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350 • BABIES AND CHILDREN
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Normal urethral meatus
Most common types
Increased incidence
of other genitourinary
abnormalities
Glandular
Coronal
Mid-shaft
Penoscrotal
Types of
hypospadias
Fig. 15.10 Varieties of hypospadias.
B
Fig. 15.11 Hypospadias and chordee. A Penile shaft hypospadias. B
Lateral view showing the ventral curvature of the penis (chordee). From
Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn. Edinburgh: Mosby; 2001.
Reflexes are brisk in term infants, often with a few beats of
clonus.
The plantar reflex is normally extensor in the newborn.
Abnormal findings
Hypotonic infants may have a ‘frog-like’ posture with abducted
hips and extended elbows. Causes include Down
meningitis and sepsis.
Increased tone may cause back and neck arching and limb
extension; the baby feels stiff when picked up. Causes include
meningitis, asphyxia and intracranial haemorrhage.
Brachial plexus injuries include Erb
brachial plexus roots C5 and C6, producing reduced movement
of the arm at the shoulder and elbow, medial rotation of the
forearm and failure to extend the wrist (Fig. 15.12). Klumpke
palsy may be seen after breech delivery due to damage to roots
C8 and T1, with weakness of the forearm and hand. These injuries can be associated with ipsilateral Horner’s syndrome and/
or diaphragmatic weakness in severe cases. Most perinatal
brachial plexus injuries recover over subsequent weeks.
Facial nerve palsy causes reduced movement of the cheek
muscles, and the side of the mouth does not turn down when
the baby cries. Most cases are transient.
0
s palsy, which affects
0
s syndrome,
Fig. 15.12 Erb’s palsy. The right arm is medially rotated and the wrist is
flexed. From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd
edn. Edinburgh: Mosby; 2001.
Primitive reflexes in newborn and young
infants
The primitive reflexes are lower motor neurone responses that are
present at birth but that become suppressed by higher centres by
4 to 6 months. They may be absent in infants with neurological
depression or asymmetrical in infants with nerve injuries. Persistence into later infancy may indicate neurodevelopmental abnormality (p. 353). There are many examples, and there is no need to
elicit them all because their individual value is limited.
Examination sequence
Grasp responses
• Gently stimulate the palm or sole with your finger to produce
a palmar or plantar grasp.
Ventral suspension/pelvic response to back
stimulation
• Hold the baby prone, and look for neck extension. Stroke the
0
s
skin over the vertebral column to produce an extensor
response with pelvic elevation.
Place-and-step reflexes
• Hold the baby upright, and touch the dorsum of the foot
against the edge of a table. The baby will flex the knee and
hip, placing the foot on the table (Fig. 15.13A).
• Lower the upright baby towards the table surface. When the
feet touch the surface, a walking movement occurs.
The physical examination of newborns • 351
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B
AC
Fig. 15.13 Primitive reflexes. A Placing reflex. B The Moro reflex. C Tonic neck reflex.
Moro reflex
• Support the supine baby’s trunk and head in a semi-upright
position. Let the head fall backwards slightly. The baby will
quickly throw out both arms and spread the fingers (see
Fig. 15.13B).
Root-and-suck responses
• Gently stroke the baby’s cheek. The baby turns to that side,
and the mouth opens, as though looking for a nipple. This is
‘rooting’. If you place your finger in a healthy infant’s mouth,
they will suck it vigorously.
Asymmetric tonic neck reflex
• Turn the supine infant’s head to the side. The arm and leg on
the same side will extend, and the arm and leg on the
opposite side will flex. This reflex is present at term and
maximal at 1 month (see Fig. 15.13C).
Limbs
Examination sequence
• Inspect the limbs, and count the digits.
• If the foot is abnormally positioned, gently try to place it in a
normal position. If the abnormal position is at all fixed, refer to
a specialist.
• Examine the hips to check for developmental dysplasia of the
hip (DDH):
• Lay the baby supine on a firm surface.
• Inspect the skin creases of the thighs for symmetry.
• Examine each hip separately. Hold the thigh with the knee
and hip flexed and your thumb on the medial aspect of the
thigh.
• Move the proximal end of the thigh laterally, and then push
down tow ards the examining table (Barlo w manoeuvre,
Fig. 15.14A); a clunk indicates that the hip is dislocatable.
• Now abduct the thigh; if you feel a clunk, this is the head of
the femur returni ng into the acetabu lum (Ortolani
manoeuvre, Fig. 15.14B) . If the femoral head feels lax and
you feel a clunk with an Ortolani manoeuvre without first
performing the Barlow manoeuvre, then the hip was
already dislocated.
Normal findings
A small percentage of normal babies have single palmar creases,
but this is also associated with Down
Fig. 3.31B, p. 40) and other chromosomal abnormalities. Tibial
bowing is common in the newborn.
It is common to hear or feel minor ligamentous clicks during
hip examination. These are of no consequence and feel quite
different to the dislocation and relocation of developmental
dysplasia of the hip (DDH). If in any doubt, obtain an expert
opinion. Never use the term ‘clicky hips’.
0
s syndrome (see
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352 • BABIES AND CHILDREN
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Fig. 15.14 Examination for developmental dysplasia of the hip. A The
hip is dislocated posteriorly out of the acetabulum (Barlow manoeuvre). B
The dislocated hip is relocated back into the acetabulum (Ortolani manoeuvre).
Abnormal findings
Oligodactyly (too few digits), polydactyly (too many) or syndactyly
(joined digits) may occur. In talipes equinovarus the foot is
plantar-flexed and rotated, with the sole facing medially. In talipes
calcaneovalgus the foot is dorsiflexed so that the heel is prominent and the sole faces laterally.
Many cases of DDH have associated risk factors, including a
family history, breech delivery, positional talipes (especially calcaneovalgus) or oligohydramnios.
Some centres offer hip ultrasound screening.
Occipital Frontal
Fig. 15.15 Measurement of head circumference.
Fig. 15.16 Measuring length accurately in infants.
Weighing and measuring
Examination sequence
• Weigh the infant fully undressed using electronic scales ac-
curate to 5 g.
• Use a paper tape to measure the maximal occipitofrontal
circumference round the forehead and occiput (Fig. 15.15).
Repeat the measurement three times, noting the largest
measurement to the nearest millimetre.
• Measure the crown–heel length using a neonatal stadiometer
(Fig. 15.16). Ask a parent or assistant to hold the baby’s head
still, and stretch out the legs until the baby is fully extended
(the least reproducible of the three measurements).
• Record the results on a centile chart appropriate to the in-
fant’s ethnic background.
Final inspection
Perform a final top-to-toe inspection to avoid missing anything
and to allow the parents a further opportunity to ask questions.
The physical examination of infants
beyond the newborn period
Examination of young infants beyond the newborn period is
similar to the newborn examination. Transient neonatal findings will no longer be present. Older infants are usually
happier when examined on their parent’s lap than on an
examination table. The examination of the ears should
include otoscopy (See Fig 15.23). You should check the hips
whenever you examine an infant until they are walking normally. After the fi rst few months the Ortolani and Barlow
manoeuvres cannot be performed and the most important
signs are limitation of abduction in the hip, and thigh skin
crease asymmetry. Neurological history and examination
should take account of the developmental stage of the child.
The primitive reflexes disappear by 4 to 6 months. In later
infancy, ask additional questions to obtain information about
neurodevelopmental progress (Box 15.5).
The history • 353
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15.5 Developmental attainment of preschool children at different ages*
Skills 4 months 6 months 10 months 1–2 years 2–3 years 3–5 years
Gross
motor
Fine
motor
Personal
social
Development is extremely variable and failure to attain only one milestone is of little significance, whereas failure to attain several milestones is cause
for concern.
Has good head control on
pull to sit
Keeps back straight
when held in sitting
position
Opens hands
Holds objects placed in
hand
Shows interest in toys
Laughs, vocalises
Supports weight on hands
when laid prone
Rolls front to back
Transfers objects from
hand to hand and to
mouth
Has a variety of speech
noises
Plays peep-bo
Sits unsupported
Pulls to stand
Uses pincer grip
bilaterally without hand
preference
Starts to understand
some words
Claps hands
Walks without
support
Holds a crayon
and scribbles
Has 10–20
recognisable
words
Runs
Bounces on
trampoline
Can draw a
circle
Can
communicate
verbally
Pedals a tricycle
Can draw a cross,
square, face/
person
Has 500–1500
words
Is dry by day
OLDER CHILDREN
Individuals between 12 months and 16 years are known by
nonspecific terms, including toddler, preschool, child, adolescent, teenager or young person. It is important to recognise and
acknowledge age-related maturation, and a common phrase to
span these years is ‘children and young people’ (CYP).
The history
Obtaining a history from children and young
people compared with adults
There are many similarities in taking a history from CYP and from
adults. Introduce yourself to the CYP and accompanying adult,
and begin your observation of the CYP. Establish who the adult
is (e.g. a parent, grandparent or carer), and begin to consider to
what extent the CYP will be able to contribute to the history. Let
the CYP become accustomed to you before asking specific
questions.
Start with open-ended questions. Most often a parent will wish
to explain their perspective on the CYP’s problem, and it is
important to enable them to do so. Young people in particular
may wish to explain the problem from their perspective, and it is
important to directly and openly engage with the CYP to give this
opportunity. Once the presenting symptoms have been outlined,
the history should focus on questions that aim to elucidate the
differential diagnosis; a CYP is often good at helping with these
more specific questions. Respect age and ability to recall events,
and adopt a balanced perspective on whether responses from
the parents or the CYP are more likely to be accurate for each
question. Children younger than 6 years often provide little history, those aged 6 to 11 years can do so if they are sufficiently
confident, and those aged 12 years and older should be able to
provide a valuable history in the correct environment and with the
use of questions that are framed in appropriate terminology. As
you would for adult history taking, include reflective summing up:
for example, ‘So what you are saying is that .’.
A paediatric history includes elements that are not part of the
adult history (obstetric, developmental, immunisation histories),
systematic enquiry has different components from those in
adults (see later) and the differential diagnosis may include
conditions seen only in children (e.g. abdominal migraine, toddler
diarrhoea, croup, viral wheeze and febrile convulsion). Most other
diagnoses also occur in adults.
Common presenting symptom s
Diagnosis is built on patterns of symptoms; rarely will any one
symptom or sign lead to a ‘spot diagnosis’. The initial history
suggests a differential diagnosis and prompts additional questions to assess the probability of particular diagnoses. As with
adults, presenting symptoms should be described in terms of
onset, frequency, severity, duration, aggravating and relieving
factors, associated features and impact on function. Pain and the
need for analgesia can be particularly difficult to assess in young
children; objective scoring systems may help (Box 15.6).
The most common presenting problems in the child affect the
respiratory, gastrointestinal and nervous systems (covered in
Boxes 15.7–15.9) and the skin.
Skin symptoms can be acute or chronic. Acute-onset rash is
common in children and can be described using the same terminology as for adults (see Chapter 14). Those who examine skin
rashes in CYP should be able to describe the rash across all skin
colours as appearances can be very different (Fig 15.17). An
excellent resource (developed by a medical student) is the
website www.blackandbrownskin.org.uk.
Most rashes are viral and resolve spontaneously. Rash with
blistering is often itchy. It may be urticarial (with an environmental,
viral, food or medicine trigger) or an insect bite. Blisters with
associated yellow crusting may be infected bullous impetigo
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15.6 Pain assessment tool: FLACC scale
01 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, uninterested Frequently or constantly quivering chin,
clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position,
Squirming, shifting back and forth, tense Arched, rigid or jerking
moves easily
Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs,
frequent complaints
Consolability Content, relaxed Reassured by occasional touching, hugging or being
Difficult to console or comfort
talked to, distractible
Each category is scored on a 0–2 scale to give a total score of 0– 10: 0 ¼ no pain; 1–3 ¼ mild pain; 4–7 ¼ moderate pain; 8–10 ¼ severe pain.
15.7 Respiratory system
Significance
Symptom
a,b
Frequency
Diagnostic
significance
heightened if
associated with Differential diagnosis
Acute
Short of breath at
rest (SOBar)
*** High (indicates loss of all
respiratory reserve)
LRTI, asthma, acute episodic wheeze, inhaled foreign
body. Rarely, supraventricular tachycardia, congenital
heart disease, heart failure or muscular weakness
Cough *** Low SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Wheeze *** Moderate SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Chest pain * High Exercise
Fever
Musculoskeletal pain, empyema, reflux oesophagitis,
cardiac ischaemia
Stridor *** High URTI, high fever, choking Croup, foreign body, epiglottitis (if not immunised)
Chronic
Short of breath on
exercise (SOBoe)
Cough *** Low Wheeze, SOBoe, failure to
** Low Cough, wheeze, failure to
thrive
thrive
Lack of fitness, respiratory pathology, cardiac pathology,
neurological weakness
Isolated cough with sputum suggests infection, commonly
bronchitis, rarely bronchiectasis, cystic fibrosis, inhaled
foreign body. If also wheezy, consider asthma or viralinduced wheeze
Wheeze *** Moderate SOBoe, failure to thrive Isolated, persistent ‘wheeze’ usually arises from the nose
(stertor (e.g. adenoidal hypertrophy)) or the largest
airways (stridor (e.g. laryngomalacia)). Episodic wheeze
with cough suggests asthma or viral-induced wheeze
Chest pain * High Exercise Nonspecific chest pain, musculoskeletal chest pain, very
rarely cardiac ischaemia
a
Respiratory sounds: clarify what noise the parent or child is describing. The history sometimes reveals the source (e.g. nose (stertor), throat (stridor)
or chest (rattle or wheeze)). A constant respiratory sound is more likely to be stertor, stridor or rattle (a sound associated with vibration of the chest). A
very loud sound, such as one heard in the next room, is not genuine wheeze.
b
Coexistent failure to thrive or weight loss always increases the significance of any symptom.
LRTI/URTI, Lower/upper respiratory tract infection.
Red, circular lesions with a pink centre are most often erythema
multiforme (target lesions). Petechial or purpuric rashes that do not
blanch with pressure are of most concern. These may be viral in
origin but importantly can be an early sign of meningococcal
disease (particularly if the CYP is febrile). A differential diagnosis of
a purpuric rash is idiopathic thrombocytopenic purpura.
15.8 Gastrointestinal system
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Significance heightened
Symptom Frequency Diagnostic significance
Acute
Vomiting *** Low: a very non-specific
Diarrhoea *** Moderate Fever, dehydration
Abdominal
b
pain
Chronic
Vomiting *** Moderate Failure to thrive
Diarrhoea *** Moderate Failure to thrive
Abdominal
b
pain
a
Symptoms of dehydration include dry mouth, foul-smelli ng breath, anuria and lethargy.
b
Abdominal pain can be diffi cult to identify in young children who are not able to express themselves.
c
Coexisting failure to thrive or weight loss always increases the significance of any symptom.
** Moderate Fever, bloody stools Acute gastroenteritis/colitis, acute surgical causes (e.g.
*** Low Pain that is not periumbilical
symptom in children
if associated with Differential diagnosis
Fever, drowsiness,
dehydration
Headache
Headaches
Diarrhoea and vomiting
Failure to thrive
a
a
c
c
c
Acute gastritis/gastroenteritis, any infection (otitis media,
pneumonia, urinary tract infection, meningitis), head injury,
encephalitis
Acute gastroenteritis/colitis, appendicitis
appendicitis) intussusception
Gastro-oesophageal reflux (rare in older children compared
with infants), raised intracranial pressure, food allergy
Commonly toddler’s diarrhoea, also lactose intolerance. If
failure to thrive, consider coeliac disease, inflammatory bowel
disease
If isolated and periumbilical, non-specific abdominal pain is
common and other diagnoses include abdominal migraine,
renal colic. If associated with other symptoms and/or failure
to thrive, consider coeliac disease, inflammatory bowel
disease, constipation
The history • 355
15
15.9 Nervous system
Symptom Frequency
Acute
Headache ** Low
Unsteady gait * High Varicella encephalomeningitis, vestibular neuronitis
a
Seizure
Disturbed level of
consciousness
Chronic
b
Headache
Failure to pass
developmental
milestones
Developmental
regression
Seizure * High Epilepsy; rarely, long QT syndrome or inborn error
a
An acute seizure can be confused with a rigor in a febrile child. A seizure involves slow (1 beat per second), coarse, jerking that cannot be stopped, lossof
consciousness and postictal drowsiness. A rigor is characterised by rapid (5 beats per second), fine jerking that can be stopped by a cuddle with no loss of
consciousness.
* High Febrile seizure, meningitis/encephalitis
* High Encephalitis, intoxication/drug ingestion
** Low Vomiting
* Moderate Widening gap between age and
* High Muscular dystrophy, inborn error of metabolism,
b
Chronic headache can also arise from the mouth (e.g. dental abscess) or face.
Diagnostic
significance
Significance heightened if
associated with Differential diagnosis
Acute (simple) headache, migraine, meningitis/
encephalitis
Vomiting, fever, neck stiffness,
photophobia
}
Abdominal pain
age when ‘normal’ milestone
should have been passed
Epilepsy, metabolic disorder
(accidental/ deliberate)
Brain tumour, migraine, chronic non-specific
headache
Cerebral palsy, neglect
neurodegenerative conditions
of metabolism
356 • BABIES AND CHILDREN
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A
Fig. 15.17 Appearance of measles rash in different skin colours. From Ottolini MG. Measles. In: Goldman-Cecil Medicine. 26th edn. Philadelphia:
Elsevier; 2020.
Chronic skin excoriation, most commonly in the flexures,
suggests eczema, whereas plaques on the elbows/knees may
indicate psoriasis.
Hair loss is distressing. If associated with itch, it is often due to
tinea capitis; with a history of preceding illness, alopecia is a likely
cause.
BC
Developmental history
This is particularly important for children under 3 years of age or
those with possible neurodevelopmental delay (see p. 353 and
Box 15.5 ).
Drug history
Past medical history
Has the CYP regularly seen a healthcare professional (current or
past) or are they currently taking any regular medication? Have
they been in hospital before, and if so, why?
Birth history
Was the CYP born at term or preterm (if so, at what gestation)?
• For those born at term, was the neonatal period normal? For
example, did the child need to go to a special care baby
unit?
• For those born preterm, take a full neonatal history to
understand any potential impact and include time ventilated and in supplemental oxygen, time on feeding support, age at discharge from hospital and any neonatal
follow-up.
• If the chi ld is under 3 years of age: what was the birth-
weight, and were there any complications during
pregnancy?
Vaccination history
Are the CYP’s immunisations up to date according to countryspecific schedules? If not, explore why and consider how best
to encourage catch-up.
Prescribing errors often arise from poor reconciliation of medication lists between different healthcare professionals. It is a
doctor’s duty to ensure that medicines are accurately reconciled
within documentation. Transcribe the medication, dose and
frequency directly from the medication package or referral letter if
possible. Enquire about any difficulties in taking medication to
establish adherence. Clarify any adverse or allergic reactions to
medications (including drug, date and reaction), and ensure this
information is shared in the appropriate section of health records.
Family and social history
The people whom a CYP may consider to be family can be
diverse. It is important to establish who the family is and
recognise that this may be in different households with different
adults at different times. Children at risk of neglect may have
complex domestic arrangements such as several caregivers; it is
important that you understand these arrangements. Ask open
and non-judgemental questions to understand:
• Who lives in the family home, and who cares for the child? Is
there another household where the child spends regular
time?
• Does anyone smoke in these places?
• Are there any pets? Are any symptoms associated with pet
contact?
The physical examination • 357
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• Are there any similar symptoms in the child’s first- or second-
degree relatives?
Sketch a family tree, noting any step-parents, step-siblings or
shared care arrangements. Consider parental consanguinity,
which is not uncommon in some ethnic groups.
Occasionally, chronic symptoms are associated with anxiety
or potential ‘secondary’ gain for the CYP; these may include
chronic cough, abdominal pain and headache in a well-looking
CYP in whom examination is normal. Look carefully at the
CYP’s facial expression, eye contact and body language when
asking questions. Ask carefully but specifically about school
(avoidance and bullying), social interactions (does the child have
many friends?) and out-of-school activities. School avoidance
should be addressed if it is related to anxiety or if the pretext of
medical symptoms is used.
Systematic enquiry
This screens for illnesses or symptoms that may be not recognised as important or relevant by the CYP or parents. For CYP
aged over 12 years, the questions used for adults are appropriate. In younger children, ask age-related questions. Specific
areas include:
• Ear, nose and throat: ask the parents about their perception
of a child’s hearing ability (reduced in chronic otitis media),
repeated sneezing (rhinitis) or the presence of regular snoring
with periods of struggling to breathe (symptomatic obstructive sleep apnoea).
• Gastrointestinal system: ask whether growth is as expected
and whether there is recurrent abdominal pain or difficulty in
opening the bowels (constipation).
• Respiratory system: ask whether the child has had a
regular cough (particularly asleep) when otherwise well
or had wheeze on a recurrent basis in response to
triggers such as viral infection or exercise (consider
asthma).
• Urinary system: 15% of children at 5 years of age will
continue to have primary nocturnal enuresis. It is embarrassing for most children and frustrating to most parents, so
be sensitive in your questioning on frequency and timing of
events.
The physical examination
Normal growth and development
An understanding of CYP development is vital to identifying
whether symptoms and signs are consistent with age.
For the first 2 years of life, children born prematurely should
have their age adjusted to their expected date of delivery instead
of their date of birth when assessing growth and development.
Failure to make this correction would otherwise create a false
impression of poor growth and developmental delay.
Prematurely born infants can be at increased risk of impaired
growth and development and merit increased surveillance,
although most develop normally.
Growth
Growth after infancy is extremely variable. Use gender- and
ethnicity-specific growth charts (e.g. those shown in
Fig. 15.18). CYP with Trisomy 21 have a differential growth
trajectory, and specific charts to support growth monitoring are
available online (https://www.cdc.gov/ncbddd/birthdefects/
downsyndrome/growth-charts.html). Growth charts enable a
comparison of the individual with the corresponding population
normal range at a single time point. As important is the abilit y of
growth charts to enable tracking of growth trajectories over
time when a CYP is regularly measured. Each child should grow
along a centi le line for height and weight throughout childhood.
Failure to thrive is failure to attain the expected growth trajectory. A child on the 0.4th centile for height may be thriving if this
has always been their growth traject ory, while a child on the
50th centile for height may be failing to thrive if previously they
were on the 99.6th centile.
A child’s height is related to the average of their parents’ height
centile Æ2 standard deviations. Parents whose average height
lies on the 50th centile will have children whose height will normally lie between the 2nd and 98th centiles (approximately
10 cm above and below the 50th centile).
Neurodevelopmental maturation
Normal development is heterogeneous within the population,
which can make abnormalities difficult to identify. Important determinants are the child’s environment and genetic potential.
Developmental assessment requires patience, familiarity with
children and an understanding of the range of normality for a
given age.
The preschool child (1 to 5 years)
At the younger end of this range, questions and observations
relating to gross motor skills are most sensitive; as the child
becomes older, questions and observations relating to fine motor
and personal social skills become more meaningful. Delayed
speech with normal attainment of motor milestones is not uncommon, particularly in boys, but should prompt hearing
assessment (see Box 15.5).
The school-age child (5þ years)
By this age, many neurodevelopmental problems have revealed
themselves to parents, and relevant agencies, such as educational ones, may already be engaged. However, more subtle
developmental problems such as dyslexia (learning disability
affecting fluency and comprehension in reading) may remain
unrecognised and can be a major handicap. Ask general questions such as, ‘How is your child getting on at school?’ and
follow up by enquiring specifically about academic and social
activity.
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Weight-for-age BOYS
Birth to 2 years (z-scores)
17
16
15
14
13
12
11
10
9
Weight (kg)
8
7
6
5
4
3
2
Months
1
2
Birth 1 year
345
6
789
10
11 1
2
345
6
789
3
17
16
2
15
14
13
0
12
11
10
-2
9
-3
8
7
6
5
4
3
2
10
11
2 years
Age (completed months and years)
WHO Child Growth Standards
Weight-for-age GIRLS
Birth to 2 years (z-scores)
3
11
2 years
17
16
15
2
14
13
12
0
11
10
-2
9
-3
8
7
6
5
4
3
2
17
16
15
14
13
12
11
10
9
Weight (kg)
8
7
6
5
4
3
2
Months
12
34
56
78
910
Birth 1 year
11
12
34
56
78
910
Age (completed months and years)
WHO Child Growth Standards
Fig. 15.18 Growth charts. World Health Organization (WHO) standard centile charts for girls and boys. From WHO Child Growth Standards. http://www.who.
int/childgrowth/standards/weight_for_age/en/ © World Health Organization 2017. All rights reserved.
Puberty
This stage of adolescence, when an individual becomes
physiologically capable of sexual reproduction, is a time of
rapid physical and emotional development. The age at the
onset and end of puberty varies gre atly but is generally 10 to
14yearsforgirlsand12to16yearsforboys(Fig. 15.19). The
average child grows 30 cm during puberty and gains 40 to
50% in weight.
The physical examination • 359
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Female
Height of growth spurt
12 years
Age of menarche
1
12
/4– 121/2 years
Breast stage
Pubic hair stage
8 1012141618209 1113151719
Male
Height of growth spurt
Penis stage
IV
III
II
IV
III
II
Years
14 years
IV
If required, use a chart to stage puberty (Fig. 15.20). Pubertal
staging has a wide normal range, with abnormalities apparent
only on follow-up. Delayed or precocious puberty is not
uncommon.
Physical examination techniques in children
and young people
CYP usually present with a symptom. Those with acute symptoms often have physical signs such as wheeze, but examination
is normal in the majority who have chronic symptoms. Routine
screening examination after infancy is unhelpful, as many paediatric diseases only produce signs late in the illness.
Similarities in examination between children
and young people and adults
The techniques used when examining CYP are the same as
those in adults, with some exceptions. Examining CYP requires a
range of skills that take time to learn. The key skills involve being:
• Observant during discussion or play, to identify elements of
the examination that are naturally displayed and so can be
partitioned from the formal examination process, reducing the
duration of what is often a stressful encounter, particularly for
younger children.
• Opportunistic, to examine systems as CYP present them.
Chest and cardiac auscultation may be better earlier in the
examination in younger children before they become restless
or upset.
• Adaptive to CYP’s mood and playfulness. A skilled practi-
tioner can glean most examination findings from even the
most uncooperative CYP. Usually the history suggests the
diagnosis; the examination confirms it.
15
Testicular volume
4mL
Pubic hair stage
8 1012141618209 1113151719
Years
Fig. 15.19 Timing of puberty in males and females.
III
Differences in examination between children
II
12mL
IV
III
II
and young people and adults
The appropriate approach varies with CYP’s age.
1 to 3 years
All children at this age can be reluctant to be approached by
strangers and particularly dislike being examined. Early on, let
children gradually become used to your presence and see that
your encounter with their parents is friendly. Carefully observe the
child’s general condition, colour, respiratory rate and effort, and
state of hydration while taking the history: that is, when the child
is not focused on your close attention. For the formal examination, ask the parent to sit the child on the parent’s knees.
Examine the cardiorespiratory system and the abdomen with the
young child sitting upright on the parent’s knee. With patience,
abdominal examination can be done with the child lying supine
on the bed next to a parent or on the parent’s lap. Taking your
stethoscope from around your neck to use it can upset the child,
so make slow, non-threatening moves. If the child starts crying,
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