PEDIATRIC PHYSICAL EXAM  NBW >2500g

Newborn Classifications
Principles of child development  Category
TH
 Child development is predictable – (measure age o SGA <10 percentile
specific milestones)  Maternal smoking
TH
 Range of Normal development is wide –( mature o AGA 10-90 percentile
th
at different rates) o LGA >90 percentile
 Physical, disease related social and env factors  Hypoglycaemia
affect dev and health
 Child’s dev affect the nature of history and PE GENERAL SURVEY and VITAL SIGNS
 Somatic growth
STAGES o measurement of growth is an
 Infancy important indicator of health
 Early Childhood o Growth charts – tools for assessing
 Middle Childhood somatic growth
 Adolescence  Normal values accdg to age and sex
 Prior reading on same child
Approach to exam of newborns and infants
 Perform non disturbing maneuvers early Length
 Examine pain last  <2 years old, child on supine; direct
measurement with tapemeasure
Newborn exam  >2 years old = 5 cms/ yr
 Observation
 Undress the baby, rock Weight
 Within 24 Hrs  Infant scale
*The first pediatric examination is performed  BMI mass = body fat
after delivery and comprehensive examination
should be completed w/in 24h; Do it in front of Head circumference
parents  Measured during the first 2 years of life
 Reflects rate of growth of cranium and brain
Immediate assessment at birth
 APGAR Chest Circumference
o Its 5 components classify newborn’s Abdominal girth
neurologic recovery from stress of
birth and imm. Adaptation to Blood Pressure
extrauterine life.  SBP increases throughout childhood
o 1 min – resuscitation  Male SBP
 8-10 normal o At birth 70 mmhg
 5-7 nervous depression o 1 month 85 mmhg
 0-4 severe depression o 6 months 90 mmhg
o 5 min – neurologic sequel
 8-10 normal Pulse rate
 0-7 HR organ dysfxn  Variable
 BALLARD  Sensitive to effects of illness, exercise and
o Gestational age and birth weight emotion
o Gestational age based on: o Birth – 1 mo = 140 (90-190)
 Physical maturity o 1-6 mos = 130 (80 – 180)
 Neuromuscular maturity o 6-12 mos = 115 (75-155)
o Estimates gestational age w/in 2 weeks  Palpate femoral arteries, brachial arteries or
o Classification (Gestational Age) auscultate heart
 Preterm <34 wks
 Late Preterm 34-36 wks Respiratory rate
 Term 37-42 wks  Variable, more responsive to illness, exercise and
 Post term >42 wks emotion
o Classification (Birth Weight)  Range 30-60 cpm
 ELBW <1000g  Periodic breathing – alternating periods of rapid
 VLBW <1500g and slow breathing
 LBW <2500g

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  RR during active sleep is 10 cpm faster than quiet
sleep.
 Diaphragmatic breathing is predominant
 Thoracic excursion is minimal
 Tachypnea > 60 birth to 2 months and >50 2 mos
to 12 mos.
Temperature
 Auditory canal temperatures are accurate
 Rectal temperatures are most accurate for
infants
 Rectal route – insert thermometer 2-3 cm deep
for at least 2 mins.
 Average rectal temp = 37.2/ 99
SKIN
 INSPECTION
 Cutis marmorata – vasomotor changes; lattice
like bluish mottled appearance on trunks, arms
and legs; in response to cooling or exposure to
heat
 Acrocyanosis – blue cast to hands and feet when
exposed to cold
 Harlequin dyschromia – transient cyanosis of half
of the body or extremity; result from temporary
vascular instability
 Lanugo – fine, downy hair at birth
 Vernix caseosa – cheesy white material
composed of sebum and desquamated epith
cells
 Vascular Markings – Salmon patch
4 common dermatologic conditions:
1. Miliaria rubra – scattered vesicles on an
erythematous base; obstrxn of sweat gland ducts
2. Ertythema toxicum – erythematous macules with
central pinpoint vesicles; unknown etiology
3. Pustular melanosis – more in black infants,
vesiculopustules on brown macular base
4. Milia – pinhead white raised areas w/o erythema
 PALPATION
 Turgor – degree of hydration
 Abdominal wall
 Tenting – delay in return; severe dehydration
HEAD
 At birth larger than body
 ¼ of body length and 1/3 of body weight
 Sutures – membranous tissue spaces
 Fontanelles – where sutures intersect in anterior
and posterior
o On palpation sutures: ridges and
fontanelles: concavity
o Anterior: 4-6 cm/ close 2-26 mos
o Posterior: 1-2 cm/ close 2 mos
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o Fullness of fontanelle: intracranial
pressure
 Asymmetry
o Caput succedaneum – asymmetric
head swelling over the occpitoparietal
region resulting from capillary
distention and extravasation of fluid
o Doliocephaly – narrow bitemporal
diameter; long occipitofrontal
diameter
o Positional plagiocephaly – flattening of
pareito occipital on the dependent side
and prominence of frontal region over
the ipsilateral side
o Macrocephaly – large head size
o Microcephaly – small head size
FACIES
 Factors
o Family history
o Perinatal hx
o PE of other parts
EYES
 INSPECTION
 Usually edematous from birth process
st
 1 10 days: Doll’s eye reflex – stare in one
direction
 Intermittent crossed eye movements
o Convergent strabismus/ esotropia
o Divergent strabismus/ exotropia
 Optic blink reflex – blinking in response to bright
light
st
 During the 1 year: visual acuity sharpens as
ability to focus improves
EARS
 Position – line across the inner and outer canthi
o Low set ears – pinna below the canthi
 Shape
 Infant’s canal is directed downward from the
outside; pull auricle gently downward to view
the eardrum
 Acoustic blink reflex – blinking of infant’s eyes in
response to sudden sharp sound
 Hearing test – may vary with age
NOSE AND SINUS
 Test patency for nasal passages
 Occlude one nostril at a time while holding the
infants mouth closed
 Most infants are nasal breathers
 Some are obligate nasal breathers: difficulty
breathing through the mouth
 Maxillary and Ethmoid sinuses are present
 Choanal atresia – nasal passages obstructed;
assess through passing feeding tube through
each nostril into posterior pharynx
MOUTH AND PHARYNX  Substernal thrust or rolling heave at the left
 Usually edentulous sternal border – right ventricular enlargement
 Epstein pearls – tiny white or yellow rounded  Apical heave – left ventricular enlargement
mucus retention cysts located along posterior  Hyperdynamic precordium –volume overload,
midline of hard palate PDA
 Gag reflex – strong reflex  Silent precordium – pericardial effusion/
 Quality of cry – lusty, strong cry cardiomyopathy, may be normal in obese patient
 Tongue tie or ankyloglossia – limiting protrusion  An increase in respiratory effort is expect from
of tongue pulmonary disease; whereas cardiac disease
 Teeth: 1 tooth/ mo from 6-24 months. Max of 20 there may be tachypnea without increased work
primary teeth of breathing (peaceful tachypnea)
 PALPATION
NECK  Thrills – rough, vibrating quality; palpable
 Palpate lymph nodes equivalent of murmurs; turbulence within the
 Infants: supine- shorter necks heart of blood vessels
 Older children: sitting  Aortic bruits – aortic stenosis
 Palpate clavicle: fractures  Pulmonary bruits – Pulmonary stenosis
 Right lower sternal border – VSD
THORAX and LUNGS  Apical thrill – mitral insufficiency
 INSPECTION  AUSCULATION
 More rounded than adults  Normal Sinus Dysrhythmia – heart rate
 Thin chest wall: lung and heart sounds increasing on inspiration and decreasing on
transmitted quite clearly expiration
 Periodic breathing  Diaphragm – high pitched sound
 Listen to breath sounds ( signs of respiratory  Bell – low pitched sound
distress)  Heart rate changes in respiration
 2 aspects of infant’s breathing:  S1: closure of AV valves
o Audible breath sounds  S2: closure of Semilunar valves
o Work of breathing o Spliting increased during inspiration
 Chest indrawing – inward movement of the skin and decreased during expiration
between ribs during inspiration o Wide splitting: ASD, PS
o 4 types of retractions:  S3: at apex; low pitched; normal in children; may
o Suprasternal be normal in adolescents with relatively slow
o Intercostal heart rate; may be heard as gallop rhythm
o Substernal  Ejection clicks: AS, PS
o Subcostal  Midsytolic clicks: MVP
 Thoracoabdominal paradox – inward movement  Murmurs
of the chest and outward movment of the o Systolic: start after S1 continuous –
abdomen during inspiration (abdominal PDA
breathing) normal in infants but not in older o Diastolic: start after S2 – insufficiencies
infants
 PALPATION BREASTS
 Tactile fremitus  May often be enlarged from the maternal
 AUSCULTATION estrogen effect
 Infant breath sounds are louder and harsher  Engorged with white liquid called “witch’s milk”
than those of adults because stethoscope is
closer to the origin of sounds ABDOMEN
 Wheezes and ronchi are common in infants  Usually protuberant as a result of poorly
developed abdominal musculature
HEART  Umbilical cord
 INSPECTION o 2 thick walled umbilical arteries
 Cyanosis – may indicate congenital cardiac o Large but thin walled umbilical vein
abnormalities o Umbilicus cutis – long cutaneous
 Cardiac causes of central cyanosis: right to left portion, covered with skin; retracts to
shunting be flushed with abdominal wall
 Precordial bulge on left of sternum –
Cardiomegaly

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 o Umbilicus amnioticus – covered with
firm gelatinous substance; falls off
within 2 weeks
 Umbilical Hernia
o Defect in abdominal wall
o Can be protuberant with increased
intra abdominal pressure
 Diastesis recti
o Separation of 2 rectus abdominis
muscle causing a midline ridge most
apparent when infants contract
abdominal muscles
 AUSCULTATION
 PERCUSSION
 Liver Span
o Liver edge: 1-3 cm below the righ
costal margin
o Male- 2.4-2.8 cm
o Female – 2.8 – 3.1 cm
 Spleen
o Spleen edge: 1-2 cm below the costal
margin
GENITALIA (Male)
 Supine position (penis, testes, scrotum)
 Foreskin – non retractable at birth; completely
covers the glans penis
 Newborn’s testes – 10 mm in width and 15 mm
in length and should lie in the scrotal sacs most
of the time.
 Cryptorchidism – undescended testicle; both
testes are descended by 1 year of age
 2 common scrotal masses:
o Hydroceles – overlie the testes and
spermatic cord, not reducible and can
be transilluminated, resolve by 18
months
o Inguinal hernias – separate from
testes, usually reducible, often don’t
transilluminate, don’t resolve
GENITALIA (female)
 Infant supine
 Genitalia will be prominent due to effects of
maternal estrogen
 Milky white vaginal discharge that may be blood
tinged
 Note vaginal opening
MUSCULOSKELETAL SYSTEM
 Focus on detection of congenital abnormalities;
particularly in hands, spine, hips, legs and feet
 Palmar grasp reflex – newborn’s hands are
clenched
 Spine – meningomyocele
 Hips
o Ortolani test– presence of posteriorly
dislocated hip
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o Barlow test- ability to sublux or
dislocate an intact but unstable hip
 Galeazzi or allis sign – test for femoral
shortening
NERVOUS SYSTEM
 Mental status
 Motor tone
 Sensory function
o Test for pain sensation
 Cranial Nerves
o I – difficult to test
o II- regard face and look for facial
response
o II, III- darken room; optic blink reflex
o III, IV, VI – how infant tracks smiling
face
o V – rooting reflex, sucking reflex
o VII – cry and smile
o VIII – acoustic blink reflex
o IX, X – coordination during swallowing,
gag reflex
o XI – symmetry of shoulders
o XII – coordination of sucking
 Deep tendon reflexes
o Anal reflex – important to illicit if a
spinal cord lesion is present
o Babinski reflex – dorsiflexion of big toe
and fanning of other toes
 Primitive reflex ( infantile automatisms)
o To evaluate newborn and infants
developing CNS
o Neurologic abnormality is suspected if
primitive reflexes are
 Absent at app. Age
 Present longer than normal
 Asymmetric
 Associated with posturing or
twitching
1. Palmar Grasp reflex
o Infant will flex and grasp fingers
2. Plantar grasp reflex
o Touch the sole at base of toes and toes
will curl
3. Rooting reflex
o Stroke perioral skin, mouth open and
infant turn head towards the
stimulated side and suck
4. Moro reflex (Startle)
o Arms will abduct and extend, hands
open and legs flex as abruptly being
lowered down
5. Asymmetric Tonic Neck reflex
o Supine, turn head on one side, the
arms, legs to which head is turned will
extend while opposite arm flex
6. Trunk Incurvation (Galant reflex)
 o Prone, stroke back, spine will curve
toward stimulated side
7. Landau reflex
o Suspend prone, head lift up and spine
straighten
8. Parachute reflex
o Suspend prone, lower head to surface,
arms and legs extend in protective
fashion
9. Positive support reflex
o Hold infant around trunk, lower until
touching ground, hips, knees and
ankles will extend, stand up partially
10. Placing and stepping reflex
o Hold infant around trunk, have one
sole touch surface, hip and knee of
that foot will flex and other foot will
step forward

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