PEDIATRICS CLINICAL

EXAMINATIONS

TESFAYE TESSEMA, MD
ASSOCIATE PROFESSOR OF PEDIATRICS

SOLOMON AMSALU, MD
ASSOCIATE PROFESSOR OF PEDIATRICS
UNIVERSITY OF GONDAR
2011

i
Copyright © 2011,

All rights reserved. No part of this

publication may be reproduced, stored in a
retrieval system or transmitted, in any form
or by any means, electronic, mechanical,
photocopying or otherwise, without the prior
permission of the publisher.

ii
 Preface

This textbook is prepared on the basis of our

perception of the need for a simple approach
to clinical examination of children. The
cornerstone of a good clinical practice in a
detailed history and complete physical
examination. We hope that the text will
enable students to examine children both
thoroughly & thoughtfully. This textbook is
primarily prepared for medical students but
can be used by all health workers involved in
providing care for children.

Tesfaye Tessema MD
Solomon Amsalu MD

Gondar, Ethiopia 2011

iii
 Acknowledgments
The Authors are grateful for the research and
community service office of the University of
Gondar for facilitating the publication of the
textbook. Printing of the textbook has been
funded by International Training and Education
center on Health (I-TECH) Ethiopia. The
authors are grateful for the support.

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CONTENTS Page
I History taking 1
- Identification
- Chief complaints
- History of present illness
- Past history
- Nutritional history
- Developmental history
- Immunization history
- Family history
- Personal and social history
- Review of systems
II Physical examination 8
- General consideration
- General appearance
- Vital signs
- Anthropometric measurement
- Head,eyes,ears,nose,mouth &throat
- Lymphoglandular
- Respiratory system
- Cardiovascular system
- Abdomen
- Genitourinary system
- Musculoskeletal system
- Integumentary system
- Central nervous system
III Neonatal history and physical
examination 44
IV Annexes 56
- Assessment of nutritional status
- Calorie & protein contents of
common nutrients in use in
Ethiopia
- Assessment of growth and
development
- Expanded programme of immunization
schedule
- Problem oriented health record
v
- Growth charts
- Weight for height for both boys and
girls
- Blood pressure charts
- Procedures
- Neonatal resuscitation
- Normal values for laboratory tests
- References

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 I. HISTORY TAKING
1. Identification:
-Name -Age –Gender -Address
-Parents name, age, and occupation.

2. Historian:- E.g. Mother, father or any

other relative or care taker with
description of extent of relation with the
patient.

3. CHIEF COMPLAINTS:-
This part of the history should hold the
main reason for parents or other caretakers to
seek medical advice. There can be one or more
chief complaints. But the health worker
should be able to extract the most pertinent
ones and present it along with the duration of
illnesses chronologically.
E.g. Cough of 2 days duration; Cough of 2
months, dyspnea of 2 weeks, leg swelling of 3
days duration.

4. HISTORY OF PRESENT ILLNESS:-

This section elaborates the chief
complaints with emphasis on the genesis of the
illness and on other associated symptoms. The
interviewer should use his fund of knowledge
to ask the historian deeply in order to have a
good outlook on which organ system affection
the patient presents. Especially in infants
and young children the historian will only
tell what he/she felt is the child illness
thus systematic approach is mandatory in order
to identify the problem of the patient.
On top of these based on the chief
complaints explorative questions should be
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forwarded to differentiate different organ
system problems with similar complaints
that requires an art of questioning and a
superb knowledge. Thus in order to reach
to tangible fact the interviewer may be
obliged to include other histories like
immunization, nutrition, growth and
development, family and social history in
the history of present illness.
The interviewer must interpret information
and formulate ideas as the historian
speaks. Initially listen attentively and
consider a wide range of possibilities -
some serious and uncommon, some trivial
and common. Select the factors to which
you will give the greatest weight and
which will help you to organize your
analysis of the problems most effectively.
In your evaluation give added weight to
symptoms that give the patient the
greatest physical and emotional
discomfort.
Estimates of probability of specific
underlying illnesses is based on the 8
characteristics of symptoms and
combinations of nonspecific symptoms and
signs.
1. Anatomic location
2. Quantity and quality of symptoms
3. Aggravating and relieving factors
4. Variations over time
5. Chronological evolution
6. Associated symptoms
7. Absent symptoms
8. Responses to intervention if any.
Besides past medical events related to
present complaints and review of symptoms

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involved by major complaints should be
included.
5. PAST MEDICAL HISTORY:-
This includes -
A Past childhood illnesses like measles,
mumps, pertussis, chickenpox etc. with
clear description of the time of illness
and outcome.
B Major chronic illnesses like
tuberculosis, cardiac diseases, diabetes
mellitus etc.
C Hospital admissions with clear
description of time, reason and
outcome
D Surgical procedures major or minor like
circumcision, uvulectomy
E accidents - time and sequele
F perinatal history
The perinatal history should include

a. ANTENATAL HISTORY
I Maternal health including general
health, specific diseases or conditions
like infectious diseases, weight gain,
edema, HTN, proteinuria, eclampsia
Previous pregnancies and their outcome
II Medications
III General nutritional status
IV Radiation exposure
V Antenatal care: number of visits,
vaccination during pregnancy,
laboratory investigations like urinalysis,
blood group, and VDRL status
b. NATAL
Duration of pregnancy, labor-
initiation, duration, time of rupture of
membrane, place of delivery, mode of delivery,
presentation and complications during delivery
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c. POSTNATAL
Apgar score, time of onset of cry,
color of infant, feeding
characteristics, history of jaundice,
bleeding tendencies, febrile episodes,
convulsions, skin lesions etc

6. NUTRITIONAL HISTORY:-

This should include nutritional history from

time of birth till present age i.e.
A Time breast feeding initiated
(immediately after birth, later or not
at all)
B Total duration of breast feeding
C History of bottle feeding
D Time formula feeding started, type of
formula, amount, concentration and
frequency
E Reasons for change of breast feeding to
formula
F Weaning age, type of weaning diet
G Present diet - type, amount, frequency

7. DEVELOPMENTAL HISTORY:-

Development is dynamic and not static thus

should be assessed from birth to present age
of the child.
Ask for certain milestones except in cases
where a detailed developmental assessment is
needed.
ASK:- when child was able to raise and support
head, show social smile , roll over, sit alone
or unsupported, crawl and creep, stand and
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walk supported and alone, use words, talk in
sentences, dress self, self feeding, toilet
trained
School- grade, performance, learning problems
Home activities and helping parents in older
children,
Dentition- age of first teeth, loss of
deciduous teeth, eruption of permanent teeth
Interaction with peer groups
Change in rate of growth or weight gain

Sexual maturation
A Female:- time of breast development,
nipples, pubic hair, menstruation
B Male:- pubic hair, voice change

8. IMMUNIZATION HISTORY:-

A Type of vaccine, age administered,

frequency of administrations, boosters,
complications of vaccines.
B If not immunized or incomplete ask for
reasons.
*See page 67 for the schedule of expanded
program of immunization

9. FAMILY HISTORY:-
A Family size, number of siblings, age
and health status
B If any death in the family, ask for
time of death, cause of death
C Familial diseases like hypertension,
diabetes mellitus, epilepsy and genetic
disorders
D Communicable disease in the family
like, Tuberculosis, pertussis,
chickenpox, etc

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10. PERSONAL AND SOCIAL HISTORY:-
A School adjustments, habits of sleeping,
eating, swimming and playing
B Accidents
C Parental occupation, marital status,
monthly income, educational background
D Housing condition
E Waste disposal and water source for the
family

11. REVIEW OF SYSTEMS:-

Here the examiner would explore other organ

system problems that have been unaddressed or
overlooked in the history of present
illnesses.
a) General constitutional symptoms- fever,
chills, malaise, fatigability, night
sweat, weight loss or gain.
b) HEENT:-
A. Headache, dizziness, syncope, head
injuries,
B. Visual acquity, blurring, diplopia,
photophobia, trauma
C. Hearing loss, pain, discharge,
tinnitus, vertigo
D. Sense of smell, colds, obstruction,
epistaxis
E. Hoarseness of voice, sore throat, gum
bleeding or swelling, taste
disturbance.
c) Respiratory system:- cough, sputum
production with amount, character and
aggravating factors, chest pain, dyspnea,
difficult breathing, wheezing, cyanosis
d) CVS:- chest pain, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, cough, leg
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 swelling, palpitation, exercise tolerance,
sore throat, joint swelling
e) Gastrointestinal:- appetite, food
intolerance, dysphagia, nausea, vomiting,
haematemesis, constipation, diarrhea,
abdominal pain, color change of stool,
abdominal distension, visible peristalsis,
jaundice.
f) Genitourinary:- dysuria, frequency,
urgency, color change, polyuria, flank
pain, incontinence, history of skin
lesions, edema.
g) Lymphoglandular:- neck, axillary or
inguinal swelling, heat or cold
intolerance, weight change, polydipsia,
polyuria, polyphagia, body hair change
distribution, voice changes, history of
menses, breast pain
h) Musculoskeletal:-leg pain, joint stiffness,
restriction of movement, swelling, redness,
heat bone deformity
I) Neuropsychiatric:- syncope, seizure,
paralysis, abnormality of sensation or
coordination, tremor, loss of memory,
headaches, mood changes, sleep
disturbances, nervousness, chorea.

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 II. PHYSICAL EXAMINATION

Examination of a child is a very difficult

task requiring great patience and is time
consuming especially for the untrained person.
Examination should begin from the very outset
by inspecting the patient without touching or
getting nearer until one is familiar. While
asking the history from the historian one
should be able to make him/her self familiar
to the patient especially young children.
Smiling faces and colorful objects soothe the
child. While inspecting the child one should
look into the different parts of the body of
the child, the way he acts and responds to his
environment & strangers, his skin color, signs
of distress, behavior, his body status in
relation to the stated age. It is wise that
the attendant undress the patient without the
examiners approach to avoid discomfort and
refusal of examination by the patient. After
that systematic examination should proceed.
For infants and young children the lap of the
mother is the preferred site for examination.

A. GENERAL APPEARANCE:-
A. Level of consciousness- conscious,
lethargy, comatose.
B. Signs of cardio-respiratory distress- not
in distress, in mild, moderate, or severe
distress
C. Nutritional status-well nourished,
malnourished, extremely emaciated
D. Status of health- whether acutely sick
looking, chronically sick looking or not
sick looking.
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B. VITAL SIGNS

Pulse
In all children all peripheral pulses should
be checked for their presence, rate, rhythm
and character.
Normal pulse rate differ from age to age.
Pulse rate being higher in younger children.

Abnormal pulses:-
A. Pulses tardus- a slowly rising pulse
due to a fixed obstruction to left
ventricular outflow
B. Pulsus parvus- a pulse of small
amplitude because of a reduction of
stroke volume.
C. Pulsus parvus et tardus refers to a
small pulse with delayed systolic peak
characteristics of severe aortic
stenosis.
D. Corrigan’s or water hammer pulse-
abrupt upstroke followed by rapid
collapse seen in aortic regurgitation
E. Bounding pulse- seen in patent ductus
arteriosus, aortic regurgitation, AV
fistula, hyperkinetic status
F. Bisferiens pulse- characterized by two
systolic peaks occurs when large stroke
volume is ejected rapidly from left
ventricle. Seen in aortic
regurgitation, combined aortic stenosis
and regurgitation, idiopathic
hypertrophic aortic stenosis.
G. Dicrotic pulse- both peaks occur in
systole, seen in hypotensive patients
with reduced peripheral resistance

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 H. Pulsus alternans - accompanied by
alternation of intensity, palpate
lightly at mid expiration,
characterized by regular rhythm
I. Pulsus bigeminus- bigemineal rhythm as
a result of premature contraction after
every other beat and results in the
alternation of strength of pulse,
rhythm irregular.
J. Pulsus paradoxus- inspiratory fall in
systolic pressure to >10mmHg as a
result of reduced stroke volume and
transmission of the negative
intrathoracic pressure to the aorta.
Seen in pericardial effusions and
cardiac tamponade, asthma and
emphysema.

Respiration

Count full minute the number of respiratory

cycle, and check regularity and pattern.
Normal respiratory rate differs by age.
Cutoffs for fast breathing at different age
groups

Age (years) RATE PER MINUTE

0-2 months 60
2 –12 months 50
12mo –5 yr 40
5-8 yr 30

Blood pressure

Appropriate cuff width should be used in

children.
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AGE CUFF WIDTH IN CMS
New born 2.5 - 3
Infants 4 - 5
1-4 years 6 - 7
5-10 years 8 - 10
> 10 years 10 - 12

Approximately two third of the upper arm or

thigh should be covered by the cuff width.
Cuff too wide will underestimate blood
pressure and those that are too narrow will
give an artificial high measurement. Values
should be computed since normal values vary in
children with age. B/P should be measured on
both right and left side and a difference of >
15mmHg should be taken as abnormal.
A difference of > 20 mmHg between the lower
and the upper is abnormal.
*See page 92-95 for normal values.

Temperature

In neonates, infants and young children

temperature measurement is best done rectally
rather than orally or axillary. In neonates
low reading thermometers may be necessary
since low temperature is an important sign.

C. ANTHROPOMETRIC MEASUREMENTS

This includes the measurements of height or

length, weight, head circumference, midupper
arm circumference & chest circumference.
The height, weight, and head circumference
should always be checked for age using a
reference data.

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LENGTH

Is taken for those less than 2 years of age

and height is taken for those greater or equal
to 2 years. Length is measured using infant
measuring board on which measuring tape is
attached that has a rigid foot board and
movable head board. The measuring board is
placed on the table so that the head and
footboards are perpendicular to the table.
The infant lies supine on the measuring board
with the head against foot board with
straightened knees. The head board is moved
until it touches the feet (figure 1).

HEIGHT

The measuring board is fixed upright where

the ground is level. The child stands,
upright in the middle, against the measuring
board. The child’s head, shoulders, buttocks,
knees, heels are held against the board by
the assistant, while the measurer positions
the head and the cursor. The height is read
to the nearest 0.1 (figure 2).

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Figure 1. Growth measurements – length of an
infant. Technique

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Figure 2. Growth measurements – height of a
child or adolescent. Technique

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WEIGHT

Measurement is done by different types of

scales. Calibrate the scale to zero before
the patient mounts the platform.

HEAD CIRCUMFERENCE

Use non-stretchable measuring tape. The

landmarks are anteriorly the glabella,
posteriorly the occipital protuberance,
laterally just above the pinna (figure 3).

Figure 3. Growth measurements – head

circumference. Technique

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CHEST CIRCUMFERENCE

Measure with non-stretchable measuring tape

along the xiphisternum perpendicular to the
spinal column between inspiration and
expiration. It is used in comparison with the
head circumference. In newborns head
circumference is greater than chest
circumference until 5 months of life, then
until 2 years they will be equal and greater
than 2 years chest circumference will be
greater than head circumference.

MID-UPPER ARM CIRCUMFERENCE

Measured at the middle of the upper arm which

is midway between the acromion process and
olecranon using non-stretchable tape. The
left arm is used for measuring midupper arm
circumference. It is useful to assess
nutritional status of under five year children
whose length is greater than 75 cm.
Measurement above 12.5cm indicates normal
nutritional status, 11.0-12.5cm moderate
malnutrition and less than 11cm indicates
severe malnutrition.

D. HEAD, EYES, EARS, NOSE AND THROAT

Head-appearance or shape, size (head

circumference), areas of swelling, scars,
tenderness, hair distribution, texture,
plukability, color, fontanel- depression,
size, closure.

Eyes
Congenital abnormalities, conjunctival
appearance, follicles on the conjunctivae,
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corneal opacity, pupillary size, and reaction
to light sclera color, xerosis, bitot spot,
vision, eye lid-retraction or dropping.

Ears
Pinna abnormalities, external ears - signs of
inflammation,
Otoscopic examination- light reflex, tympanic
membrane patency, discharge, hearing ability,
foreign bodies

Nose
Shape septum, discharge, mass

Mouth and throat

Lips - congenital abnormalities, fissure.
Tongue - hydration status, fissuring, texture
Teeth - development, shape, number, any
carious process.
Throat - tonsils, uvula, pharynx for any
enlargement and signs of inflammation.

Generally look for dysmorphic features like

low set ears, oblique palpabral fissure,
epicanthal folds, hyperteleorism, flat
occiput, high arched palate, depressed nasal
bridge.

Neck
Mobility, swelling, tenderness, deformity and
stiffness

A. LYMPHOGLANDULAR

Thyroid enlargement by looking at the site

while patient swallows and palpating on both
hands standing posteriorly.

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- Lymphnodes at all sites which includes
preauricular, postauricular, occipital,
submandibular, cervical, supraclavicular,
axillary, epitrochlear, inguinal. Describe
their size, consistency, mobility, tenderness
and discharge.
Normally lymphnodes are not palpable in
neonates. But during childhood they are
palpable. But they are not considered
enlarged until their diameter exceeds 1 cm for
cervical and axillary nodes and 1.5 cms for
inguinal nodes.
-Testis should be palpated for presence at all
ages, and describe if there is any mass
attached to it and look for tenderness.
-Female breast development

F. RESPIRATORY SYSTEM

The respiratory system can be examined

following the cardinal steps of physical
examination:- inspection, palpation,
percussion and auscultation.

Inspection
A. Start by counting the respiratory rate,
inspect for the pattern of respiration
like apnea, paroxysmal breathing,
Kussmaul breathing, chyne-stokes
respiration, central neurogenic
hyperventilation, ataxic breathing.
B. Listening to abnormal sounds with bare
ears have got great value in detecting
certain respiratory disorders in
children. These include inspiratory
stridor which indicate upper air way
obstruction, barking cough, whooping

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 cough, hoarseness of voice, grunting,
and wheezes.
Then inspect for
A. Flaring of alae nasi, cyanosis on the
lips, tongue, finger tips and nail beds,
retractions at suprasternal notch,
intercostal space and subcostal region
which all indicates the presence and
degree of respiratory distress.
B. Chest wall appearance:- whether there are
deformities like pectus excavatum, pigeon
chest, Harrison's groove, gibbus at the
thoracic vertebrae, rachitic rosaries at
the costochondral junctions
C. Symmetry of chest wall movements and
appearance

Palpation
A. Check for any sites of tenderness over the
ribs and at intercostal spaces
B. Subcutaneous crepitations
C. Tactile fremitus- a cooperative child can
be asked to say 44 in amharic and the
examiner puts his/her hand at different
sites of chest and check for sound
transmission comparing left and right side
whether it is increased or decreased or
normal.
D. Chest expansion- a measuring tape is put
around the mid-thorax perpendicular to
vertebrae and patient is asked to breath in
maximally and the difference between full
inspiration and expiration is recorded.
Normally it is 2 cms.
E. Position of trachea- whether it is central
or deviated

Percussion
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A. Systematic percussion comparing both sides
of the chest starting from the apex
avoiding bony areas like scapula and
vertebrae and cardiac dullness is
mandatory.
B. Normal percussion note of the lung is
resonance. Pathological percussion notes
include dullness and hyperresonance.
C. Check diaphragmatic excursion in older and
cooperative children
D. Percuss parallel to the vertebra down wards
posteriorly until the end of the resonance
note, mark there and then you ask the
patient to breathe in maximally and
continue percussing again until the
resonant tone disappears and measure the
distance from the previous mark.

Auscultation
A. Use diaphragm of the sthetescope. Ask
patient to breath if old enough and
cooperative. Begin anteriorly and at the
top of the chest. Compare one side to the
other as you move down the chest and move
posteriorly in the same manner.
B. Normal breath sounds are
vesicular - low pitched and fine heard
during inspiration
broncho-vesicular in areas of tracheal
bifurcation
C. bronchial - high pitched and harsher heard
both during expiration and inspiration on
the trachea.
D. Abnormal breath sounds include bronchial
breath sound out of the normal site,
decreased air entry, absent air entry,
crepitation, rhonci, and wheeze.

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E. Crepitation - these are sounds produced by
air and fluid in the alveoli. Their
presence always indicates fluid in the
alveolar spaces. Sound is identical to
sound one hears as a ball of compressed
cellophane uncoils while held close to the
ear.
F. Rhonchi - are the result of air turbulence
around the mucus or other fluid debris
within large airways. The sound is harsh,
continuous and can vary from breath to
breath as the material shifts position.
G. Wheezes - imply narrowing of airways.
They are high-pitched sounds from air
acceleration through pathologically
narrowed lumens. Localized wheezes means
localized partial obstruction.
H. Check for vocal fremitus in cooperative
children. Listen over the lung for the
spoken and whispered sound. Normally the
whispered voice cannot be heard at the
periphery. In consolidated lung the
whispered voice is conducted well to the
periphery.
I. Bronchophony is the sound of the spoken
voice over a bronchus. When heard
elsewhere, it indicates consolidation.
J. Whisper pectoriloquy is the reproduction of
a bronchial whisper in an area that doesn’t
normally register any sound with a whisper.
The exact whispered word may not be heard
but the syllabic representation of the word
will be clear.
K. Egophony - when patient says 'e' on
consolidated area it is heard as 'a'.
L. Friction rub - This is a to-and-fro sound
synchronous with respiration and resembles

21
 creaking leather and appears closer to the
ear.

G. CARDIOVASCULAR SYSTEM

Examination of the CVS should be approached

systematically. Because one the examination
should not be localized to the chest and heart
but should extend to other parts of the body
and secondly every step should guide the
examiner to a certain pathology which can be
anticipated. One way of systemic approach is
an approach from periphery to central. This
will not only make one be systematic but will
also help not to overlook or skip important
findings.
Examination can start from inspecting for
cyanosis, clubbing and pallor and proceed with
examination of the arterial and venous system
to the examination of the precordium.
Cyanosis should be checked on the fingertips,
lips and tongue. In neonates and infants
peripheral cyanosis, seen in the fingertips
may be found in cold exposure thus attention
should be taken and rely on examination of
lips and tongue. Administration of oxygen may
alleviate cyanosis in the majority of cases if
the cyanosis is of pulmonary origin where as
if it is of cardiac origin it may persist.
Then proceed examining the nail beds for
clubbing.
Grade I- Spongy feeling on pressing the
nailbed
Grade II- loss of angle at the nail bed
Grade III- widening of the distal part of
phalanx with a drumstick appearance

Arterial system examination

22
All peripheral pulses should be checked for
their presence then comparison should be made
between the left and right and the upper and
the lower extremities and determine if there
is radiofemoral delay.
Then check the rate, rhythm, character and
volume of the pulses. Commonly examined sites
are carotid, brachial, radial, femoral,
popliteal, posterior tibial and dorsalis
pedis.

Abnormal pulses- see vital sign examination on

page 9.
Blood pressure measurements:- See examination
of vital signs on page 10.

Venous system examination

Jugular venous pressure (JVP) measurement:- In
young infants owing to the short neck may be
difficult and impractical.
It indicates the dynamicity of the right side
of the heart and is obtained by observing the
internal jugular venous pulse which is
localized deep within the neck laterally
covered by sternocleidomastoid muscle. It is
more readily analyzed on the right side of the
neck and the most effective position in
patients with heart disease is 45 degree
inclination. Examination should be done by
shining a light tangentially across the neck.
Look for transmission of the pulse to the skin
of the neck; take the measurement from the
level of the sternal angle.
Normal is 4 cms above the sternal angle =
Central venous pressure of 9cmH20.
Clues to differentiate from carotid pulse
a. Carotid pulse is sharply localized,
rapid and strikes the palpating finger
23
 with considerable force while the
venous pulse is readily visible but
disappears when palpating finger is
placed on the pulsation
b. Arterial pulsation do not change with
position
c. Compression of the root of the neck
does not affect the arterial pulse but
usually abolishes venous pulsation.
d. Venous pulse is double whereas
arterial pulse is single.

Examination of the precordium

Inspection
A. Activity of precordium, whether it is
active or not
B. Any shape abnormality especially
bulging at the precordium. This should
be assessed from the foot of the bed to
see any asymmetry in position.
C. Visibility of apical pulsation

Palpation
A. Point of maximal impulse- identified as
impulse of maximal intensity, characterize
whether tapping or diffuse. Should be
localized in relation to the intercostal
space and the midclavicular line it is
felt.
B. Apical impulse is the most lateral and
downward impulse.
C. Check for thrill which is a palpable
murmur, by placing the palm of your hand
at different parts- apex, lower left
sternal border, aortic area, pulmonic
area, suprasternal notch and over both
sides of the neck and xiphisternum. Then
characterize according to timing either
24
 systolic or diastolic. Murmurs of grade 4
and above are associated with thrill.
D. Check for parasternal or apical heave by
placing the ulnar part of your hand and
looking for upward thrust at the left
sternal border and at the apex.
E. Check for palpable P-2 at the pulmonic
area.

Percussion
Delineating cardiac border by percussing
has been practiced but it is now abandoned
because it lacks specificity.

Auscultation
A. Should be done carefully and needs time
especially to calm infants and young
children in order to hear all heart sounds
and adventitious sounds. Take the time to
isolate each sound and each pause in the
cycle, listening separately and
selectively.
B. Should be done in each of the five cardiac
areas using the diaphragm and then the bell
of the sthetescope
C. The five auscultatory areas are:
a. aortic valve area - 2nd right
intercostal space.
b. pulmonic valve area - 2nd left
intercostal space
c. tricuspid area - 4th left intercostal
space along the lower left sternal
border
d. mitral area - at the apex of the heart
in the 5th left intercostal space at
midclavicular line.

25
 e. 2nd pulmonic area - 3rd left
intercostal space at left sternal
border.

When you examine

A. Assess the overall rate and rhythm of the
heart
B. Listen each sounds independently for
intensity and any variations
C. Assess the heart beat in relation to
breathing
D. Concentrate on systole and diastole
listening for any extra sounds or murmurs.
E. Listen for splitting of the heart sounds
and its relation with respiration.

There are four basic heart sounds S-1, S-2, S-

3, and S-4.
S1 and S2 are the most distinct heart sounds
and should be characterized separately. S3
and S4 may or may not be present, their
absence is not an unusual findings. They must
be evaluated in relation to other sounds and
events in the cardiac cycle.
S1 is louder than S2 at the apex where as S2
is louder than S1 at the base. S1 is usually
heard as one sound. S2 is actually two sounds
that merge during expiration. During
inspiration P2 occurs slightly later, giving
S2 two distinct components split S2.
Normally A2 and P2 are separated by 0.04 to
0.05 seconds during inspiration with a single
S2 heard during expiration.
Wide splitting is when the splitting is wider
than normal and is seen in ventricular septal
defect, mitral insufficiency and total
anomalous of pulmonary venous return.

26
Fixed splitting is when the splitting is heard
both during inspiration and expiration and is
seen in patients with atrial septal defect,
and right bundle branch block.
Paradoxical splitting is when the splitting is
heard during expiration without splitting
during inspiration. It is seen in patients
with severe aortic stenosis, large patent
ductus arteriosus, left bundle branch block
and mitral insufficiency.
Extra sounds
A. S3 early diastolic sound
B. S4 a late diastolic sound.
C. Pericardial friction rub - rubbing
sound audible through the sthetescope,
occupies both systole and diastole and
overlays the intracardiac sounds
D. Opening snap -usually indicate mitral
stenosis and is heard early in diastole
E. Ejection click - as a result of
diseased semilunar, aortic or pulmonic
valves.
F. Heart murmurs - are caused by some
disruption in the blood flow into,
through or out of the heart. Therefore
characterizing murmurs would be of
great value in detecting pathological
changes in the heart.

Characterization of heart murmurs

Timing and duration
A. Early systolic - begins with S1, ends
well before S2
B. Mid systolic - begins after S1, ends
before S2
C. Late systolic - begins mid-to-late
systole, ends at S2
D. Early diastolic - begins with S2
27
 E. Mid diastolic - begins at clear
interval after S2
F. Late diastolic - begins immediately
before S1
G. Holosystolic - begins with S1,
occupies all of systole ends at S2
H. Holodiastolic - begins with S2,
occupies all of diastole, ends at S1
I. Continuous - starts in systole,
continues without interruption through
S2 into all part of diastole

Pitch
A. High, medium, low: depends on pressure
and rate of blood flow

Intensity
Grade I: barely audible in quiet room
II: quiet but clearly audible
III: moderately loud
IV: loud associated with thrill
V: very loud, audible with the
sthetescope partially of the chest.
VI: very loud, audible with sthetescope
not in contact with the chest.

Pattern
B. Crescendo: increasing intensity caused
by increased blood velocity
C. Decrescendo: decreasing intensity
caused by decreased blood velocity

Quality
A. Harsh, raspy, machinery, vibratory,
musical, blowing

Location

28
 B. Anatomic landmarks at area of greatest
intensity
Radiation
C. Sound usually transmitted in direction
of blood flow
Variation with respiration
D. Intensity, quality and timing may
vary. Venous return increases on
inspiration and decreases on
expiration.

H. ABDOMEN

Use the four cardinal ways of examination.

Patients should lie down on their back
relaxed. In infants usually they should sit on
the lap of their mother for the best
relaxation. In describing findings
topographic regions should be used. Commonly
the four quadrants namely the right upper and
lower, the left upper and lower quadrants are
used. To be more specific epigastric,
periumbilical, suprapubic and flanks can be
used for description.

Inspection
Patients should be undressed fully so that
hernial sites could be inspected.
Look for appearance (scaphoid, distended,
full) symmetry, movements with respiration,
umbilicus (inverted, everted or flat), scars,
dilated vessels, flank fullness, congenital
abnormalities.

Palpation
Let the patient assume a relaxed position
either supine or on the mothers lap. Ask if
the child has any pain in the abdomen. Start
29
from areas that are reported to be not
painful. Use a warm hand gently avoiding
tender areas.
Superficial palpation to check for tenderness
and mass, then deep palpation moving
synchronous with respiration for mass at all
quadrants, for liver and spleen describing
their size below the costal margin,
consistency, surface, edge and tenderness.
If there is any mass describe its location,
size, mobility and attachment to the
underlying tissue, consistency, shape,
tenderness and surface.

Percussion
Percuss the abdomen which is normally
tympanic.

Check for fluid thrill

Put on one side of the flank the palm of
your hand and tap at the other flank
area. Let an assistant put the hand at
the umbilicus vertically by the ulnar
side. This will avoid the wave that can
be produced by the abdominal wall.
Appreciate the thrill by the palm of your
other hand.

Check for shifting dullness

Let the patient lie on the back relaxed.
Start percussing from the umbilicus
where you found tympanicity. Then proceed
percussing horizontally to the left side
until you find dullness. Do not move your
finger from that site. Holding your
finger at that spot rotate the patient to
the right side. Then percuss at the site
where you found dullness. If the dullness
30
 is changed to tympanic sound then there
is shifting of the dullness. If there is
a mass on the left side you should
percuss from the umbilicus to the right
side and rotate the patient to left side.

Check for total liver span

Start percussing at the right chest at
mid-clavicular line vertically downwards
until you find liver dullness and mark
the site. Then palpate the abdomen and
find the liver edge at the right mid-
clavicular line and mark it, then measure
the distance between the two marks which
gives the total liver span.
Total vertical span of the liver at birth
is 4-5 cm and at 12 years it is around 9
cm. In general the liver edge is usually
felt less than 2 cm below coastal margin
in right mid-clavicular line of the
newborn infant and about 1 cm below
coastal margin throughout childhood.

Auscultation
Auscultate for bowel sounds, bruit on enlarged
liver and around great vessels.
Unlike examination of other systems
auscultation of the abdomen should immediately
follow inspection. Palpation may disturb the
bowel sounds.

Rectal examination
This is part of any routine physical
examination. Use the smallest finger in
children. Check for external lesions, rectal
prolapse, sphincter tone, palpable mass, then
check for blood on examining finger and gross
appearance of stool.
31
I. GENITOURINARY SYSTEM
Check for costovertebral angle tenderness.
Check for external genitalia for congenital
abnormalities like hypospadias,
cryptorchidism, imperforate hymen, hydrocele,
and hernias.
Check for development of genitalia.

J. LOCOMOTOR SYSTEM
Check for congenital malformations, muscle
volume and tenderness, bone deformities and
shortening. Check the joints for mobility in
adduction, abduction, extension, flexion,
internal and external rotation, and describe
the limitation. Assess if there are swellings
and describe the site, size, tenderness,
hotness and limitation of movements.
Check the spine by inspection for deformities,
checking for tenderness by percussion and by
functional tests.
Kyphosis is abnormal outward lump of the
thoracic spine.
Lordosis is exaggerated incurving of the
lumbar spine.
Scoliosis is lateral curvature of the spine
which is best appreciated by looking at the
back in forward bending.

K. INTEGUMENTARY SYSTEM.
Skin
Check texture, pigmentation, lesions, turgor.
Lesions should be described according to
their site and appearance as macular, papular,
pustular, vesicular, bullous, nodular, crusty
or scaly.
32
Hair
Look for distribution, color, texture and
pluckability.
Nail
Look for any abnormality or deformity and
haemorrhages.

L. CENTRAL NERVOUS SYSTEM

This part of the examination is very difficult
especially in the early period of life and
needs a thorough and meticulous practice to
master it. Normal findings differ with age
since maturation of the CNS is not yet
complete at birth. Besides unlike older
children and adults cooperation of neonate,
infants and young children may be lacking to
complete the whole system. Trying to win
attention of the patient and postponing
irritative exam to the end of the exam may be
important to elicit proper findings.
Usually one can start with assessing the
mental function.

A. Mental status examination

I. LEVEL OF CONSCIOUSNESS
The initial step in a formal mental status
examination is the determination of the
patient's level of consciousness.
There are many general terms used to describe
the basic levels or state of consciousness.
These levels represent points on a continuum
from full alertness to deep coma. Most
clinicians distinguish five principal levels.

1. Alertness

33
 Alertness implies that the patient is
awake and fully aware of external and
internal stimuli.
2. Lethargy
A state in which the patient is not fully
alert and tends to drift off to sleep
when not stimulated. Spontaneous
movements are decreased and awareness
limited.
3. Obtundation
Refers to a transitional state between
lethargy and stupor. The obtunded
patient is difficult to arouse and when
aroused, is confused. Usually, constant
stimulation is required to elicit even
marginal cooperation from the patient.
4. Stupor or semi-coma
Used to describe patients who respond
only to persistent and vigorous
stimulation. The patient doesn't rouse
spontaneously and, when aroused by the
examiner, is able only to groan or mumble
and move restlessly in the bed.
5. Coma
Completely unarousable to external or
internal stimulus (Deep or light reflexes
may be there like decorticate and
decerebrate posturing.)

N.B.-Amend any qualitative term such as

"lethargy" with a series of short statements
that describes the level of stimulus necessary
to arouse the patient and the actual
behavioral response.

34
 MODIFIED GLASGOW COMA SCALE

EYE OPENING

SCORE Greater than 1 year Less than 1 year

Spontaneously Spontaneously
4
To verbal command To shout
3
To pain To pain
2
No response No response
1
BEST MOTOR RESPONSE
Obeys Spontaneous
6
Localizes pain Localizes pain
5
Flexion withdrawals Flexion withdrawal
4
Flexion abnormal Flexion abnormal
3 (decorticate rigidity) (decorticate rigidity)
Extension Extension
2 (decerbrate rigidity) (decerebrate rigidity)

1 No response No response
BEST VERBAL RESPONSE

Score >5yrs 2-5 years 0-23 months

5 Oriented and Appropriate words Smiles, coos

converses and phrases appropriately

4 Disoriented Inappropriate Cries, consolable

and converses words

3 Inappropriate Persistent cries Persistent

words or scream inappropriate
crying or screaming

2 Incomprehensi Grunts Grunts, agitated

ble sounds or restless

1 No response No response No response

A score < 5 has grave prognosis, 5-8 better and > best prognosis.

II. Orientation to time place and person

III. Emotional state - reaction to strangers,

35
 depressed, elated, flattening, interest
to the environment.
IV. Intellectual performances - response to
questions
V. Language - development, fluency, and
articulation.

B. Motor function test

. Muscle volume - measure the volume by
comparing both sides at a same distance
starting from a certain landmark; it could be
atrophied, hypertrophied or normal.
. Muscle tone - checked by passive movements
of all extremities; it can be hypertonic
(spastic, or rigid), hypotonic or normotonic.
. Muscle strength - check individual muscles
of different parts of the body. It is graded
from 0 - 5.
Grade 0 - no movement at all
1 - flickering of movement at joints
2 - moves the extremities but not
against gravity
3 - moves against gravity
4 - moves against minimal resistant
5 - normal movement
. Coordination:
- Finger - to - finger
- Finger - to - nose
- alternate movement of hand in supination
and pronation.
- Heel to sheen, heel to toe walking
- walking in one line
- Romberg sign- a test for loss of position
sense (sensory ataxia) in the legs. Patient
is asked to stand with his feet close together
and if he can do this he is then asked to
close his eyes. If he sways or may even fall
it is a positive sign.
36
. Involuntary movements:
- Fasciculation- ripple like flickering
involuntary contractions of small muscle
groups, indicates lower motor neuron disease.
- Tremor- rhythmical distal movements which
lessens with motion but reappears in a new
posture, absent during sleep.
- Chorea- brief involuntary movements
- Athetosis - writhing movement more
pronounced in distal, often seems to consist
of a relatively constant interaction between
two postures.
- Myoclonus- sudden jerks of muscle groups.
Gait:
- Sensory ataxia- described as stamping;
patient raises his feet very suddenly, often
abnormally high and then jerks them foreword,
bringing them to the ground again with a stamp
and often heel first.
- Cerebellar ataxia- drunken or reeling -
broad based, feet planted widely apart and
placed irregularly.
- Waddling- like a gait of duck. Body tilted
backwards with an increase in lumbar lordosis,
feet are planted widely apart and body sways
from side to side as each step is taken.
- Spastic- patient walks on a narrow base, has
difficulty in bending his knees and drags his
feet along as if they were glued to the floor.
Characteristic of corticospinal lesion.
. Reflexes
Superficial:
- Corneal - cranial nerve V
- abdominal - T8 - 12 stroke upper, middle and
lower skin on abdomen. Abdominal muscle
contract with retraction of umbilicus toward
stimulated side.

37
- cremasteric - T12 - L1 stroke medial upper
leg in adductor region. Testicles move up.
- plantar - L5 - S1 stroke lateral side on
sole of foot, plantar flexion of toes occurs.
Deep:
- Biceps- C5-6 tap biceps tendon, forearm
flexes at elbow
- Triceps- C6-7 tap triceps tendon, forearm
extends at elbow
- Supinator- C5-6 holding forearm in
semipronated position, tap styloid process
- Knee- L2,3,4 tap tendon of quadriceps
femoris, lower leg extends
- Achillus- S1 tap achillus tendon, plantar
flexion of foot occurs.
Reflexes can be graded as:
Grade 0 - absent Grade 1 - present
Grade 2 - brisk Grade 3 - very brisk
Grade 4 - clonus
C. Sensory function tests
- Superficial:- touch, temperature, and pain
- Deep:- pain, vibration, position
- Cortical:- two point discrimination (check
child’s ability to tell whether two parts of
the body are being touched simultaneously),
stereognosis (place a familiar object like key
paper clip, coin, comb in the child's hand and
have the child identify by feel.),
graphesthesia (have a child identify numbers
or letters written on palm of hand with
examiners finger)
- Thalamic function in sensation.

D. CRANIAL NERVES

I:- Olfactory nerve

The sense of smell can be tested in
cooperative children. Test substances
38
familiar to the child are more suitable than
the more esoteric odours of adult neurology.
Though to name an odour a smell child
nonetheless can say that he smells something,
and the facial expression of the non vocal
child may indicate that he has smelled the
test substance.

II:- Optic nerve

-Vision:- in older and cooperative child
similar to the adults. From about 2 weeks of
age onwards infants watch mothers face while
feeding. 4 - 6 months old infant shows smooth
following eye movements for a dangling ball,
watches the movements of his hands and feet,
and reaches out accurately for toys, which he
grasps and regards closely.
The pupil reaction to light, present from 30
weeks of gestation onwards depends on a
functioning reflex arc and is absent with
complete but not with partial optic atrophy.
- Stycar series of tests for - rolling balls,
ability to fixate, and peripheral vision
(mounted balls).
- 2-5 years name and/or match with a duplicate
seven toys
- greater than 5 years stycar letter test
using letters
- Abnormal eye movements:- seen in all
children with congenital blindness. Roving eye
movements often with disconjugate character.
Unilateral nystagmus- asymmetrical visual
impairment
- Visual field:- examiner faces the child,
who sits on his mother's lap, and dangles an
object to maintain fixation while another
object is silently introduced in to the
quadrants of the visual field. The examiner
39
watches for accurate refixation by the child.
A homonymous hemianopsia can be shown in this
way but bitemporal hemianopsia requires one
eye to be covered at a time.
- Pupillary reaction to light, directly and
consensually, size on both sides
- Accommodation.

III, IV and VI:- Notice for the position of

the eyes at rest, the presence or absence of a
squint, spontaneous movements of the eyes and
eye movements on following a visual lure, and
when possible and appropriate, on command and
reflexively with the dolls head maneuver.

V:- The muscle of mastication, can be tested

in older children. The masseters, temporalis
muscles can be palpated as the child clenches
his teeth. Jaw is opened with or without
resistance.
Jaw jerk
Sensation may be tested over the 3 divisions
of the 5th nerve.

VII:- The motor branches of the facial nerve

supply all the muscles of the face and ear -
the stapedius, platysema, stylohyoid muscles
and posterior belly of the digastrics. The
facial muscles are easily studied in all
children by observation during spontaneous
movements. Older more bidable children will
perform to request when asked to smile, frown,
raise their eyebrows, puff out their cheeks,
whistle, close their eyes and keep them closed
against resistance. Movements of the upper
and lower parts of the face should be studied
separately since lower motor neuron weakness,
such as that due to facial nerve lesions,
40
affects both parts whereas the upper face is
usually spared in upper motor neuron lesions.

With involvement of the nerve to the stapedius

muscle the patient may complain of an
unpleasant, exaggerated perception of sound in
the affected ear, known as hyperacusis. The
symptom is difficult to assess in children.
When the chorda tympani nerve is affected
there is impairment of salivation and of taste
over the anterior 2/3rd of the tongue.
Lacrimation is impaired in the ipsilateral
eye, with lesions affecting the pathways
involved (petrosal nerve, geniculate ganglion,
facial nerve proximal to ganglion).
In uncooperative patients we can observe when
patient smiles or cry and look for nasolabial
fold.

VIII:- Test of hearing - In the vocal child

his vocalization give valuable clues to his
ability to appreciate the elements of spoken
language so that his utterances should be
observed and his mother's report of them
noted. Infants aged 6 - 12 months are fairly
easy to test and look enquiringly for the
source of a sound. The sound sources used are
a high pitched rattle, a spoon in a cup,
tissue paper, a hand bell and selected speech
sound (the low - tone vowel 'oo-oo', repeated
and high tone consonants, 's-s', 't-t', ps-
ps, pth-pth, ' repeated rapidly several times.
A clear cut response to four of the five test
sounds suggests that the child has adequate
hearing for speech.
The 12 - 14 months old child may be more
difficult to test, since he is active, resents

41
interference and may show only limited
interest in test sounds.
At 14 months to 2 years the child will often
cooperate in tests involving the recognition
and naming of four or five familiar toys. 2 -
3 yrs he may take part in a game involved a
cued action.
Vestibular function testing is not usually
tested and is complex.

IX and X:- The 9th nerve supply only the

stylopharyngeus muscle. Paralysis of which
may be very difficult to detect. Those of the
10th nerve supply all the voluntary muscles of
the soft palate, pharynx and larynx, except
the stylopharyngeus. Unilateral lesions cause
drooping of palatal arch on the affected side
with the uvula and median raphe deviating
towards the normal side. This deviation
increases on phonation. With bilateral vagal
paralysis the palatal arch may be fairly well
maintained but the palate does not elevate
normally on phonation. The palatal reflex can
be elicited by touching the lower surface of
uvula or soft palate and retraction of the
uvula. The sensory arc of the reflex is via
the 9th nerve and the 4 motor arc via the 10th
nerve. The same pathway in the gag reflex
which is obtained by stimulating the
pharyngeal wall, pillars of the tonsils or
base of the tongue on either side. This can
wait until the late stage of the examination.
Glossopharyngeal sensation is tested to touch
and pinprick (when indicated by the clinical
feature) on the pharyngeal walls around the
tonsils and posterior third of the tongue.
9th nerve also on the same site of tongue.

42
XI:- Motor nerve which supplies the upper
fibers of the trapezius and
sternocleidomastoid muscle.
-Inspection and palpation of the muscles
-raise shoulder against resistance in a
shrugging action
-turn head to one side against resistance for
a hand applied to his chin

XII:-protruding out the tongue, and pushing it

against the inside of the cheek
-look for atrophy and fasciculation
-with unilateral lesions of the 12th nerve or
its nucleus the tongue is deviated towards the
side of the lesion and may show unilateral
atrophy and fasciculation.

E. Language and motor speech

. Expressive language
. Receptive language
. Language development

F. Signs of meningeal irritation

- Neck stiffness- inability to touch chin to
chest when flexing the neck actively or
passively
- Kernig's sign- with the child in the supine
position, flex one leg at the hip and knee so
that the thigh is flexed on the hip and the
leg is flexed on the knee, then straighten
(extend) the knee. Pain when knee is extended
is positive sign.
- Brudzinski sign- with the child in supine
position, rapidly flex the neck. Note flexion
of the hips and knees.

43
 III. NEONATAL HISTORY AND PHYSICAL
EXAMINATIONS

Neonatal problems are unique in that in the

majority of cases it originates from perinatal
events.
In this section emphasis is given to
particulars only where as the remaining
examination is similar to that of the older
children.
HISTORY
Identification:- similar to the others, but
when age is written it is preferably be in
hours especially in the first 72 hours.
Chief complaints:- If the examination is going
to be done in a neonate without problem as a
routine check-up it can be passed. But
otherwise the chief complaints should be
stated as the other children.
History of present illness:-
Maternal history:
-Age, occupation, marital status, socio-
economic status
-Previous obstetric history - gravidity,
parity, number of children alive, if there is
death at what age and with what sign, symptom
or diagnosis if known, history of abortion (if
yes at what gestational age and when), history
of still birth
-Past medical history like diabetes mellitus,
hypertension, tuberculosis etc.
44
-Present obstetric history - antenatal care,
blood group and VDRL status, immunization
status (especially TT), gestational age by
date (LMP), illness during pregnancy,
radiation exposure, drug intake
-Delivery history - onset of labor
(spontaneous or induced), duration of labor,
time of rupture of membrane in relation to
labor; date, time, place and mode of delivery
-Postpartum events

Neonatal history:
Immediately after birth:- Crying immediately
or not any color change (cyanosis), Apgar
score if known, sex and weight
Later:- sucking effectively, drooling of
saliva, breathing pattern, passage of urine
and stool, overall activity, bleeding from any
site
Care given: vaccinations (specify), vitamin K,
any procedures done like umbilical
catheterization, blood transfusion, NG tube
insertion, IV administration of fluids or
drugs.
If the neonate has any chief complaints the
history should be elaborated like that of the
other children.

PHYSICAL EXAMINATION OF THE NEWBORN

Serial evaluation of the newborn is more
valuable than a single examination at any
particular age. Optimum evaluation would
include a delivery room examination, a natal
45
day examination, and a more detailed
examination after the infant is 24 hours old.
* Delivery room examination:
. Apgar score at 1 and 5 minutes (see page
for details)
. Look for cyanosis, pallor, congenital
anomalies
. Check vital signs:
Pulse should be checked for a full one minute,
rate and rhythm should be assessed. Normal
value ranges from 120-160/min. Femoral pulse
should be checked for presence and radio-
femoral delay.
Respiratory rate should be checked for a full
one minute, assess the pattern. Apnea
(cessation of breathing for more than 20
seconds) is a common sign of problems in
neonates.
Temperature should be checked rectally. Use
low reading thermometers. Both hypothermia
(temp. < 36.50C) and fever (T0>37.50C) have got
implications in the newborn period.
. State of maturity: Gestational age is
determined by
1. External signs - using different signs and
giving score
2. Neurologic signs - which is modified by
Ballard.
See pages 53-55 for details of the signs and
scores.
After examination the score given for external
signs and neurologic criteria will be added

46
and the sum will be computed for gestational
age.
Based on the gestational age alone neonates
can be classified as:
Preterm - gestational age < 37 weeks
Term - gestational age 37-42 weeks
Post-term - gestational age > 42 weeks
. Measurements:
Take the head circumference, length and weight
just as the other age groups. When computing
these results the gestational age found by the
examination is important. Using the curve by
Lubchenco (see page 83-84) neonates can be
classified as:
Appropriate for gestational age (AGA)-10th-90th
centile
Small for gestational age (SGA) - < 10th
centile
Large for gestational age (LGA) - > 90th
centile.

Based on the weight only neonates can be

classified as:
Low birth weight - 1500gms - 2500gms
Very low birth weight - < 1500 gms
Normal birth weight - 2500-4500 gms
Other measurements include chest circumference
and body segment measurements.
* Post natal day examination
General appearance

47
. gross anomalies like anencephaly,
omphalocele, meningocele, phocomelia
. dysmorphic features
. Status of nutrition
. activity
. cry
. color- cyanosis, jaundice, pallor,
plethora
. edema
. evidence of respiratory difficulty -
tachypnea, flaring of alae nasi,
grunting, retraction.
. posture
. vital signs
. measurements
* Skin- color, vernix caseosa, consistency,
and hydration, edema, hardness (sclerema)
- congenital anomalies - nevi, spots,
defect
- trauma, rashes- milia, petechia,
maculopapular or bullous lesions
* Head - size, shape, fontanels and sutures
- caput - edematous swelling of the presenting
part on the scalp,
- cephalhematoma - subperiosteal bleeding
which is differentiated by not passing the
suture line
- subgaleal bleeding - subaponeurotic bleeding
which is identified by being diffuse passing
over the suture lines

48
* Eyes - conjunctival or scleral haemorrhage,
size of eyeball, haziness of cornea or lens,
pupillary reactions
* Ears - shape, congenital abnormalities,
* Nose - patency can be checked by closing
infant’s mouth and listening to breathing
through the nostrils. If any doubt try using
NG tube.
* Mouth - Cleft lip and palate, palatal arch,
check for excessive salivation indicating
oesophageal atresia which can further be
confirmed by inserting NG tube.
* Neck - mobility, masses like brachial cleft
cyst, congenital goiter, thyroglossal duct
cyst, hematoma
* Thorax - shape (AP diameter), breast
hypertrophy, respiratory distress signs like
retractions, respiratory rate and pattern like
apnea (cessation of respiration >20 sec),
light percussion, and auscultation (in the
first days fine crepitant rales are very often
normal)
* Heart - palpation of arteries at all
peripheral areas, heart rate and rhythm,
apical impulse (to rule out dextrocardia),
heart sounds (distant) rhythm, murmurs,
* Abdomen - use the four cardinal ways of
examination
Check the umbilical cord for staining with
meconium, number of vessels which normally is
two arteries and one vein, any sign of
inflammation at the base
Look for congenital abnormalities - hernias,
abdominal wall defects
49
* Genitalia - look for congenital
abnormalities
- look for testis
* Anus - check for patency, if doubtful use
thermometer
* Trunk and spine - for deformity and
congenital abnormalities like coccygeal sinus,
spina bifida occulta, meningiomyelocele
* Extremities - congenital abnormalities
-Check especially for congenital hip
dislocation
* Neuromuscular status
- Neonatal reflexes
.Moro: With the infant in supine position,
gently support head and lift it a few cms off
the surface. As soon as neck relaxes,
suddenly release the head and let it drop
back. Normal response is present at birth.
The arms extend outward, the hands open, and
then are brought together in midline. Usually
disappears by 3-4 months. Asymmetry indicates
possible paralysis. Absence suggests
neurologic disease. Persistence for more than
4 months may indicate neurologic disease, if
it lasts more than 6 months it is definitely
abnormal.
.Palmar Grasp: with infant’s head positioned
in midline, place examiner’s index fingers
from ulnar side into infant’s palm and press
against palm. Normal response is flexion of
all fingers around examiner’s fingers.
Present at birth and disappears by 4 months.
.Plantar Grasp: Examiner’s finger is placed
firmly across base of infant’s toe, toes curl
50
downward. Present at birth and disappears by
10-12 months.
.Rooting: Infant is held in supine position
with head in midline and hands against chest.
Examiner strokes perioral skin at corner of
mouth or cheek. Infant opens mouth and turns
head toward stimulated side. Present at birth
and disappears by 3-4 months (awake), 7 months
(asleep).
.Sucking: with infant in supine position place
nipple or finger 3-4 cms into mouth. Present
at birth and disappears by 3-4 months (awake)
7 months (asleep).
.Glabellar: tapping the glabella lightly will
induce blinking of both eyes.
.Crossed extension: with infant supine, press
the sole of one foot with a thumb. The other
extremity hip and knee flexes, then adducted
and extended.
.Placing: Infant is held erect and the dorsum
of one foot touches the undersurface of the
examining table top. Infant flexes hip and
knee and places stimulated foot on top of the
table. Present at birth and disappears by 6
weeks.
.Stepping: Infant is held upright and soles
and feet are put in touch with solid surface.
Infant “walks” along surface. Present at
birth and disappears at 6 weeks.
. Tonic-neck: with infant in supine position
passively rotate head to one side. Arm and
leg on side to which head is turned extend,
and opposite arm and leg flex (fencer’s
position). Present sometimes at birth but
usually by 2-3 months. Disappear by 6 months.
51
. Galant’s (trunk incurvation): infant is held
prone in examiner’s hand. With the other hand
the examiner moves and finger down the
paravertebral portion of the spine, first on
one side, then on the other. Infant’s trunk
should curve to the side being stimulated.
Present at birth and disappears by 2 months.

52
 ESTIMATATION OF GESTATIONAL AGE – BALLARD
SCORING SYSTEM
The Ballard Score assesses the physical and neuromuscular maturity of
newborn infants.

Study Parameters:

neuromuscular maturity: 6 parameters

physical maturity: 7 parameters

Neuromuscular Maturity

0 1 2 3 4 5

posture wrists, wrists bent elbows, elbows, elbows & NA

arms, hips and legs hips and hips and legs bent
and legs slightly bent legs bent legs bent and
straight but do not to 90 drawn
reach 90 close to
body

square 90 60 45 30 0 NA
window
(wrist)

arm recoil 180 NA 110-180 90-100 < 90 NA

popliteal 180 160 130 110 90 < 90

angle

scarf sign elbow elbow to elbow to elbow to elbow to NA

beyond opposite opposite midline axillary
opposite axillary line midclavicul line
axillary ar line
line

heel to ear leg knee knee bent, knee bent knee NA

straight, slightly heel to 90, heel bent, heel
toes reach bent, heel reaches reaches 90 reaches
chin reaches 140 120 from from prone 45 from
from prone prone prone

53
 Physical Maturity

0 1 2 3 4 5

skin gelatinous, smooth, superficial cracking parchment, feathery,

red, pink, peeling pale deep cracked,
translucent visible &/or rash, areas, cracking, no wrinkled
veins few veins rare vessels
veins

lanugo none abundant thinning bald mostly bald NA

areas

plantar no crease faint red anterior creases creases NA

surface marks transverse anterior over entire
crease only two sole
thirds

breast barely flat areola, stippled raised full areola, NA

perceptible no bud areola, 1-2 areola, 5-10 mm
mm bud 3-4 mm bud
bud

ear pinna flat, slightly well- formed thick NA

stays curved curved & firm cartilage,
folded pinna, soft pinna, soft with ear stiff
with slow with ready instant
recoil recoil recoil

genitals, scrotum NA testes testes testes NA

male empty, no descend- down, pendulous,
rugae ing, few good deep rugae
rugae rugae

genitals, prominent NA majora & majora majora NA

female clitoris & minora large, cover
labia equally minora clitoris &
minora prominent small minora

Ballard Score = SUM (points for each parameter)

Interpretation:

minimum score: 0

maximum score: 54

54
 Correlation of score with gestational age

Score Week

5 26

10 28

15 30

20 32

25 34

30 36

35 38

40 40

45 42

50 44

APGAR SCORE
SCORE
0 1 2

Appearance Blue/ Blue Completely

(color) White extremities pink
Pulse Nil less than greater
(heart rate) 100 than 100
Grimace None Grimace Cry or
(response cough
to stimuli)
Activity Limp Reduced Normal
(muscle tone) active
movement
Respiratory Absent Gasping or Regular
effort irregular respirati
on
or strong
cry

55
 IV. ANNEXES

I. ASSESSMENT OF NUTRITIONAL STATUS.

1. Dietary history
Ask about feeding from the very first day of
life and describe feeding history till the
present age.

A. Breast feeding:

. Time of initiation
. Up to what age it was given exclusively
. The total duration of breast feeding
. If breast milk was not given at all or
discontinued before 6 months of life ask
the reasons why.
B. Complimentary feeding:
. Type of food given in addition to breast
milk
. Age when these foods are introduced
. Amount and frequency these foods are given
at different age
. Age child is totally weaned,
. Problems child had during the weaning
period
C. Present diet of the child:
. Type of diet
. Amount and frequency per 24 hours
. Available foods in the community and
household
. Affordable foods in the area

2. Anthropometric examinations
This includes the measurements of weight,
height/length, head circumference, mid-upper
arm circumference and skin fold thickness.

56
For techniques of measurement of weight,
height/length, head circumference, and mid-
upper arm circumference see page 14-15.
Skin fold thickness (SFT) provides rough
estimates of the body composition. Triceps
SFT is measured over the half way between the
acromion and olecranon as the arm hangs
vertically in a relaxed fashion at the
patients’ side. Subscapular SFT is measured
below the angle of the left scapula. For
measuring there is a special instrument called
Harpenders caliper. Values obtained may be
converted to estimates of body fat using
conversion tables.
All measurements require accuracy and after
measurement all data should be interpreted.
For interpretation references should be used.
For wt for age, ht or length for age, HC for
age, wt for ht, references are given on pages
70-86.

3. Clinical signs:
- examination of hair for color, lusterness,
distribution and pluckability
- examination of skin for pigmentation and
peeling
- examination of the eyes for xerosis of
conjuctivea and cornea, corneal opacity,
keratomalacia, bitot's spot
- atrophy of buccal mucosa
- edema of legs and foot
- atrophy of muscle and subcutaneous tissue
- apathy

4. Measurement of dietary intake

- precise weighing of food eaten
- chemical analysis of replicate diets.
5. Biochemical assessment
57
 - plasma albumin
- other serum protein-transferrine
ceruloplasmin, B-lipoproteins
- serum aminoacid patterns
ratio= glycine+ serine+ glutamine + taurine
valine+leucine+isoleucine+methionine
- urinary urea/creatinine ratio
- urinary hydroxyproline excretion
- urinary creatinine-height index
- 3-methylhistidine excretion
6. Morphological assessments
- hair morphology(shaft, and root of hair)
- buccal mucosal change

58
II.CALORIE AND PROTEIN CONTENT OF COMMONLY USED FOODS.

Food Amharic name Calories/ Protein

description 100 gm of gm/100gm
edible of
portion edible
portion
Barley Gebs 354 8.9
Barley flour Gebs duket 370 11.1
Beans Baquela 347 22.4
Beans split Baquela kik 346 25
Chickpea Shimbra 370 15.6
Chickpea Shimbra duket 375 19.4
flour
Corn dried Bequollo 359 8.6
Corn flour Bequollo 372 8.6
duket
Corn bread Bequollo dabo 211 5.7
Corn Bequollo 168 3.4
porridge genfo
Corn injera Bequollo 176 4.6
injera
False banana Ensette-bulla 205 1.2
-kocho 191 1.2
Fenugreek Abish 381 22.1
Fenugreek Abish wuha 10 0.5
weaning food
Fish- raw Asa 92 15
Barley- Gebs injera 163 5.5
injera
Injera-2/3= 155 4.4
barley 1/3
Millet Dagussa 193 2.8
injera injera
Sorghum Mashilla 142 3.3
injera injera
Tef injera Tef injera 162 4.6

59
CALORIE AND PROTEIN CONTENT OF COMMONLY USED FOODS

Food Amharic Calories Protein

description name /100 gm gm/100gm
of of
edible edible
portion portion
Tef porridge Tef 144 4.6
genfo
Kale Yabesha 35 4.4
gommen
Lentil Missir 348 22.8
Lentil split Missir 352 23.4
kik
Linseed Telba 482 17
Milk Wotet 76 3.8
Yorghut Irgo 82 3.8
Millet Dagussa 355 7.2
Oil-niger Nug zeit 493 17.6
Peas-whole Ater 347 19.6
Peas-split Ater kik 343 22.8
Peas-flour Shiro 350 20.6
Pea flour Shiro 51 2.2
sauce wot
Sunflower Suf 471 11.7
Sesame Selit 584 17
Sorghum Mashilla 378 7.8
Soybean Akuri 420 33.7
ater
Vetch -whole Guayya 351 21.7
Wheat-whole Sinde 344 10.2
Wheat-bread Sinde 184 5.7
dabo
Wheat Sinde 48 1.7
porridge genfo

60
 III. ASSESSMENT OF GROWTH AND
DEVELOPMENT.

History: In the assessment of growth and

development perinatal history is very
important and should be included.
(See page 3). History after birth should
include about milestones of development from
birth upto the stated age. Do not ask
questions that are not expected at the present
age of the patient because it will frustrate
the mother or care taker.
For systematic approach the assessment is
divided into:
- gross motor,
- fine motor and adaptive,
- social and personal,
- language.
Gross motor assessment should include
. lifting head and chest from bed, supporting
head, sitting with or without supporting,
rolling over, stands holding, standing without
support, pulling self to stand, getting to
sit, walking with support or without support,
walking backwards, walking up or down stairs,
kicking ball, balancing on one foot, jumping
or running, heel to toe walk.
Fine motor and adaptive assessment should
include
. following objects to midline or past
midline, reaching for object, grasping
objects, bringing hand together, transferring
objects from one hand to another, banging two
objects held in hands, thumb finger grasp,
pincer grasp, making tower of objects,
scribbling, imitating and copying lines and
drawings.

61
Language assessment should include
. responding to bell or loud noise, laughs,
turn to voice, say mama or dada, imitating
speech, words other than mama and dada,
combing words, pointing to body parts, naming
pictures, following directions, using phrases,
giving first and last names, recognizing
colors.
Personal and social assessment should include
. regards face, smiles responsively and
spontaneously, plays pat-a-cake, peek-a-boo,
drinking from cup, feeding self, helps some
home task, wash and dry hand, dressing self
with or without supervision, plays interactive
games.
This assessment should be done upto the
present age of the child. In older children
who are attending school their performance at
school, interaction with peer groups, their
home activities in general should be stated.

After the history is taken systematic

examination of the development can be done
using the above description for the five
divisions.

For the assessment of growth one should do

physical measurements. This should have
a) continuity- i.e., if possible since birth
and should be documented to see variations in
growth.
b) accuracy- measurements should be done in
accordance to the standards and measuring
instruments should be standardized.
(c) interpretation- all measurements should be
interpreted using known standards.
62
Measurements should include - height or
length, weight, head circumference, length of
body segments (eg. extremities span, sitting
height, trunk extremities ratio)

Neurodevelopmental assessment in the first

year of life.
- prone position:
. note position of head (lateral, midline,
raised from coach);
. lower extremities (extended or flexed, under
or behind the abdomen);
. upper extremities (flexed, partially
extended, fully extended to raise trunk from
coach).
- supine position:
. note position of hand (midline or not)
. lower extremity (flexed, brought to mouth)
. spontaneous movements
- from supine pulled to sitting:
. head lag or not,
. back on sitting curved or not
. head bobbing on sitting,
. sit leaning forward or straight
- ventral suspension:
. seen by holding the neonate or infant on the
abdomen face down wards.
. note whether extremities are flexed or
extended
. note relation of head to trunk (whether head
is below, straight with, or above the
trunk.
- reaction to objects:
. use attractive objects (rattle, light,
moving colored objects)
. note fixation of eyes

63
. note eye movement in order to follow the
moving stimulus at 90, 180, 360 degrees from
midline.
. present the objects to be hold and assess

the grasp pattern (palmar, radial, ulnar,

pincer grasp)
. notice whether the objects are transferred

from one hand to another

. check whether objects are released on
request
or not.
4. Evaluation of dental development

a. Primary or deciduous teeth.

Eruption (in months) Shedding (in yrs)

Maxillary Mandibular Maxillar Mandibular

Central incisors 6-8 5-7 7-8 6-7

Lateral incisors 8-11 7-10 8-9 7-8

Cuspids (canines) 16-20 16-20 11-12 9-11

1st molar 10-16 10-16 10-11 10-12

2nd molar 20-30 20-30 10-12 11-13

64
b. Eruption of secondary or permanent teeth.

Maxillary Mandibular

Central incisors 7-8 yrs 6-7 yrs

Lateral incisors 8-9 yrs 7-8 yrs
Cuspids (canines) 11-12 yrs 9-11 yrs
1st premolars 10-11 yrs 10-12 yrs
2nd premolars 10-12 yrs 11-13 yrs
1st molars 6-7 yrs 6-7 yrs
2nd molars 12-13 yrs 12-13 yrs
3rd molars 17-22 yrs 17-22 yrs

5. Sexual maturity rating for evaluation of

adolescents.
This is based on the changes in female
breasts, in male genitalia and in the pattern
and quantity of pubic hair in both sexes. The
score ranges from 1-5. A score of 1
represents the pre-pubertal child and a score
of 5 corresponds to the adult status.

65
Classification of sexual maturity rating in
males.
Stage Pubic hair Penis Testis
1. None Preadolescent Preadolescent
2. scanty,long slight enlargement enlarged scrotum
slightly pigmented
pink texture

3. darker,starts longer larger

to curl
small amount

4. resemble adult larger,glans and larger, scrotum

type but less breadth increase in dark
in quantity size
coarse, curly

5. Adult distribution adult size adult size

spread to medial
surface of thighs.

Classification of sexual maturity rating in

females
Stage Pubic hair Breasts
1. Preadolescent Preadolescent

2. sparse, lightly pigmented, breast & papilla elevated

straight, medial border of as small mound areolar
labia diameter increased

3. Darker, beginning to curl breast & areola enlarged

increased in amount no contour separation

4. coarse, curly, abundant but areola & papilla form

amount less than in adult secondary mound

5. adult feminine triangle, mature, nipple project,

spread to medial surface of areola part of general
thighs breast contour.

66
 ONSET
Early adolescence(=SMR 2) 10.5-14 yrs in boys
10-13 yrs in girls
Middle adolescence(=SMR3&4)12.5-15yrs in boys
12-14 yrs in girls
Late adolescence(=SMR 5) 14-16 yrs in boys
14-17 yrs in girls

VI. EXPANDED PROGRAM OF IMMUNIZATION SCHEDULE

At birth - OPV0 and BCG

At 6 weeks - OPV1 and DPT1- HepB1-Hib1
At 10 weeks - OPV2 and DPT2- HepB2-Hib2
At 14 weeks - OPV3 and DPT3- HepB3-Hib3
At 9 months - Measles

67
 V. PROBLEM ORIENTED HEALTH RECORD

Problem oriented recording is the current form

of written communication among health
professionals. While there are variations in
the implementation of the problem-oriented
form of recording this note offers a
foundation from which to build.
Expertise with it.

a. What is a problem?

A situation identified by either client

or health provider that requires management.

b. How are problems formulated for the problem

list?
A problem statement:
-doesn't contain "rule-outs, "probably," or
question marks (querries)
-doesn't state any guesses
-is a symptom, a finding or a diagnosis
-is specific
-is stated at the highest level of
understanding
-is stated succinctly
-reflects only what is known from reviewing
the data base.

c. How are problems categorized?

Problems are categorised by type and status.
Type:- 1) medical 2) social 3) psychiatric
4) behavioural 5) environmental
Status
1) Active problem (currently requiring
management)

68
2) Inactive or resolved problem (one that
either no longer requires management or is
stable but may recur.)
3) Temporary problem (minor problem identified
in progress note)

PROGRESS NOTES

Progress notes are the mechanisms for

monitoring the progress of each problem.
Progress notes are the mechanisms for
monitoring the progress of each problem.
Progress notes are divided into three types:-
a. Narrative notes
b. flow sheets
c. discharge summaries

Narrative notes:-
Commonly referred to as SOAP notes, the format
of the narrative notes is as follows.
Date, problem title, and problem number.
Subjective - interval history from patient
regarding problem
Objective - information gathered from physical
examination, lab result, screening tests and
observation of child's behavior and
interaction.
Assessment - conclusion or comparison stated
to level of knowledge, the sum of subjective
or objective information.
Plan - the initial plan organizes the plan of
management for the problem.
The initial plan has several components.
a) Diagnostic - a list of probable causes and
specific plans to rule out each cause
b) Therapeutic - palliative or curative
measures for alleviation of the problem
69
c) Patient education - explanation of the
problem and therapeutics.
d) Follow-up - plans for the patients to
return to health care facility.
The narrative notes are written with attention
to previous progress notes.
FLOW SHEETS:-
Several variables can be monitored at a glance
with the use of flow sheets, providing a
concise picture of the patients’ progress.
Flow sheets are usually kept for routine care
or for monitoring stable disease, such as
diabetes mellitus. Examples include vital
signs sheet and medication sheets.

DISCHARGE SUMMARY:-
It should comprise summary of history,
physical examination, investigation and
identified problems and management of the
patient. And a precise information on the
course in hospital is vital with future plans
and advice given to the patient.

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84
85
VII. WEIGHT FOR HEIGHT FOR BOTH BOYS AND GIRLS
Height median 90% 80% 70%
50 3.4 3.1 2.7 2.4
51 3.5 3.2 2.8 2.5
52 3.7 3.3 3.0 2.6
53 3.9 3.5 3.1 2.7
54 4.1 3.7 3.3 2.9
55 4.3 3.9 3.4 3.0
56 4.6 4.1 3.7 3.2
57 4.8 4.3 3.8 3.4
58 5.1 4.6 4.1 3.6
59 5.3 4.8 4.2 3.7
60 5.6 5.0 4.5 3.9
61 5.9 5.3 4.7 4.1
62 6.2 5.6 5.0 4.3
63 6.5 5.9 5.2 4.6
64 6.7 6.0 5.4 4.7
65 7.0 6.3 5.6 4.9
66 7.3 6.6 5.8 5.1
67 7.6 6.8 6.1 5.3
68 7.9 7.1 6.3 5.5
69 8.2 7.4 6.6 5.7
70 8.5 7.7 6.8 6.0
71 8.7 7.8 7.0 6.1
72 9.0 8.1 7.2 6.1
73 9.2 8.3 7.4 6.4
74 9.5 8.6 7.6 6.7
75 9.7 8.7 7.8 6.8

86
 Weight for height for both boys and girls
Height median 90% 80% 70%
76 9.9 8.9 7.9 6.9
77 10.1 9.1 8.1 7.1
78 10.4 9.4 8.3 7.3
79 10.6 9.5 8.5 7.4
80 10.8 9.7 8.6 7.6
81 11.0 9.9 8.8 7.7
82 11.2 10.1 9.0 7.8
83 11.4 10.3 9.1 8.0
84 11.5 10.4 9.2 8.1
85 11.7 10.5 9.4 8.2
86 11.9 10.7 9.5 8.3
87 12.1 10.9 9.7 8.5
88 12.4 11.2 9.9 8.7
89 12.6 11.3 10.1 8.8
90 12.8 11.5 10.2 9.0
91 13.0 11.7 10.4 9.1
92 13.2 11.9 10.6 9.2
93 13.5 12.2 10.8 9.5
94 13.7 12.3 11.0 9.6
95 14.0 12.6 112 9.8
96 14.2 12.8 11.4 9.9
97 14.5 13.1 11.6 10.2
98 14.8 13.3 11.8 10.4
99 15.0 13.5 12.0 10.5
100 15.3 13.8 12.2 10.7

87
 Weight for height for both boys and girls
Height median 90% 80% 70%
101 15.8 14.2 12.6 11.1
102 16.1 14.5 12.9 11.3
103 16.4 14.8 13.1 11.5
104 16.7 15.0 13.4 11.7
105 16.9 15.2 13.5 11.8
106 17.2 15.5 13.8 12.0
107 17.5 15.8 14.0 12.3
108 17.8 16.0 14.2 12.5
109 18.1 16.3 14.5 12.7
110 18.4 16.6 14.7 12.9
111 18.8 16.9 15.0 13.2
112 19.1 17.2 15.3 13.4
113 19.4 17.5 15.5 13.6
114 19.8 17.8 15.8 13.9
115 20.1 18.1 16.1 14.1
116 20.5 18.5 16.4 14.4
117 20.8 18.7 16.6 14.6
118 21.2 19.1 17.0 14.8
119 21.6 19.4 17.3 15.1
120 22.0 19.8 17.6 15.4
121 22.4 20.2 17.9 15.7
122 22.8 20.5 18.3 16.0
123 23.3 21.0 18.6 16.3
124 23.7 21.3 19.0 16.6
125 24.2 21.9 19.4 16.9

88
 Weight for height for both boys and girls
Height median 90% 80% 70%
126 24.7 22.2 19.7 17.3
127 25.2 22.7 20.1 17.6
128 25.7 23.1 20.6 18.0
129 26.2 23.6 21.0 18.4
130 26.8 24.1 21.4 18.7
131 27.5 24.8 22.0 19.3
132 28.0 25.2 22.4 19.6
133 28.6 25.7 22.9 20.0
134 29.2 26.3 23.4 20.4
135 29.9 26.9 23.9 20.9
136 30.5 27.5 24.4 21.4
137 31.1 28.0 24.9 21.8
138 31.8 28.6 25.4 22.3
139 32.4 29.2 25.9 22.7
140 33.1 29.8 26.5 23.2
141 33.8 30.4 27.0 23.7
142 34.4 31.0 27.5 24.1
143 35.1 31.6 28.1 24.6
144 35.8 32.2 28.6 25.1
145 36.5 32.9 29.2 25.6
146 37.2 33.5 29.8 26.0
147 37.9 34.1 30.3 26.5
148 38.6 34.7 30.9 27.0
149 39.3 35.4 31.4 27.5
150 40.0 36.0 32.0 28.0

89
Percentile of intrauterine growth in weight
and length

90
Percentile of intrauterine growth in head
circumference and weight-length ratio

91
92
93
94
95
Usage of standardized pediatric Blood pressure
charts
To use the standard charts, first make sure
that you choose the proper male or female
chart. Scan the left-most vertical column to
find the row that matches your child’s age.
Notice that each age has individual rows for
the 90th and 95th percentile blood pressure.
The vertical columns each represent a height
percentile. Matching a height column with the
90th or 95th percentile age-specific blood
pressure row shows you the numerical value
for that blood pressure percentile.

This process sounds more complicated than it

actually is. Let’s try an example. Say that
you have a 4-year-old boy who is 103cm tall.
You first look at the CDC height by age chart
to find your child’s height percentile. A 4-
year-old boy who is 103cm tall would be in
approximately the 75th height percentile
(find the point where the age and height
intersect, and choose the nearest curve).
Now, using the blood pressure percentile
chart, you can find the cutoff values for the
90th and 95th percentile blood pressures in a
4-year-old boy who is in the 75th height
percentile. Using the blood pressure chart
yields these values for our example child:

 90th percentile blood pressure = 109/66

 95th percentile blood pressure = 112/70
Normal Bp - Systolic and diastolic Bp <90

96
Prehypertension - Systolic and/or diastolic Bp
90-95mmHg
Hypertension - Systolic and/or diastolic Bp >
95mmHg

97
VIII. PROCEDURES

External Jugular Vein Puncture

A. Preparation: Wrap the child firmly so that
the arms and legs are adequately restrained.
The wraps should not extend higher than the
shoulder girdle. Place the child on a flat,
firm table so that both shoulders are touching
the table; the head is rotated fully to one
side and extended partly over the end of the
table so as to stretch the vein. Adequate
immobilization is essential.
B. Technique: Use a 21 or 23- gauge
pediatric scalp vein infusion set or butter
fly needle. The child should be crying and
the vein distended when entered. Thrust the
needle under the skin and enter the vein.

Femoral vein puncture

Caution: This is a hazardous procedure,
particularly in the neonate, and should be
employed only in emergencies. Septic arthritis
of the hip may complicate femoral vein
puncture as a result of accidental penetration
of the joint capsule. Arteriospasm with
serious vascular compromise of the lower
extremity may result from hematoma formation.
Great care should be exercised in cleansing
the skin prior to venipuncture so as to
decrease the risk of infection.
A. Preparation: Place the child on a flat,
firm table. Abduct the leg so as to expose the
inguinal region. Use strict sterile
precautions.
98
B. Technique: Locate the femoral artery by its
pulsation. The left femoral vein is
preferable because it lies medial to the
artery throughout its course. Be certain of
the position of the femoral pulse at the time
of puncture. Insert a short-bevelled needle
into the vein (perpendicularly to the skin)
about 3 cm below the inguinal ligament; use
the artery as a guide. If blood does not
enter the syringe immediately, withdraw the
needle slowly, drawing gently on the barrel of
the syringe; the needle sometimes passes
through both walls of the vein, and blood is
obtained only when the needle is being
withdrawn. After removing the needle, exert
firm, steady pressure over the vein for 3-5
minutes. If the artery has been entered,
check the limb periodically during the next
hour. If blanching of the extremity occurs,
the application of heat may be of value.

Venous cutdown
Venous cutdown is indicated for small infants
and for situations in which a seriously ill
older child is in urgent need of fluids and
difficulty is encountered in entering a vein.
In these cases, expose a vein surgically and,
under direct visualization, insert a Teflon
catheter with an inner needle stylet.

A. Sites: The saphenous vein running anterior

to the medial malleolous of the tibia will be
found the most satisfactory. It can be
entered at any point along its course. Hence,
by starting at the ankle, the same vein can be
used 2 or 3 times if necessary.
99
B. Equipment: An intravenous infusion set is
prepared as for continuos venoclysis. A
Teflon catheter with inner stylet is easiest
to use. A paediatric cutdown tray containing
scalpel, haemostats, forceps, and curved
clamps should be available.

C. Preparation: Apply a tourniquet. Cleanse

the skin and drape the leg as for a surgical
procedure, using a sterile precautions. The
foot can be securely taped to a sandbag or
board splint. Make a large wheal with 1 or 2%
lidocaine solution (without epinephrine) in
the skin over the vein.

D. Technique:
1. Incision- With a scalpel, make an incision
just through the skin. The incision should be
about 1 cm long and at a right angle to the
direction of the vein. Using a fine curved
clamp, spread the incision widely, dissecting
through the subcutaneous fat in a direction
parallel to the vein.
2. Identification of the vein- Usually the
vein is seen lying on the fascia. Some
dissection of subcutaneous fat may be
necessary. Insert a curved clamp to the
periosteum and bring the vein to the surface.
Be certain it is a vein, not a nerve or
tendon, by noting the flow of blood. Pass 2
silk ties (No.00) under the isolated vein.
Using a haemostat, dissect the vein free for a
length of 1-2 cm. Apply gentle traction on
proximal and distal ties to maximally expose
100
the vessel. In small infants, the vein is
small and fragile; great care must be taken in
handling it.

3. Insertion of the catheter-Introduce the

catheter with the stylet needle. While the
needle is in vessel lumen, hold the stylet
stationary and gently advance the catheter.
Withdraw the stylet and release tension on the
proximal tie so that the catheter may be
threaded and blood return ascertained. If
there is no blood flow, remove the tourniquet
and attempt to inject a small amount of
intravenous solution into the vein. Watch for
a wheal or extravasation of fluid, indicating
that the catheter is not in the vessel. If
the catheter flushes easily, remove the
proximal and distal ligatures and suture the
plastic wings of the catheter hub to the skin.
This can most easily be accomplished by
placing a skin closure suture on either side
of the catheter hub. Tie the suture, and then
pass the free ends through holes provided in
the wings of the plastic hub. Tie the suture
again. This should hold the catheter securely
in the vessel. Apply tape across the hub and
tubing for further security.

Suprapubic percutaneous bladder aspiration

This procedure is preferable to
catheterization when a sterile urine specimen
is required for culture and bacterial count.
A. Preparation: The bladder must be full
before the procedure is attempted. Co-
operative patients should be urged to drink
101
liberal quantities of fluid without voiding.
Inadvertent perforation of a distended
adjacent viscus may occur if the bladder is
not sufficiently distended. Place the patient
in a supine position, with the lower
extremities held in the frog-leg position.
Prepare the skin with iodine and alcohol or
other antiseptics and drape the area with
sterile towel.
B. Technique: Introduce a 22 gauge needle
attached to a syringe 1 cm above the pubis,
with the needle perpendicular to the skin.
With a quick, firm motion, advance the needle
while applying gentle traction on the syringe.
Stop when urine is aspirated. After urine
has been obtained, withdraw the needle with a
single, swift motion.

Lumbar puncture for obtaining spinal fluid

A. Preparation: Have a helper restrain the
patient in the flexed lateral position on a
firm, flat table (figure 4). Scrub and wear
sterile gloves. Draw an imaginary line
between the 2 iliac crests and use the
intervertebral space immediately above or
below this line (L3-4 interspace)(figure 5).
Prepare the skin surrounding this area as for
a surgical procedure, with iodine and alcohol
or other suitable antiseptic. Drape the area
with sterile towels.
B. Technique: Use a short 21-to 23-gauge
needle for infants; use a long 21-gauge needle
for older children. Insert the lumbar
puncture needle, with the stylet bevel-up,
just below the vertebral spine in the midline.
Keep the needle perpendicular to both planes
102
of the back or pointing a little towards the
head (figure 6). A distinct "give" is usually
felt when the dura is pierced; if in doubt,
remove the stylet to watch for fluid. When
fluid is obtained take in two different test
tubes 2cc each for analysis.
In neonates and small infants fluid may flow
very slowly, and the "give" may not be felt.

Figure 4. Lumbar puncture, lateral decibitus

position

103
Figure 5. Lumbar puncture. Technique for
locating the preferred site (L3-L4 interspace)

Figure 6. Lumbar puncture. Technique for

proper alignment of spinal needle.
104
Subdural puncture
A. Preparation: Shave the scalp overlying the
anterior fontanel to a distance of at least 2
cm beyond the margin of the fontanel. Use
sterile precautions as for any surgical
procedure. Restrain the child securely. The
operator's hands should be braced against the
skull during the procedure to minimize
undesired movement of the needle in the event
of unexpected motion by the patient.
B. Technique: Insert a 22-gauge lumbar
puncture needle with a very short bevel at the
extreme lateral margin of the fontanel, at
least 2 cm lateral to the midline, to avoid
damage to major blood vessels. After
penetrating the skin, pass the needle 2-3cm
parallel to the scalp; then point the needle
tip perpendicular to the surface and advance
cautiously. Piercing the tough dura is easily
recognised by a sudden "popping through"
feeling. Remove the stylet.
Normally, not more than a few drops (upto 1
ml) of clear fluid is obtained. If the
subdural fluid contains blood or pus, remove a
sufficient amount of fluid to decompress the
fontanel, but never remove more than 10-15 ml
at any one time on one side; removal of too
much fluid may result in a shift of midline
structures. Repeat the procedure on the
opposite side. After removing the needle,
elevate the head 10-15 degrees and exert firm
pressure for a few minutes. Apply a sterile
dressing over the puncture sites.

105
Bone marrow puncture
A. Sites: In children, the posterior iliac
crest is the preferred site. When the child
is restrained in a prone position, the iliac
crest can be located and a spot can be marked
approximately 1 cm below the crest. Puncture
of the sternal marrow is rarely indicated in
children. The site between the tibial
tubercle and the medial condyle over the
anteromedial aspect is recommended by some for
bone marrow puncture in infants.
B. Preparation: Prepare the skin surrounding
the area as for a surgical procedure. Scrub
and wear sterile gloves. use 1% lidocaine
solution to infiltrate the skin and tissues
down to the periosteum.
C. Technique: Use a 21-gauge lumbar puncture
needle for infants; use an 18-or 19-gauge
special marrow needle with a short bevel for
older children. Insert the needle with stylet
in place, perpendicular to the skin, through
the skin and tissues, down to the periosteum.
Push the needle through the cortex, using a
screwing motion with firm, stead, and well-
controlled pressure. Generally some "give" is
felt as the needle enters the marrow; the
needle will then be firmly in place.
Immediately fit a dry syringe (20-to 50-ml)
onto the needle and apply strong suction for a
few seconds. A small amount of marrow will
enter the syringe; this should be smeared on
glass cover slips or slides for subsequent
staining and counting. Remove the needle
after withdrawing marrow, and exert local
pressure for 3-5 minutes or until all evidence
of bleeding has ceased. Apply a dry dressing.
106
Thoracentesis
Ideally perform procedure with the patient
sitting on the side of the bed, and with an
assistant standing in front to support him.
Select the interspace to be tapped on the
basis of dullness to percussion and the level
of effusion on the erect chest x-ray. In the
event of a small effusion the patient may be
tilted laterally toward the affected side to
maximize yield.
Technique:
1. Carry out preparation of the site by
iodine and draping
2. A large bore needle or IV catheter
attached to a 3 way stop cock and syringe are
the necessary equipment. With needle bevel
down, insert into skin at lower edge of the
selected rib and "walk" needle over superior
edge into the pleural space.
3. Upon entering the pleural space, apply
negative pressure on the syringe and slowly
withdraw the desired amount of fluid.
4. At the end withdraw needle, dress the site
and obtain chest x-ray follow-up.

Exchange transfusion
For removal of sensitized cells or bilirubin
1. Cross match donor blood against maternal
serum for first exchange and against post
exchange blood for subsequent exchanges.
2. Blood
107
a. Type - O negative (low titer) any time
- Infants type if no chance of
maternal infant incompatibility
b. Temperature - room temperature
c. Age - fresh upto 48 hours old
3. Infant feeding - NPO during exchange
- Empty stomach if infant was fed within 4
hours of exchange
4. Procedure
a. Provide for cardiorespiratory monitoring
and frequent temperature measurements,
have resuscitation equipment ready
b. Prepare and drape patient for sterile
procedure
c. Cut umbilical cord 1 cm or less from skin
margin and find thin walled veins.
Differentiate the umbilical arteries
which are two and thick walled
d. Clear thrombi with forceps and insert
catheter to
Minimum - until blood returns
Maximum - 1/2 to 2/3 of vertical distance
from shoulder tip to umbilicus
e. Pre-warm blood in quality controlled blood
warmer if available; do not improvise
with a water bath.
f. Use 15 ml increments in vigorous full term
infants , smaller volumes for smaller,
less stable infants. Do not allow cells
in donor unit to sediment.

108
g. Rate: 2-3 ml/kg/min avoiding mechanical
trauma to patient and donor cells.
h. Total volume exchanged should be 160
ml/kg.

Endotracheal intubation
A. The patient should be well oxygenated and
lying on his back on a firm surface with the
head midline prior to intubation.
B. Holding the laryngoscope blade in the left
hand, and with the patient's head extended,
insert the blade on the right side of the
mouth and sweep the tongue to the left out of
the line of vision.
C. Advance the blade to the vallecule and
gently raise the epiglottis by lifting the
laryngoscope straight up. The cords can now be
visualized.
D. Advance the endotracheal tube from the
right corner of the mouth and pass it through
the cords while maintaining direct
visualization.
E. Auscultate the chest noting any asymmetry
of breath sound. Secure the tube with benzoin
and adhesive tape and check its position
radiographically.

Intraosseous infusion:
Used as alternative mode of IV access in
children less than 5 years old when peripheral
IV access is unobtainable or unacceptably
delayed.

109
Technique:
1. Use the tibia, approximately 2 cms below
the tibial tuberosity on the anteromedial
surface. Alternatively, use the femur in the
midline 2-3 cms superior to the lateral
condyle. Finally, consider using the medial
surface of the distal tibia, proximal to the
medial malleolus (figure 8).
2. Prepare and drape the patient for a sterile
procedure.
3. Anesthetize the puncture site down to the
periosteum.
4. Use an intraosseus needle, a 16 0r 18
gauge bone marrow needle or an 18 gauge spinal
needle.
5. Insert the needle perpendicular to the
skin and advance to the periosteum. Then,
with a boring motion, penetrate into the
marrow.
6. Remove the stylet, and aspirate some
marrow into a saline filled syringe. Next
infuse some saline to insure location and
remove any clotted material from the needle.
Make sure the needle is firmly embedded in
bone.
7. Attach standard IV tubing. Any
crystalloid, blood product or drug that may be
infused into a peripheral vein, also may be
infused into the intraosseus space.

110
Figure 8. Intraosseous infusion. Technique
Ref: Intraosseous cannulation, emedicine. medscape.com, Aug 2010

Inserting nasogastric tube

Appropriate an end point for insertion by a
single two-step process. First holding the
tip of the tube at the patients ear lobe,
stretch a length of tube to the tip of the
patients nose. Second, keeping the first
measured length of tube below the xyphoid,
stretch a second length between the xyphoid
and the lip of the patient nose (figure 9).
Make a mental note of which mark on the
premarked tube represents the proximal end of
the second measured length. This mark should
be passed to the point entry into the nostril
once the tube is inserted.

Gently & slowly insert the lubricated tube

into the nasal passage. For infant and young
children the procedure in best performed
111
while the child is restrained and lying on
his right side. In an older, more cooperative
patient, the tube can be more easily inserted
in sitting position. Once the tube has passed
the posterior pharynx gently presses the head
forward so that the chin touches the anterior
chest. By doing this gagging sensation is
decreased and facilitates passage of the tube
towards the esophagus and away from the
larynx. Pass the tube in to the stomach by
feeding the tube into the point where the
predetermined mark reaches the opening of the
nostril.

If severe laughing occurs or the patient is

unable to cry during the passage of the tube
immediately withdraw the tube and reinsert it
as these signs generally indicate tracheal
passage of the tube. Verify tube position by
aspirating gastric contents from the tube or
injecting air through the tube and
auscultating over the stomach to hear gastric
bubbling.

After passage of the nasogastric tube and

ascertainment of its position in the stomach,
securely tape it into the nose and then tape
it at a second point, either on the check on
the forehead.

112
Figure 9. Enteral intubation - nasogastric
tube. Technique for estimation of appropriate
nasogastric tube length

113
 Neonatalresuscitation
 Dry baby with clean cloth and place where the
baby will be warm

Yes
Look for – Breathing or crying Routine care
- Good muscle tone
- Colour pink

No Breathing
And Pink
 Position the head of the baby in neutral position to
open the airway Routine care
 Clear airway, if necessary and observe
 Stimulate, reposition. closely
 Give Oxygen, as necessary

Not breathing, cyanosed
Breathing
 Use a correctly fitting mask and give the baby 5
 Give Oxygen, as necessary Routine care
slow ventilations with bag.
and observe
closely

If not breathing

 Check position and mask fit.

 Adjust position, if necessary. CALL FOR HELP;
 Provide ventilation with bag and mask.
 If chest not moving well. If
 Suction airway. HR<60
/min

Check the heart rate (HR) (cord pulsation or by Compress the

listening with stethoscope). Chest

If HR>60/min

 Continue to bag at rate of about 40 breaths per minute

 Make sure the chest is moving adequately
 Use oxygen if available.
 Every1-2 minute stop & see if the pulse or breathing has improved.
 Stop compressions once the HR >100/min
 Stop bagging when respiratory rate >30/min
 Continue oxygen until pink and active.

114
IX. NORMAL VALUES FOR LABORATORY TESTS

NB: Lab tests normal values may vary among

laboratories and thus should be checked if
values for specific laboratory is available.

Blood chemistry
Alkaline phosphatase
Newborn - 20-266 IU/l
6m-1yr - 50-260 IU/l
1-2 yr - 146-477 IU/l
2-6 yr - 76-160 IU/l
7-10 yr - 45-273 IU/l
Puberty - 56-258 IU/l
Adult - 13-40 IU/l

Bicarbonate - 22-30 meq/l

Newborn -Premature- 18-26 meq/l
-Full term - 20-26 meq/l

Bilirubin (total)mg/dl
Cord <1.8mg/dl
24 hrs 48 hrs 3-5 days
premature 1-6 6-8 10-15
full term 2-6 6-7 4-12
1 month - adult 1 mg/dl
Conjugated <0.4 mg/dl

115
Calcium (total)
Premature < 1 week 6-10 mg/dl
Full term < 1 week 7-12 mg/dl
Child 8-11 mg/dl
Adult 8.5-11 mg/dl

Calcium (ionized) 4.4-5.4 mg/dl

Chloride 24-106 meq/l

Cholesterol (total)
Full term 50-120 mg/dl
1-2 yrs 70-190 mg/dl
2-16 yrs 135-250 mg/dl
Adult 130-270 mg/dl

Creatinine (serum)
1-18 month 0.2-0.5 mg/dl
2-12 yrs 0.3-0.8 mg/dl
13-20 yrs 0.5-1.2 mg/dl
Adults 0.8-1.5 mg/dl

Glucose (serum)
Children 60-110 mg/dl
Premature >30 mg/dl
Full term >40 mg/dl

116
Osmolality 285-245 mosm/kg (270-285 mosm/l
plasma)
Potassium
<10 days of age 3.5-7 meq/l
>10 days of age 3.5-5.5 meq/l

Protein (gm/dl)
Age Total Albumin Globulin Gamma glob.
Premature 5.5(4-7) 3.7(2.5-4.5) 1.8(1.2-2) 0.7(0.5-
0.9)
Full term 6.4(5-7.1) 3.4(2.5-5) 3.1(1.2-4) 0.8(0.7-
0.9)
1-3months 6.6(4.7-7.4) 3.8(3-4.2) 2.5(1-3.3) 0.3(0.1-
0.5)
3-12 mos. 6.8(5-7.5) 3.9(2.7-5) 2.6(2-3.8) 0.6(0.4-
1.2)
1-15 yrs 7.4(6.5-8.6) 4(3.2-5) 3.1(2-4) 0.9 (0.6-
1.2)

Sodium
Premature 130-140 meq/l
Older 135-145 meq/l

Transaminases (SGOT)
1-3 day 16-74 u/l
<6/12 20-43 u/l
6mo-1yr 16-35 u/l
1-5 yr 6-30 u/l
5yr -adult 19-28
Adults male 8-46 u/l
females 7-34 u/l
117
SGPT
Infants <54 u/l
Children 1-30 u/l
Adults 0-19 u/l

Urea nitrogen 6-23 mg/dl

Uric acid 2.5-8.0 mg/dl
Vitamin A Retinol
<6 mo 20-90 ug/dl
1-5 yrs 30-100 ug/dl
5-16yrs 60-100ug/dl
Adult 20-80 ug/dl

Normal serologic reference value

ASO titer - Pre-school < 1:85

- School age and adults < 1:170
ANA < 1:40
Rheumatoid factor <20 meq = normal
20-40 meq = suggestive
> 80 = positive

118
Cerebrospinal fluid

cell count %PMN

Preterm 9 (0-25)wbc/mm3 57%
Term 8.2 (0-22) wbc/mm3 61%
>1 month 0-5 wbc/mm3 0
Glucose
Preterm 24-63 mg/dl (mean 50)
Term 34-119 mg/dl (mean 56)
Children 40-80 mg/dl

CSF glucose/ Blood glucose (%)

Preterm 55-105
Term 44-128
Children 50

LDH mean 20 u/ml (5-30)

Pressure newborn 80-110 mmH2O
Infants and children <20 mmH2O
Protein
Preterm 65-150 mg/dl (mean 115)
Term 20-170 mg/dl
Children Lumbar - 5-40 mg/dl
Ventricular - 5-15 mg/dl
Cisternal - 5-25 mg/dl

119
References

1. Kevin B. Johnson. The Harriet Lane Hand

Book, 13th edition
2. Michael Stuart Mason, Hutchinson’s
clinical methods, 18th edition
3. Behrman, Kliegman and Jenson.
Nelson’s Text book of pediatrics, 18th
edition, 2007
4. Guanor Agren, Rosalinol Gibson,
Food composition table for use in
Ethiopia. I,1975.
5. Chow, Dupano, Feldaman and Mills.
Handbook of pediatrics primary care,
2nd edition, 1984
6. Huges and Bueschar, Pediatrics
procedures, 1980
7. Pediatric outpatient procedures, Jacob
A. Lohr, 1991.
8. Pocket book of hospital care for
children, World Health organization
2005.
9. World Health Organization, child growth
standards.
10. CDC growth charts: United States, 2000
11. Fourth report on diagnosis, evaluation
and treatment of high blood pressure in
children and adolescents, US department
of health and human services May 2005.
12. Anthropometric measurement techniques,
assessed from
http://motherchildnutrition.org on March
11, 2011

120