Key stages for developmental assessment
• Supine infant (1.5–2 months)
• Communicating child (3–4 years)
The four areas in which development is assessed
• Introduce yourself to the parent and child, and confirm the child’s name and date of birth.
• Explain that you would like to ask a few questions about how the child is doing, and obtain
• Ensure that the child is comfortable. Younger children may need toys to keep them distracted.
• Ask to look at the child health record or ‘red book’.
• Confirm the sex and preferred name of the child.
• Do not ask whether the child is ‘developing normally’. Ask instead, “Do you have any concerns
• Be sure to verify whether any delay is in just one area or all four (gross developmental delay).
160 Station 59 Developmental assessment
Table 23. Average age for the acquisition of milestones
Supine infant 2/12 Raises head in
Sitting infant 6/12 Rolls over
Toddler 1 year Takes first steps Starts to feed
Station 59 Developmental assessment 161
Table 23. Average age for the acquisition of milestones – continued
• ‘Red flags’ that call for further investigation include the absence of:
– 2–3 word sentence construction at 2.5 years
• Ask the parent if there is anything they might add that you have forgotten to ask about.
• Ask the parent if they have any specific questions or concerns.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a developmental assessment station
• Visual or hearing impairment.
• Developmental disorder, e.g. autism.
• Emotional disorder, e.g. enuresis (>5 years), elective mutism, sleep disorder.
• Behavioural disorder, e.g. conduct disorder, ADHD.
• Gross developmental delay from e.g. mental retardation, genetic abnormality, brain injury,
congenital infection, endocrine disorder.
Specifications: A mannequin in lieu of a baby. The baby’s ‘mother’ is also in the room.
• Introduce yourself to the mother, and confirm the baby’s name and date of birth.
• Explain the examination, and ask for consent.
– complications of the pregnancy, if any
– type of delivery and any complications
– the baby’s gestational age at the time of birth
– the baby’s feeding, urination, and defecation
– any concerns that she might have about the baby
– how she herself is coping with the new arrival
• Although it is important to be systematic, an opportunistic approach to the examination may
• Note size, colour (e.g. cyanosis, jaundice), posture, tone, movements, skin abnormalities (e.g.
birth marks, petechiae, rash, haemangioma, Mongolian blue spot), and any other obvious
abnormalities (e.g. dysmorphic features or birth trauma such as forceps marks or chignon). Are
there any signs of pain or respiratory distress?
• Gently palpate the anterior and posterior fontanelles for bulging (raised intracranial pressure)
Figure 39. Neonatal examination, general order of the
Station 60 Neonatal examination 163
• Inspect the face for dysmorphological features, e.g. dysplastic or folded ears, upward slanting
palpebral fissures, and a flat nasal bridge (all may be seen in Down syndrome).
• Inspect the sclerae for redness (subconjunctival haemorrhage related to birth trauma) and the
irises for Brushfield spots (Down syndrome).
• Using an ophthalmoscope, test the red reflex (congenital cataracts if the red reflex is absent,
retinoblastoma if instead there is a white reflex) and pupillary reflexes.
• Test eye movements (squint).
• Check the patency of the ears and nostrils.
• Elicit the rooting reflex by lightly touching a corner of the baby’s mouth.
• Introduce a finger into the baby’s mouth and palpate the roof of the mouth with the finger pulp
to assess the sucking reflex and soft palate (cleft palate).
• Also examine the soft palate using a torch and spatula.
• Inspect the chest for signs of laboured breathing and for deformities, e.g. pectus carinatum,
pectus excavatum, shield-shaped chest with widely-spaced nipples (Turner syndrome).
• Take the brachial and femoral pulses, one after the other and then both at the same time
(brachio-femoral delay). Pulse rate in the neonate should be 100–160.
• Palpate the precordium and locate the apex beat.
• Auscultate the heart using the bell of your stethoscope (congenital heart defects).
• Auscultate the lungs using the diaphragm of your stethoscope. Turn the infant over and listen
over the back. The respiratory rate should be less than 60 breaths per minute.
• Examine the spine, focusing on the sacral pit (neural tube defects).
• Check the position and patency of the anus (anal atresia).
• Enquire as to when the baby first passed stool. Ideally, this should have been within 24 hours
• Inspect the abdomen and the umbilical stump.
• Auscultate for bowel sounds.
• Feel in the inguinoscrotal region for inguinal hernias.
• Examine the genitalia, in male infants note the position of the urethral meatus (hypospadias)
and feel for the testicles (undescended testes).
• Feel for the femoral pulses (coarctation of the aorta).
• Ortolani test. With your thumbs on the inner aspects of the thighs and your index and middle
fingers over the greater trochanters, flex the hips and knees to 90 degrees and then abduct the
hips (an audible and palpable clunk indicates relocation of a dislocated hip).
164 Station 60 Neonatal examination
• Inspect the arms and hands, paying particular attention to the palmar creases (Simian crease –
• Count the number of digits on each hand (polydactyly).
• Count the number of digits on each foot (polydactyly).
• Head lag. Lay the baby supine and pull up the upper body by the arms – the head should first
‘lag’ back, then straighten and fall forward.
• Ventral suspension. Hold the baby prone – the head should lie above the midline.
• Moro or startle reflex. Lift the head and shoulders and then suddenly drop them back – the
arms and legs should abduct and extend symmetrically, and then adduct and flex (NB. This test
should be conducted as safely and sensitively as possible. For instance, it could be carried out
with the baby only slightly raised from the cot mattress.).
• Grasp reflex. Place a finger in the baby’s hand – the hand should close around your finger.
Barlow test Figure 40. The Ortolani and Barlow tests.
Station 60 Neonatal examination 165
After the neonatal examination
• State that you would also measure and weigh the baby and record your findings on a growth
• Reassure the mother, and tell her that you are going to have the baby examined by a senior
Figure 41. Eliciting the Moro reflex.
The six-week surveillance review
Specifications: A mannequin in lieu of a baby. The six-week ‘baby check’ is part of the Newborn and
Infant Physical Examination programme. It involves a physical examination and review of development.
However, it is also an opportunity to give health promotion advice and for the parent or parents to
• Introduce yourself to the parent, and confirm the baby’s name and date of birth.
• Explain the nature of the examination and obtain consent.
• Ask for the child health record or ‘red book’.
• Ask for the exact age, sex, and preferred name of the child.
• Ask if the parent has any specific concerns.
– current health status, including feeding regimen and weight gain
PART 1 – DEVELOPMENTAL ASSESSMENT
• Ask parent if they are concerned about the baby’s hearing.
Station 61 The six-week surveillance review 167
• Overall size and colour, i.e. is the baby cyanosed or jaundiced?
• Skin abnormalities such as birth marks, petechiae, or rash.
• Other obvious abnormalities such as dysmorphic features.
• Posture, tone, and movements.
• Signs of respiratory distress
• Plot findings on a centile chart.
• Eyes: red reflex, pupillary reflexes, and eye movements (squints).
• Mouth – use a pen torch (high arched or cleft palate).
• Feel for the radial and femoral pulses.
• Examine the spine, particularly the sacral pit.
• Inspect and palpate the abdomen.
• Examine the external genitalia.
• Abduct the hips (Ortolani test, see Figure 40).
• Next, adduct them whilst applying downward pressure with your thumbs (Barlow test, see
168 Station 61 The six-week surveillance review
• Discuss your findings with the parent.
services available for the parents of young children.
• Consider maternal mental health. How is mum coping? Is there any suggestion of postnatal
• Elicit any remaining concerns that the parent may have.
Paediatric examination: cardiovascular system
Read in conjunction with Station 13.
If you are asked to examine the cardiovascular system of a younger child (an unlikely event), be
prepared to change the order of your examination and to modify your technique as appropriate. For
example, you may need to examine the child on his parent’s knees or auscultate his heart as soon
• Introduce yourself to the child and the parent, and confirm the child’s name and date of birth.
• Explain the examination and ask for consent to carry it out.
• Position the child at 45 degrees, and ask him to remove his top(s).
• Ensure that he is comfortable.
• From the end of the couch, inspect the child carefully, looking for any obvious abnormalities
in his general appearance and in particular for any dysmorphic features suggestive of Down
syndrome (e.g. oblique eye fissures, epicanthic folds, Brushfield spots, flat nasal bridge, Simian
crease), Turner syndrome (e.g. short stature, low-set ears, webbed neck, shield chest), or Marfan
syndrome (e.g. tall stature, elongated limbs, pectus carinatum or pectus excavatum).
• Does the child look his age? Ask to look at the growth chart.
• Is he breathless or cyanosed?
• Look around the child for clues such as a oxygen, PEFR meter, inhalers, etc.
• Inspect the precordium and the chest for any scars and pulsations. A median sternotomy or
thoracotomy scar under the axillae may indicate the repair of a congenital heart defect such as
a patent ductus arteriosus or a ventricular septal defect.
Inspection and examination of the hands
• Take both hands and assess them for:
– clubbing (cyanotic congenital heart disease)
• Determine the rate, rhythm, and character of both radial pulses (in younger infants, the brachial
pulses). Take both femoral pulses at the same time to exclude a radiofemoral delay (coarctation
• Indicate that you would record the blood pressure in both arms. If you are asked to record the
blood pressure, remember to use a cuff of appropriate size.
170 Station 62 Paediatric examination: cardiovascular system
Table 24. Normal pulse rates in children
Age in years Pulse (beats per minute)
Inspection and examination of the head and neck
• Inspect the conjunctivae for signs of anaemia or jaundice.
• Inspect the mouth and tongue for signs of central cyanosis and a high arched palate (Marfan
• Assess the jugular venous pressure (difficult in very young infants).
• Locate the carotid pulse and assess its character.
Ask the child if he has any pain in the chest.
• Determine the location and character of the apex beat. In children (up to 8 years), this is found
in the fourth intercostal space in the mid-clavicular line.
• Palpate the precordium for thrills and heaves.
Warm up the diaphragm of your stethoscope.
• Listen for heart sounds, additional sounds, and murmurs. Using the stethoscope’s diaphragm,
• Any murmur heard must be classified according to:
– timing (systolic or diastolic)
– site (aortic, pulmonary, tricuspid, or mitral)
– radiation (carotids or axilla, or no radiation)
Innocent murmurs are common in childhood
• Heard over only a relatively small area.
No comments:
Post a Comment