularly
• Says 3 consonants, for example, P M
B W H N / Says 3 or 4 words
Developmental Milestones by Age and Type

Age Gross Motor Fine Motor Personal/Social Language/Cognitive

2 years  Tries  Puts objects  Copies adult  At least 1 new word/week
running into a small behaviours  2-word sentences
container  Develops new  Many words
skills
 Concept of
today
3 years  Twists lids  Shares  Understands 2-step directions
off jars or sometimes
turns knobs  Listens to
 Turns
 pages one music or
at a time stories for 5–
 Copies 10 minutes
circle with an adult
 Concept of
yesterday
4 years  Stands  Draws a  Toilet trained  Understands 3-part directions, if
on 1 person with during the day related
foot for at least 3  Tries to  Asks lots of questions
1–3 body parts comfort
seconds  Copies “+” someone who
is upset
5 years  Hops  Throws and • Shares willingly • Counts to 10 and knows common
on one catches a colours and shapes
ball • Works alone on
foot • Speaks clearly in sentences
something for
 Copies 20–30 minutes
square
• Separates easily
from parents
• Dresses
without
assistance

6 years  Copies  Well-developed vocabulary,

triangle quickly retrieves words
 Draws 6  May stutter
part person

8 years  Concept of  Can follow complex directions

right and left  Tells jokes
10 years  Has a special  Able to discuss ideas and
friend (same understand inflections and
sex) metaphors
12 years  Language is a  Can think about sophisticated
means of concepts
socializing  Ability to express emotions