Indications and Procedures
A pediatrician or nurse practitioner usually performs the routine physical examination of an infant. Because the child may be frightened, some steps in the examination may be performed while the baby is being held in the parent’s lap. If the baby or child is ill, the health care provider will look for signs of dehydration and possible lethargic mental status. Dehydration is always checked in cases where fever is present. A child’s normal oral temperature is similar to an adult’s (98.6 degrees Fahrenheit). A rectal temperature will typically be 1 degree higher. It is not uncommon for a young child to have a temperature of 105 degrees with even a minor infection.
Respiration and pulse are measured. Young children and infants breathe with their diaphragm; therefore, the movements of the abdomen can be counted. Periodic breathing is common in infants. Respiratory rates for newborns are 30 to 50 respirations per minute. Toddlers average rates of 20 to 40 respirations per minute. The pulse of a newborn baby is detected best over the brachial artery. The rate is usually in the range of 120 to 160 beats per minute; this figure declines as the child grows older.
Blood pressure, length, weight, and head circumference are measured and checked against charts showing norms. Infants are weighed without clothing and are measured on a firm table. The head is measured at the maximum point of the occipital protuberance posteriorly and at the mid forehead anteriorly. The shape of the child’s head, such as flatness or swelling, is observed. Hair is checked for quantity, color, texture, and infestations. The presence of a fungus can be indicated by alopecia (hair loss), but this cause must be distinguished from trichotillomania. Hypothyroidism can be indicated by dry, coarse hair.
An eye examination can give information about systemic problems and about the eyes themselves. The eyes are observed working together; reaction to light, pupil size, cornea haziness, excess tearing, vision, visual fields, and the distance between the eyes are checked. Observations for nystagmus (involuntary movement of the eyes) and for the abnormal upward outward eye slant and epicanthal folds associated with Down syndrome are also made. Newborns have about 20/400 vision, which improves to 20/40 by six months of age.
During an ear examination, the tympanic membrane is checked for perforations, color, lucency, and bulging (indicating pus and/or fluid) in the middle ear. A rough hearing acuity may be determined by eliciting from the child a startle reflex to sound.
The nose is checked interiorly, and the nasal mucus is checked for watery discharge (indicating allergy) and mucopurulent discharge (indicating infection). The nasal septum and passages are also checked, and any foreign bodies are removed.
The oral cavity examination consists of checking the lips for asymmetry, fissures, clefts, lesions, and color. The tongue is examined for color, size, coating, and dryness. The tonsils are observed for signs of infection and color, while the palate is observed for arch and possible lesions. The throat is examined for signs of inflammation and other problems. The neck is checked for tilt and range of motion. The thyroid gland is palpitated and evaluated for symmetry, consistency, and surface characteristics. Any other swellings are noted and their causes determined.
The neurologic examination is extensive and begins with an assessment of a child’s milestones. An infant’s primitive reflexes—Moro, asymmetric tonic neck, Babinski, palmar grasp, rooting, and parachute reflexes—are checked. Cranial nerves that can be assessed at the child’s stage of development may be assessed. General sensation and response to touch and muscle tone and movement are checked for unusual responses. The musculoskeletal system and extremities are checked for gross deformities and congenital anomalies. Gait and stance are observed, as well as muscle tone and range of motion. Posture in older children may be observed for spinal curvatures.
The lungs are checked to evaluate air movement, to identify breath sounds and chest sounds, and to inspect the shape of the chest. The physician will note any physical deformities and listen to rhythms that could indicate abnormal blood circulation. Indications of circulatory system problems in infants are cyanosis, clubbing of fingers or toes, tachycardia (rapid heart rate), peripheral edema, and tachypnea (rapid breathing). Examination of the abdominal contour and auscultation and palpation of the abdomen are done. In newborns, the genitals are checked for ambiguity, and the rectal area is checked for fissures or anal prolapse. Skin is checked for color, pigmentation, rashes, or burns.
Vaccinations—either oral or by injection—and boosters are a part of some well-baby visits. Occasionally, blood or urine samples are taken for analysis.
Uses and Complications
The challenge of keeping the child calm enough for the clinician to perform a valid exam is important in the diagnostic process. Although an older child can usually be examined easily in standard adult order, this does not work well for pediatric patients. The younger the patient, the more important it is that crucially affected areas be examined first, before the child becomes upset or cries. Clinicians and parents should work together to minimize a child’s fears during the examination.
Bibliography
Albright, Elizabeth K. Pediatric History and Physical Examination. Updated and revised ed. Laguna Hills, Calif.: Current Clinical Strategies, 2003.
Barness, Lewis A. Manual of Pediatric Physical Diagnosis. 6th ed. St. Louis, Mo.: Mosby Medical, 1991.
"Children's Health." MedlinePlus, June 26, 2013.
Hay, William W., Jr., et al., eds. Current Diagnosis and Treatment in Pediatrics. 19th ed. New York: Lange Medical Books/McGraw-Hill, 2009.
"Middle Childhood (9-11 years of age)." cdc.gov, August 15, 2012.
"Preschoolers (3-5 years of age)." cdc.gov, August 12, 2012.
Sanghavi, Darshak. A Map of the Child: A Pediatrician’s Tour of the Body. New York: Henry Holt, 2003.
Schwartz, M. William, ed. Schwartz’s Clinical Handbook of Pediatrics. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009.
Zitelli, Basil J., and Holly W. Davis, eds. Atlas of Pediatric Physical Diagnosis. 5th ed. St. Louis, Mo.: Mosby/Elsevier, 2007.
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